Journal of Developmental and Physical Disabilities (2022) 34:1–42

https://doi.org/10.1007/s10882-021-09790-0
REVIEW ARTICLE

Augmentative and Alternative Communication

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

Becky Crowe 1 & Wendy Machalicek 1 & Qi Wei 1 & Christine Drew 2 & Jay Ganz 3

Accepted: 11 February 2021 / Published online: 31 March 202

# The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract
Establishing evidence- and research-based practices relies upon research synthesis of
individual studies in reviews and meta analyses. Further summarizing scientific evi-
dence 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 weak-
nesses 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.

Keywords Mega-review . Research synthesis . Augmentative and alternative

communication . Aided communication . Developmental disabilities . Review

* Becky Crowe
[email protected]

1
Department of Special Education and Clinical Sciences, University of Oregon, 1589 E 15th Street,
Eugene, OR 97403, USA
2
Department of Special Education, Rehabilitation and Counseling, Auburn University, Auburn,
AL, USA
3
Department of Special Education and Educational Psychology, Texas A&M University, College
Station, TX, USA
2 Journal of Developmental and Physical Disabilities (2022) 34:1–42

Individuals with complex communication needs (CCN) comprised approximately 1.3%

of the total United States population in 2013, or approximately 4 million people
(Beukelman & Mirenda, 2013); however, this figure has likely increased along with
the increasing incidence rates of autism spectrum disorder (ASD) and other disabilities
impacting communication and language skills (Light & McNaughton, 2012). Augmen-
tative and alternative communication (AAC) interventions for children with intellectual
and developmental disabilities and complex communication needs increase functional
communication skills (Drager et al., 2010), increase language and social competence
(Light et al., 2003), and can increase natural speech in some individuals (Millar et al.,
2006). The ability to effectively and efficiently communicate wants and needs and
actively participate in social exchanges can improve quality of life and independence
(Chan & Zoellick, 2011). Communication increases social closeness, or relationships
between individuals characterized by positive exchanges, mutuality, sharing, and
mutual enjoyment (Howes, 1983).
AAC includes unaided systems such as manual sign and gestures as well as aided
systems such as the Picture Exchange Communication System (PECS; Bondy & Frost,
1994) and speech generating devices (SGD). Aided AAC systems include high tech
speech generating aided communication systems (e.g. apps on Apple™ devices,
GoTalk9+, AMDi Tech/Plus 32, ablenet® BIGmack; Logan, Iacono, & Trembath,
2017) and low tech communication systems (e.g. PECS, eye gaze board, symbols on a
ring or in a notebook). Aided AAC specifically refers to systems requiring external or
additional supports outside of the speaker’s body. AAC modalities refers to the
different systems of AAC: aided or unaided, low or high tech, and the different access
methods (e.g. eye gaze, touchscreen, head pointer). Unaided AAC systems such as
gestures and manual sign require gross and fine motor skills (Fuller, Lloyd, & Stratton,
1997), functional use of hands and fingers and trained communication partners familiar
with idiosyncratic gestures and sign languages (Mirenda, 2003). Aided AAC systems
are most often selected for individuals with CCN (Mirenda, 2001) due to their
accommodation of alternate access for individuals with fine motor impairments, intel-
ligibility to unfamiliar listeners without training, and visual symbols that resemble their
referents (Mirenda, 2001).
The growing number of reviews that summarize the extant AAC intervention
literature has utility in informing clinical decisions and aiding policymakers in making
research-based decisions about educational and medical policies. However, reviews of
studies are subject to publication bias (Shea et al., 2007, 2017) and can include studies
of poor methodological quality (Sharif et al., 2013). Synthesizing results across sys-
tematic reviews, literature reviews, and meta-analyses is difficult due to the use of
different methodologies, conceptual frameworks, and, if used, effect size calculations
(Shea et al., 2007, 2017). Moreover, methodological procedures, rigor, and purposes
and findings of systematic reviews often differ, contributing to potential practitioner
confusion in determining whether a particular intervention or practice has sufficient
evidence to warrant adoption (Wells & Littell, 2009). A previous practitioner
megaanalysis on special education interventions summarized 18 meta-analyses to
indicate which interventions have the largest effect sizes. This paper was the first to
indicate a need for synthesizing syntheses of research to inform practices, encourage
selection of highly effective interventions for use with individuals with disabilities, and
recommend discontinuation of use of ineffective practices (Forness et al., 1997).
Journal of Developmental and Physical Disabilities (2022) 34:1–42 3

Mega-review methodology originated in the healthcare field as a method by which

researchers gather systematic reviews into a single synthesis of combined findings
about an intervention or topic of interest (e.g., Dragioti et al., 2017; Seida et al., 2009).
Researchers conduct mega-reviews, also called umbrella reviews, to collect, collate,
and summarize the evidence base provided by systematic reviews of individual studies
to present a cohesive synthesis of the extant literature, identify gaps and blind spots
with a field’s published evidence base, and identify promising practices for researchers
and practitioners (Ioannidis, 2009). Mega-reviews also provide an opportunity to
examine the methodological quality of included reviews. Mega-review methodology
applied to AAC interventions is very limited: to date, there is a single overview of
review studies (Nam et al., 2018) examining five reviews on AAC for individuals with
developmental disabilities. This mega-review was limited to reviews of single case
research designs comparing AAC systems and did not assess review methodological
quality. There has been an increase of published systematic reviews and meta-analysis
in recent decades, thus a systematic review of reviews in the area of AAC implemen-
tation is warranted.
What Works Clearinghouse (WWC) standards for single-case research design
studies provide rigorous methodological requirements for researchers that are used to
determine study quality and establish evidence-based practices (Kratochwill et al.,
2010). There are no similarly clear standards for conducting and reporting reviews of
literature. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis
(PRISMA) guidelines focus on reporting of randomized control trial data using quan-
titative methodologies (Moher et al., 2009). There is no quality indicator measure to
compare review quality across group and single case research designs. Due to the
inconsistent reporting of quality of evidence on AAC interventions, researchers and
clinicians are unable to make clear and conclusive recommendations to practitioners
and families about best practices or research-based interventions (e.g., Ganz et al.,
2017; Holyfield et al., 2017).
The Scottish Intercollegiate Guidelines Network (SIGN) checklist was developed to
assess methodological quality of systematic reviews and meta-analyses of single case
research (Manolov et al., 2017); however, SIGN does not address methodological
quality of other design types. A MeaSurement Tool to Assess systematic Reviews
(AMSTAR) was developed by Shea et al. (2007) and revised to include non-
randomized studies (AMSTAR 2; Shea et al., 2017). AMSTAR 2 has been evaluated
for inter-rater reliability (median Cohen’s kappa range: 0.51–0.71) and found to have
moderate to substantial agreement (Lorenz et al., 2019; Shea et al., 2017). AMSTAR 2
was also found to have validity of appraising systematic reviews and determined to be
easy to administer (Lorenz et al., 2019; Pieper et al., 2015) and had good inter-rater
reliability with the risk of bias in systematic reviews tool (Pieper et al., 2019).
The purposes of this mega-review are to summarize published peer-reviewed
literature reviews about aided AAC interventions that included children with develop-
mental disabilities, to present an overview of the most frequently used aided AAC
interventions, and to appraise each review’s quality using AMSTAR 2. The following
research questions were asked: (a) what is the methodological quality of peer-reviewed
published literature reviews on interventions for teaching communication skills using
aided AAC to children with developmental disabilities and complex communication
needs; (b) has the methodological quality of reviews of aided AAC interventions for
4 Journal of Developmental and Physical Disabilities (2022) 34:1–42

children with developmental disabilities and complex communication needs changed

over time; (c) how are aided AAC interventions described regarding participants,
interventionists, and interventions; (d) what are the review-reported communications
outcomes of aided AAC interventions and review-reported recommendations for future
research; and (e) what intervention methodologies have been used to produce and
report knowledge about aided AAC interventions for children with developmental
disabilities and complex communication needs?

Method

A mega-review of the literature on interventions for individuals with CCN who use
aided AAC was conducted to summarize the published literature and provide guidance
to researchers on areas of further research, ways to increase methodological rigor, and
any blind spots within the literature. Aided AAC was operationally defined as AAC
requiring materials external to the body, such as icons and/or voice-output systems.
This mega-review was conducted as a systematic review of literature reviews including
systematic reviews, meta-analyses, and narrative reviews with systematic and replicable
methods replacing individual studies. By completing a review of reviews, the authors
aimed to summarize extant literature and identify areas commonly featured in aided
AAC research and bring to light areas of need identified by authors reviewing
individual studies. Unpublished and gray literature, including dissertations, book chap-
ters, and reports, were excluded from this mega-review due to limiting searches to peer-
reviewed journals.

Search Strategy

The electronic databases ERIC, PsycINFO, and Academic Search Premier were sys-
tematically searched by the first author using combinations of the following free term
keywords: (a) “augmentative and alternative communication or AAC”, OR (b) “assis-
tive technology”, OR (c) “aided communication”, AND (a) “literature review”, OR (b)
“systematic review”, OR (c) “meta-analysis”. In this paper, meta-analyses referred to
reviews that statistically combine data from multiple studies, assess effect sizes, and
analyze research results (Uman, 2011) and literature review referred to a review,
including systematic reviews, that reported completing systematic searches but did
not explicitly declare a priori methods or research question(s) and also did not use
meta-analysis procedures. The following restrictions were placed on the electronic
searches: (a) peer-reviewed publications; (b) published between January 1, 1999 and
August 1, 2020 to capture the last 20 years of research in this area; (c) published in
English; and (d) no dissertations, books, book chapters, or government reports. Narra-
tive and scoping reviews (e.g. Schlosser & Sigafoos, 2006) were excluded from the
present mega-review due to AMSTAR 2 being developed for use with systematic
reviews/meta-analyses. Scoping reviews were excluded due to their not being research
question-driven, disparities in reporting replicable methods of the review process, and
scoping reviews are often not intended to synthesize research evidence (Munn et al.,
2018).
Journal of Developmental and Physical Disabilities (2022) 34:1–42 5

Initial searches returned 1215 articles. Titles and abstracts of each article were
reviewed by the first author after removal of duplicates, and 185 met inclusion criteria.
Hand searches of the most frequently appearing journals (i.e., Augmentative and
Alternative Communication and Journal of Speech, Language, and Hearing Research)
were completed by the first author in July 2018, looking at titles and keywords for
“review” or “summary” and “AAC” or “assistive technology”. The journal Augmen-
tative and Alternative Communication was searched from January 1999–August 1,
2020 and yielded 1 new article. A hand search of the Journal of Speech, Language, and
Hearing Research was conducted from January 1999 and August 1, 2020; no new
articles were identified. The first author also completed ancestral searches by reviewing
the articles cited by reviews identified for inclusion and published in the last 20 years;
no new articles were identified. Four reviews identified via expert nomination were
included for full text analysis. During title and abstract screening, 15 scoping and
qualitative reviews were excluded.
During full text coding, each article was reviewed by the first author against the
following inclusion criteria: (a) literature review, systematic review, or meta-analysis;
(b) replicable methods that included single case or group design research methodolo-
gies; (c) reported or addressed use of aided AAC; (d) reported communication out-
comes, operationalized as a change in receptive or expressive communication skills
(e.g. syntax, verbal operants, initiations, responses) for at least one participant per
study; (e) included at least one participant diagnosed with a developmental disability;
(f) reported at least one participant 0–18 years; and (g) evaluated the results of the
studies or interventions using a narrative summary, table, or quantitative analysis.
A total of 185 reviews were identified that met inclusion criteria and were coded via
full text review. During full text coding, 101 reviews were excluded. Reviews were
excluded from analysis for the following reasons: (a) qualitative methodology (n = 8);
(b) narrative reviews without systematic replicable methods (n = 11); (c) scoping
reviews (n = 5); (d) participants’ principal diagnosis was sensory impairment (n = 6);
(e) no communication outcomes reported (n = 36); (f) only adult participants (n = 5); (g)
only unaided AAC used in interventions (n = 11); and (h) duplicates (n = 19). Reviews
that did not synthesize intervention results (Binger & Light, 2008) or did not report
intervention results were also excluded (e.g. Gevarter et al., 2013). Searches and
application of inclusion and exclusion criteria are detailed in Fig. 1. A list of excluded
reviews is available upon request. There were 84 reviews included in this mega-review.
Population, intervention, comparator group, outcome, and study design (PICOS) in-
formation for this mega-review are depicted in Fig. 3, available in supplemental
materials.

Data Extraction

The first author created a coding sheet in Microsoft Excel™ to code each article
selected for full text review (available upon request). Variables and coding categories
were identified through close reading of each review, then counted via event recording
by the first author for each occurrence. Primary coded variables were (a) type of
designs; (b) number of included studies; (c) age of participants; (d) participant and
interventionist demographics; (e) type of intervention; (f) intervention setting; (g) inter-
rater agreement; (h) generalization; (i) maintenance; (j) outcomes and findings reported
6 Journal of Developmental and Physical Disabilities (2022) 34:1–42

Additional records identified

Records identified through through other sources
Identification

database searching
(n = 1,215) Journal search (n = 17)
Ancestral search (n = 76)

Records after duplicates removed

(n = 263)
Screening

Records screened Records excluded

(n = 197) (n = 13)

Full-text articles Full-text articles excluded (n = 101)

assessed for eligibility
Eligibility

(n = 185) No communication outcomes (n =

36)
Expert nomination No aided AAC (n = 11)
(n = 4) Sensory impairment only (n = 6)
No children participants (n = 5)
Qualitative methods only (n = 8)
Narrative review (n = 11)
Studies included in Scoping review (n = 5)
Duplicates (n = 19)
Included

mega-review and
AMSTAR 2 analysis
(n = 84)

Fig. 1 PRISMA Diagram for mega-review

by review authors; (k) limitations; and (l) recommendations. Additional variables that
were coded were: (a) participant race/ethnicity; (b) participant gender; (c) type of
interventionist (e.g., clinician, teacher, or parent); (d) disability diagnoses; (e) interven-
tion setting: and (f) type of AAC (e.g. PECS/PCS, SGD, mobile tablets as SGD.
Specific types of SGD were coded but were aggregated due to a wide variety of
devices and systems used over 20 years of technology development. Types of inter-
faces and complexity were not coded due to lack of reporting by review authors.
Behavioral intervention was defined as the use of an intervention strategy based on
principles of applied behavior analysis (e.g., forward chaining, prompt hierarchy, time
delay). Due to intervention development and terminology evolution and inconsistent
reporting of intervention strategies by review authors, specific intervention types were
not coded. Variables were coded using key words and quantitative data reported by
each review and hand-typed or copied and pasted into the Excel sheet. A complete
coding form is available upon request.
Following coding for variables of interest, the first author coded each review using
the AMSTAR 2 tool. Items not applicable to each review’s included designs were
coded “not applicable” and not calculated in total points possible (e.g., a literature
review was coded not applicable for having done appropriate statistical analyses).
AMSTAR 2 results were compared across reviews by calculating percent of points
possible: number of items marked “Yes” or Partial Yes” divided by the total number of
Journal of Developmental and Physical Disabilities (2022) 34:1–42 7

applicable items × 100. Because the authors of AMSTAR 2 did not create guidance
around cutoff levels for review quality, no reviews were excluded due to review
quality.

Reliability

Search and inclusion reliability were independently conducted by the fourth author, an
assistant professor in special education. Electronic database searches were completed
using free term keywords and applying inclusion and exclusion criteria to titles and
abstracts following a 1-h training via Zoom. Training procedures are available upon
request and included modeling free term searches in each database, tracking number of
hits per database, and applying inclusion and exclusion criteria to each title and
abstract. Agreement across the three electronic databases averaged 93.3% (range:
87.5%–98%), calculated by the total number of agreements divided by the total number
of agreements plus total number of disagreements × 100 for each database. Disagree-
ments at the title/abstract level were discussed until the two authors reached consensus
on inclusion/exclusion of reviews.
Data extraction inter-coder agreement (ICA) was completed by random number
generation to select 37% of reviews (n = 31) from an alphabetical list of
included references. The third author, a special education doctoral student,
compared a copy of the completed coding sheet for each review against review
full text and marked each Excel cell for disagreement in red. Data extraction
ICA was 98.26%, calculated by dividing 396 agreements by 403 possible
agreements × 100. AMSTAR 2 coding agreement was similarly completed by
the third author reviewing scores for another 31 randomly selected articles. The
third author used a copy of the completed data codes and marked disagreements
in red. Initial independent AMSTAR 2 coding ICA was 89.72%, calculated by
dividing 445 agreements by 496 possible agreements × 100. Disagreements on
variable coding and AMSTAR 2 ratings were discussed between the first and
third authors until consensus was reached.

Results

Included reviews were coded according to reported variables and results are summarized
in narrative form. Results were calculated by frequency count of variables per review
and reported by content area. Most of the reviews that met inclusion criteria were
identified as systematic reviews (n = 36), followed by literature reviews (n = 26) and
meta-analyses (n = 22). Research designs encompassed solely single case research
designs (n = 43), single case and group designs (n = 31), single case and group designs
in combination with qualitative methodology (n = 6), mixed methods (n = 2), and not
explicitly reported (n = 2). Table 1 aggregates how many reviews reported variables of
interest such as type of designs, ages of participants, and type of AAC used. Reviews
and meta-analyses reporting on the same studies or multiple publications about a single
set of searches were counted as individual separate reviews, thus variables of interest
could have been coded and counted multiple times.
8 Journal of Developmental and Physical Disabilities (2022) 34:1–42

Table 1 Variables of Interest Reported by Reviews

Variables of interest Number of reviews reported

Research design
Single case 43
Single case and group 31
Single case and group and qualitative methods 6
Mixed methods 2
Not reported 2
Review type
Systematic review 36
Literature review 26
Meta-analysis 22
Other 4
Mega-review 1
Intervention type
Behavioral 63
Not behavioral 16
Not reported 7
Disability category
Autism spectrum disorder 62
Other health impairment 36
Developmental disabilities 34
Intellectual disability 33
Speech language impairment 7
Augmentative and alternative communication
Speech-generating device 38
iPad/iPod as speech-generating device 7
PECS/picture communication symbols 34
Other 15
Intervention setting
General education/inclusive classroom 37
Self-contained/special education classroom 23
Home 23
Outpatient clinic 13
Other 28
Review reported:
Generalization 33
Maintenance 30
Social validity 5
Age of participants
Birth - kindergarten/preschool 50
Kindergarten - 6th grade/elementary 62
6th grade - 12th grade/middle - secondary 55
Adults 38

Note. Some reviews reported multiple characteristics of interest, e.g., children ages 3–21, which the author
coded as participant ages of all four age categories listed, therefore, not all categories total 84
Journal of Developmental and Physical Disabilities (2022) 34:1–42 9

Participants

The most commonly reported participant disability condition was autism spectrum
disorder (ASD), reported by 62 reviews. Thirty-six reviews reported disabilities that fall
under the disability category aggregate of other health impairments, including cerebral
palsy and other reported conditions (e.g., epilepsy, cleft palate, behavior and attention
disorders). Developmental disabilities (n = 34), intellectual disability (n = 33), and
speech language impairment (n = 7) were the next most frequently reported participant
disabilities. Reviews also reported that participants had multiple disability diagnoses or
aggregated diagnoses as developmental disabilities. Participants in single-case research
and group designs were mostly male, had a diagnosed disability impacting their
functional communication, and were school-aged or 3–18 years old.
Due to variations in review reporting of ages and school levels, the authors created
participant age categories of (a) birth through kindergarten or 0–5 years old (n = 50); (b)
elementary school age of kindergarten through sixth grade or 6–10 years old; n = 62);
(c) adolescents 11–17 years old or sixth grade through twelfth grade (n = 55); and (d)
adults or ages 18 years and up (n = 38). Reviews reported participants by numerical age
as well as age category (e.g., elementary or secondary) and often reported multiple age
categories, thus the sum of these categories exceeds 84. In reporting participant
demographics, four reviews included race/ethnicity data (Barton et al., 2017; Chung
et al., 2012; Ganz et al., 2014a; Shire & Jones, 2015), 31 reviews reported participant
gender, and type of disability was reported in all 84 reviews.

Interventionists

Most reviews did not report on (a) study interventionists other than the researchers; (b)
participant demographics, especially data specific to race or ethnicity; (c) intervention-
ist or researcher demographic information; or (d) the identity, expertise or training
level, or role within the study of the interventionist. Fifteen reviews reported a teacher
or paraprofessional as the interventionist, 13 reviews reported the researcher was the
sole interventionist, and 9 reviews reported parent interventionists. One review reported
the education level and race/ethnicity of communication partners (Shire & Jones,
2015).

Settings

Interventions took place in (a) a general education or inclusive classroom setting (n =

37); (b) other settings such as residential facility or hospital (n = 28); (c) a self-
contained or special education classroom (n = 23); (d) participant’s home (n = 23); or
(e) an outpatient clinic setting (n = 13).

AAC Modalities and Interventions

The most frequently reported AAC modalities were SGDs (n = 38), PECS or picture
symbols (n = 34), other (n = 15), and specified iPad1/iPod as an SGD (n = 7). The use of

1
The iPad and iPod are products of Apple Computers Inc., Cupertino, CA, www.apple.com
10 Journal of Developmental and Physical Disabilities (2022) 34:1–42

behavioral interventions or strategies, such as PECS (Tincani & Devis, 2011);

prompting, shaping, and modified interrupted chain procedures (Alwell & Cobb,
2009); practitioner-implemented functional communication training focusing on single
mands, intraverbals, or tacting (Alzrayer et al., 2014), was reported by most reviews
(n = 65). Sixteen reviews reported interventions that were not explicitly based on
principles of behavior, and seven reviews did not report enough information about
the interventions of included studies to determine whether behavioral strategies were
used.
Review authors determined some AAC interventions to have enough well-
designed studies to be established as evidence-based practices. These included
PECS (Tincani & Devis, 2011), the use of assistive technology for activities of
daily living (Cumming & Draper Rodríguez, 2017), the use of high-tech AAC
to teach social communication skills (Morin et al., 2018), computer-aided
instruction (Barton et al., 2017), tablet-based video modeling (Hong et al.,
2017), aided AAC modeling (Lynch et al., 2018), and inclusive education for
increasing communication skills (Alquraini & Gut, 2012). Claims regarding
evidence-based practices were made by reviews on the basis of moderate to
strong intervention effects on dependent variables of interest and by quality of
evidence analyses; however, reviews used varied effect size calculations and
different evaluations of methodological rigor from one another.
Interventions with sufficient evidence and quality to meet the criteria of emerging
evidence-based practices according to review authors included aided AAC input in
which the communication partner/interventionist also uses the AAC system (Branson
& Demchak, 2009; Ganz et al., 2012b; Sennott et al., 2016; Shire & Jones, 2015;
Therrien et al., 2016), AAC-based interventions to reduce challenging behavior
(Walker & Snell, 2013; Walker et al., 2018), tablets and mobile devices as AAC
(Cumming & Draper Rodríguez, 2017; Kim & Kimm, 2017; Lorah et al., 2015;
Stephenson & Limbrick, 2015), and using symbols and icons to represent words and
phrases in aided AAC systems (Roche et al., 2014).
Reviews that compared different types of AAC (e.g., comparison of high- to low-
tech systems) found that PECS compared to speech-generating devices did not have
significant differences in communication outcomes (Ganz et al., 2014). Greater com-
munication skills gains were found for individuals using aided compared to unaided
AAC, and individuals with ASD made greater gains in communication skills than
individuals with intellectual disabilities (Holyfield et al., 2017). A systematic review of
studies comparing participant preference for SGDs compared to other modes of AAC
found that 67% of participants who had developmental disabilities had some degree of
preference for using SGD and 33% of participants preferred picture exchange (van der
Meer et al., 2011).

Generalization, Maintenance, and Social Validity

Very few reviews reported maintenance or generalization data from the included
studies, a criticism noted by many review authors about individual studies and which
prompted calls to action for researchers to program for and report these data. Reviews
that measured social validity (n = 5), generalization (n = 33), and maintenance (n = 30)
were in the minority of the total included 84 reviews.
Journal of Developmental and Physical Disabilities (2022) 34:1–42 11

Experimental Designs

AAC interventions for individuals with intellectual and developmental disabilities who
have complex communication needs were most frequently studied in single-case
research designs (n = 38), using primarily multiple-baseline or multiple probe designs.
Alternating treatment or multielement designs were used to compare contexts, com-
munication partners, and most frequently used to compare investigate replacement of
challenging behavior with functional communication responses.
Reviews including group designs investigated effects of PECS interventions (e.g., Allen
et al., 2017; Alsayedhassan et al., 2016; Flippin et al., 2010; Ostryn et al., 2008; Preston &
Carter, 2009) or comparisons of different types of AAC (e.g., Brunner & Seung, 2009;
Lancioni et al., 2007; Branson & Demchak, 2009; Schlosser & Wendt, 2008). Summaries of
type of AAC intervention reported outcomes and recommendations made by review authors
are presented in Table 2, available in supplemental materials.

Review Methodological Quality

Since 2001, when the first systematic review specific to AAC and assistive technology was
published (Lancioni et al., 2001), review quality, as evaluated by AMSTAR 2, has been
highly variable but has improved over time. There was considerable variation in review
quality, but an overall increasing trend, as shown in Fig. 2, which indicates greater adherence
to best practices in completing systematic reviews and meta-analyses over time.
Areas of strength in methodological quality included explicitly stating the research
question and reporting information on participants, intervention, comparison groups,
and outcomes (n = 73), explicitly established the methods before conducting the review
(n = 80), explained inclusion/exclusion criteria (n = 81), comprehensively searched at
least two databases, conducted a reference search, and searches within 24 months of
completion of the review (n = 80), and described included studies with sufficient detail
(n = 78). Data on the percent of reviews that scored a “yes” for each AMSTAR 2 item
are reported in Table 3, available in supplemental materials. Areas of need included
providing a list of excluded studies and reasons for exclusion (n = 4), accounting for risk
of bias in individual studies when interpreting the review results (n = 22), and providing
a satisfactory explanation for heterogeneity in the results of the review (n = 21).
The reviews with the highest AMSTAR 2 scores were primarily systematic reviews
and meta-analyses, which could reflect the validity of the tool to assess the methodo-
logical quality of group designs. These reviews were all published after the introduction
of AMSTAR, and were all published in the last 10 years with one exception (Rispoli
et al., 2010). The 11 highest scoring reviews scored 80% or greater of possible points
on AMSTAR 2, and the four next top scoring reviews achieved 77% of items possible.
Each included review’s AMSTAR 2 scores and total achieved are shown in Table 4,
available in supplemental materials.

Discussion

This mega-review synthesizes information reported by literature reviews, meta-analyses,

systematic reviews, and one mega-review on aided AAC interventions for children with
12 Journal of Developmental and Physical Disabilities (2022) 34:1–42

Table 2 Interventions, Outcomes, and Recommendations Reported in Each Included Review

Review Intervention Outcomes Recommendations

Allen et al., (2017). Aided augmented input. Receptive and expressive Studies need to report more
vocabulary skills increased, detail on dosage of
pragmatic skills increased. intervention, specific AAC
Aided input more effective used, provide data on
than non-aided. receptive syntax skills
before and after
intervention.
Alper & Raharinirina, Effectiveness of assistive Very young individuals with Explore use of assistive
(2006). technology: 5.88% of disabilities are not receiving technology with more
included studies on AAC (n assistive technology. varied types and degrees of
= 4). Participants mostly disability, investigate
children: 25% of effective teaching strategies
participants over 22 years. for maintenance and
Assistive technology generalization.
interventions resulted in
skill improvement in
67.65% of studies.
Alsayedhassan et al. Picture Exchange Overall positive and successful Trainers should provide more
(2016). Communication System outcomes: 8 out of 13 immediate feedback during
(PECS). studies reported mastery of intervention. Researchers
PECS. need to take data on and
report procedural integrity.
Alwell & Cobb, (2009). Social and communication Increase in communication Researchers should replicate
interventions for skills in all studies and intervention studies with
secondary-aged youth with overall mean slightly additional participants,
disabilities. AAC subgroup positive effect. Use of AAC increase methodological
(n = 5): milieu teaching, in secondary settings can quality, and report effect
prompting, shaping, modi- support student sizes.
fied interrupted chain pro- participation and
cedures. interaction.
Alzrayer et al., (2014). Mobile tablet use in Communication skills Future research should
communication increased for all participants investigate using
interventions with and some participants communication apps other
individuals with autism continued communication than Proloquo2Go and
spectrum disorder and other using tablets after investigate wider range of
developmental disabilities. intervention ended and verbal behaviors as well as
across novel contexts. device navigation.
Andzik et al., (2016). Practitioner implemented From total of 15 studies, 30 out Need more information about
functional communication of 31 participants had specific training for
training. reported positive results, 1 interventionists, need more
mixed. Teacher is most treatment fidelity data
common intervention agent reported, need more
and most interventions took programming for
place in special education generalization and
settings. maintenance.
Anttila et al., (2012). Overview of systematic Communication addressed in 8 Urgent need for further and
reviews of assistive reviews: review authors better quality research
technology interventions concluded that quality of across different participant
across recreation, evidence is low but AAC demographics and types of
vocational support, and may be beneficial for AAC.
communication. individuals with autism.
de Barbosa et al., AAC for children with Down Speech-generating devices (n = Need more research on AAC
(2018). syndrome. Review of 13 4) and PECS (n = 3) most for individuals with Down
studies: 4 studies used SGD frequently used with syndrome and need to
(29 px), 3 used PECS, 2 children with Down measure changes in
used manual sign system, 2 syndrome. Both increased communication,
used picture symbols, 1 communication skills. socialization, language, and
motor skills.
Journal of Developmental and Physical Disabilities (2022) 34:1–42 13

Table 2 (continued)

Review Intervention Outcomes Recommendations

each other types of assistive

technology.
Barker et al., (2012). Reading instruction for Most participants used SGDs Need standardized assessments
children who use AAC. (n = 16 participants). of phonological awareness
Total of 8 studies: n = 5 Difficult to compare results and reading that don't
instruction that directly and due to different measures require speech responses,
explicitly taught and strategies used. assess validity of new
phonological awareness, assessments, assess validity
reading, and/or spelling of interventions modified to
skills. remove speech elements.
Barton et al., (2017). Technology-aided intervention Computer-aided instruction is More research about TAII to
and instruction (TAII) for an evidence-based practice determine components,
students with autism spec- for students with ASD. need more research on
trum disorder (ASD) AAC and virtual reality not AAC and virtual reality,
identified as evidence-based specifically group design
practices. studies.
Battaglia & McDonald, PECS for children with ASD All participants made gains on Further research on functional
(2015). and effects on maladaptive proficiency with PECS and relation between PECS use
behavior. increased verbal speech but and decrease in maladaptive
three out of seven total behavior, researchers
participants did not should determine function
demonstrate decreases in of challenging behavior
maladaptive behavior. prior to implementation of
PECS.
Biggs et al., (2018). Aided AAC modeling. All participants (children and Further research on aided AAC
youth with CCN) made modeling for older children
gains in expressive and adults, more research
communication however on focused aided AAC
due to packaged modeling. Study authors
interventions, benefits should report with greater
cannot solely be attributed detail for replicability.
to aided AAC modeling.
Boyle et al., (2017). Interactive reading/shared Initial evidence of benefit: Need more research into how
reading with digital texts. increases in communication visual scene displays can be
Digital text on turns, word learning. used to develop interactive
tablet/computer with visual reading interventions. Need
scene display programmed research on whether
with hotspots to label pic- interactive reading between
tures. peers and children with
disabilities could lead to
greater social interactions.
Branson & Demchak, AAC interventions with infants Improved communication Need more research on
(2009). and toddlers with skills for 97% of comparative effectiveness
disabilities. Most studies on participants, of various types of AAC for
unaided AAC and 42% of communication partners kids with specific
studies on aided AAC. successfully taught to create disabilities, compare aided
more opportunities and vs unaided AAC,
increase child's use of investigate use of AAC
intentional communication with infants and toddlers.
acts.
Brunner & Seung, Communication treatments for Manual sign used successfully Provide more participant
(2009). children with ASD. AAC for longer to teach receptive information because of
interventions covered were and expressive vocabulary heterogeneity of individuals
PECS and manual sign. skills; has strong empirical with ASD, have to
support. PECS is widely understand typical
utilized in school settings interaction/ communication
and across verbal operants. before teaching individuals
with ASD.
14 Journal of Developmental and Physical Disabilities (2022) 34:1–42

Table 2 (continued)

Review Intervention Outcomes Recommendations

Brunner et al., (2017). Technology in rehabilitation AAC increased independence Need further research into
for people with traumatic and participation. apps, social media, virtual
brain injury. AAC (n = 27) reality, blogs, more about
interventions addressed user perspectives or
communication needs, experiences accessing
increasing participation, internet and using mobile
improving quality of life. devices and apps.
Bryant et al., (2010). Assistive technology as a AAC helps users communicate Study authors need to report
support for individuals with and learn new concepts. participant standardized test
intellectual disability. scores, age, and gender data
of participants.
Campbell et al., (2006). Practices for teaching young One of the included studies Researchers should provide
children (infants and addressed AAC: using a more information about
toddlers) to use assistive “voice output context of communication
devices. communication aid” during device use and teach skills
snack and play routines. All within natural contexts and
participants increased settings.
communication over
baseline.
Chapin et al., (2018). Peer support for preschoolers Children who used AAC prior Continue research on
with ASD. to intervention activities developmentally
demonstrated moderate appropriate partner training
level of effect, children who activities, need more
used AAC during research due to small
intervention reported very number of studies providing
strong effect. Mostly PECS information on peer
used (n=3) with only one characteristics.
study with SGD.
Chung et al., (2012). Interventions to increase peer Peer training and Investigate peer training as
interactions for students multicomponent important component,
with complex intervention packages are research multicomponent
communication needs. promising interventions for interventions, more research
increasing social into adult facilitation,
communication. research pragmatics,
functions, topics of social
communication.
Cumming & Draper Mobile technology supporting Communication skills (n = 7) Further high quality research in
Rodriguez (2017). individuals with disabilities. overall indicated a weak mobile tech and
effect overall for AAC communication. Use greater
interventions on variety of apps on mobile
communication outcomes. technology devices (not just
Proloquo2Go for
communication).
Desideri et al., (2013). Assistive technology Overview of models and Need to transition from
recommendations for instruments to guide AT unsystematic experiences
children with multiple professionals for and intuitions of clinicians
disabilities. assessment of children with and establish
multiple disabilities. evidence-based practices
and need to use validated
intervention models and in-
struments.
Douglas (2012). Communication partner Paraeducators’ results: positive Need more research to
training for paraeducators to behavior changes reported strengthen findings of
support the communication (n= 7), individuals who use review, investigate the
of individuals who use AAC: increase in impact of paraprofessionals
AAC. communicative behavior, to support communication
decrease in challenging and research on how
behavior, increase in communication partner
responding and requesting.
Journal of Developmental and Physical Disabilities (2022) 34:1–42 15

Table 2 (continued)

Review Intervention Outcomes Recommendations

training impacts individuals

who use AAC.
Dunst et al. (2013). Assistive technology device All AT device use resulted in Research on promoting use of
use by young children with improvements in child assistive technology needs
disabilities. outcomes except to pay explicit attention
weighted/pressure vests; ef- paid to differences between
fect sizes all very large. implementation and
intervention practices.
Erdem (2017). Assistive technology for Assistive technology provides Researchers should share
students with special needs. equal educational results of literature reviews
Communication: aided and opportunities for students at conferences and with
unaided AAC. with disabilities and teachers, parents, admin,
improve quality of life. students, assessment of
tech, tools, guide materials,
teacher training, sample
implementations,
cooperation among
professionals.
Flippin et al., (2010). PECS effectiveness for Speech outcomes varied and Need to research moderators
children with ASD on mixed, questionable on effectiveness, why Phase
communication and speech effectiveness for increasing IV results in more speech
outcomes. speech. Children who gains, and what
complete Phase IV of PECS pretreatment characteristics
higher rates of speech gains. lead to more gains.
Evidence for maintenance
and generalization limited
and mixed.
Ganz et al., (2012a). PECS interventions for AAC has small to moderate Further research into measures
PECS with individ- children with ASD. effects on speech outcomes, of speech outcomes
uals with ASD SGD most effective for pre/post intervention, report
ASD without IDD, PECS standardized definitions of
most effective for ASD and language levels, report
IDD, PECS most effective standardized diagnostic
for preschool. Participants measures.
who started with more
speech had better speech
outcomes, aided AAC
doesn’t inhibit speech but
may enhance.
Ganz et al., (2012b). Aided AAC for individuals All participants had moderate Investigate specific types of
Aided AAC for indi- with ASD. or better effects. AAC has AAC with different ages
viduals with ASD. small to moderate effects on and diagnostic categories.
speech outcomes. Researchers should provide
more information about
participants to determine
possible mediators (age,
severity of disability, level
of language skills)
Ganz et al., (2014a). In- Comparison of three types of Overall small to moderate Further research into impacts
teraction of partici- aided AAC: PECS, SGDs, positive effects on speech of SGDs and picture-based
pant characteristics other picture-based. outcomes. SGDs most AAC on speech outcomes,
and type of AAC. effective for individuals need to report participants’
with ASD, PECS most communication skills from
effective for individuals standardized assessments,
with ASD and comorbid and report diagnostic infor-
intellectual and mation.
developmental disabilities.
Ganz et al., (2017). High-tech AAC for individuals Need more research impact of
with intellectual and PECS on academic
16 Journal of Developmental and Physical Disabilities (2022) 34:1–42

Table 2 (continued)

Review Intervention Outcomes Recommendations

developmental disabilities Moderate positive effects of performance, utility of

and complex high-tech AAC on social speech-generating devices
communication needs. communication outcomes. and other picture based
AAC to improve social
skills, component analysis
of aided AAC when part of
intervention package.
Ganz et al., (2014b). Effects of aided AAC across Aided AAC resulted in the Need research on the effects of
Moderation of effects settings for children with largest effects in general AAC on skills other than
of AAC based on autism spectrum disorder. education settings. Both communication, investigate
setting and types of speech-generating devices instructional elements of
aided AAC. and PECS had larger effects AAC interventions to find
than other picture-based most effective, different
systems. Speech-generating types of symbols on
devices produced larger ef- behavioral objectives.
fects than PECS.
Gevarter et al., (2013). Comparing AAC intervention Evidence that PECS More research into differences
components for individuals acquisition doesn't differ based on iconicity and
with developmental based on use of low and receptive learning, compare
disabilities. Comparing high iconicity symbols, different symbol sets and
symbol sets, instructional pictures and photographs. SGD-based comparisons.
strategies, speech output in Effect of type of speech Need more research on
aided AAC, verbal operants output on increasing whether presence/absence
in unaided AAC. vocalizations were of speech output, type (dig-
inconclusive. itized or synthesized), long
or short output influences
AAC acquisition.
Gevarter & Zamora, Naturalistic interventions for Mostly positive results (19 of Strategies and intervention
(2018). increasing expressive skills 32 included studies) across procedures should be
of children who use SGDs variety of types of SGDs, individualized, further
in natural contexts. natural change agents as research into interventions
interventionists, for individuals with ASD,
peer-mediated interventions research with individuals
successful. with multiple disabilities,
component analysis of
strategies.
Gilson et al., (2017). Methods to teach employment AAC: strong positive effect (n Need to target social skills in
skills to secondary students = 1), mostly positive effects employment interventions.
with intellectual and (n = 5), no studies with Need more research to
developmental disabilities. mixed effect or no effect support more legislation to
included. create opportunities for
adults with disabilities and
need more research with
participants with severe
disabilities.
Hart & Banda, (2010). PECS with individuals with PECS interventions resulted in Researchers should investigate
developmental disabilities. increases in functional completing formal
communication in all but 1 preference and reinforcer
participant, decreased assessments before
problem behavior, conducting intervention
increased vocal verbal studies. Need research into
speech in some participants. how manipulating symbol,
referent and instructional
variables affects acquisition
of pictures during training.
Heath et al. (2015). Impact of FCT on CB and Highest gains for verbal Research to determine
communication outcomes individuals, then aided cognitive ability or
AAC, then unaided AAC. communicative ability
Highest gains for ASD impact on FCT, secondary
Journal of Developmental and Physical Disabilities (2022) 34:1–42 17

Table 2 (continued)

Review Intervention Outcomes Recommendations

compared to ID. FCT is age participants, component

evidence based practice for analysis, brief FAs vs FAs
ASD. and FBA, generalization
and maintenance data
needed
Holyfield et al., (2017). AAC interventions for Very large effect size for effect More intervention research for
adolescents and adults with of AAC interventions on older children and adults
ASD. targeted behaviors for with ASD, studies need to
adolescents and adults with have higher methodological
ASD. rigor, and more research
focusing on social
interaction.
Hong et al., (2017). Tablet-mediated interventions Tablet-mediated interventions Need additional research on
with individuals with ASD. for individuals with ASD tablet-mediated interven-
have overall large effects tions’ effect on academic
across all age groups for skills, life skills, community
social and communication access, household chores,
outcomes. school readiness.
Iacono et al., (2016). Review of reviews of AAC for Included reviews favored aided Researchers and review authors
children with ASD across AAC. Most evidence should provide details of
developmental domains. supports PECS and SGD in participant characteristics
interventions, manual sign including communication
only used to compare to skills of participants at start
aided systems. Most of intervention, research
research on teaching FCT AAC interventions on more
and focuses on requests. functions than requests, do
Most research on efficacy research in real world
of PECS for kids with ASD. environments, and address
needs of children with
severe and complex
disabilities.
Kagohara et al., (2013). Mobile tablets as Participants requested preferred Mobile devices (iPads, iPods,
communication devices for stimuli (food, items) by iPhones) can successfully
children with selecting icons via apps be used by individuals with
developmental disabilities. installed on mobile developmental disabilities;
touchscreen tablets. expand communication
functions beyond
requesting and naming
preferred stimuli, assess
social validity as SGDs.
Kent-Walsh et al., Communication partner Communication partner Need to support and teach
(2015). instruction interventions instruction within AAC communication partners
and effects on interventions has positive within educational, medical,
communication of effects on communication and private sector service
individuals who use AAC. skills of individuals using delivery settings, and
AAC. Most frequently integrate communication
targeted strategies are aided partner instruction in
AAC modeling, expectant preservice personnel
delay, and open-ended preparation programs.
question asking.
Kim & Kimm, (2017). Mobile device-based technolo- Mobile device-based interven- Research on effectiveness of
gy for individuals with in- tion very effective for indi- mobile devices in various
tellectual disabilities. Video viduals with intellectual settings and functions
prompting, video self-- disabilities, effect sizes did beyond instructional in the
prompting, video modeling, not significantly differ classroom is in beginning
picture prompting, system- across target skill domains. stages: researchers and
atic instruction with device, practitioners should use
speech-generating app. functional technology in
daily activities to improve
18 Journal of Developmental and Physical Disabilities (2022) 34:1–42

Table 2 (continued)

Review Intervention Outcomes Recommendations

independence and
integration.
Lancioni et al. (2007). PECS and “voice output Most participants who used Further research into individual
communication aids” PECS and speech output preference for type of AAC
interventions’ effects on devices gained and impact on use of AAC
requesting by students with communication skills and and benefits of either type
developmental disabilities. successfully learned to of AAC on speech
make requests. development.
Lancioni et al., (2001). Microswitches and speech Positive and mixed findings. Need research on strategies to
output systems with Speech output resulted in introduce microswitch to
individuals with intellectual more expressive individuals with severe
or multiple disabilities. communication, usually disabilities and ways to
with one communication integrate switch use into
modality, most often daily routines and activities.
requesting.
Logan et al., (2017). Aided AAC to increase Emerging evidence that AAC Included studies did not
social-communication skills interventions can be used to address generalization,
in children with ASD, fo- teach variety of maintenance, or social
cusing on communicative communication functions to validity of interventions.
functions other than children with ASD other Future research on
requesting. than object requests. communication functions
other than requesting is
needed and whether
intervention effects are
sustained over time.
Lorah et al., (2015). Tablets and portable media Promising evidence for mobile Need research into how AAC
players as SGDs for technology as AAC but can grow with individual,
individuals with ASD. tablets only compared so research app interface
far. Most studies used one design, user interaction,
app on mobile tablets. Most user experience, research
participants prefer tablet into creating training
over manual sign or PECS. protocols on how to learn
different functions of
communication, and how to
program and use devices.
Lynch et al., (2018). Interventions to support Aided AAC modeling can be Researchers should compare
graphic symbol learning considered an effectiveness of
and aided language evidence-based practice. instructional strategies at
development by children Also there is strong research different stages of aided
who use aided AAC. evidence to support use of language acquisition and
narrative-based interven- use consistent terminology
tions and mand-model pro- across research literature.
cedures to facilitate graphic
symbol learning and lan-
guage acquisition.
Machalicek et al., Literacy interventions for Systematic instruction was Researchers should conduct
(2010). students with physical and most effective to increase more rigorous experimental
developmental disabilities literacy skills and increase designs, component
who use aided AAC. participation in literacy analysis of packages to
activities. Outcomes mostly determine individual
positive for all studies and if instructional components
literacy skills didn’t effectiveness, and evaluate
increase, communication general education teachers’
skills did improve. delivery of literacy
instruction to students
included in general
education classrooms.
Mancil (2006). All included studies were Researchers should use natural
successful in reducing opportunities (e.g., lunch
Journal of Developmental and Physical Disabilities (2022) 34:1–42 19

Table 2 (continued)

Review Intervention Outcomes Recommendations

Functional communication challenging behavior and time, routines in classroom)

training interventions for increasing communication during interventions and
children with ASD. but communication mands train natural change agents.
limited in scope (e.g. taught
a single mand).
Millar et al., (2006). AAC interventions’ impact on Included studies: 11% Researchers should investigate
speech production of demonstrated no change in effects of aided AAC on
individuals with speech production as a speech production for
developmental disabilities. result of AAC intervention, children and adults with
89% demonstrated modest developmental disabilities,
gains in speech, 82% what factors may best
reported speech increase, predict gains in speech
11% no change, 7% production, and determine
decrease in speech. comparative effectiveness
and efficiency of
interventions to promote
speech production.
Morin et al., (2018). High tech AAC interventions. High tech AAC to teach Researchers should increase
social-communication skills methodological rigor when
can be considered an designing and
evidence-based practice al- implementing single case
though comparison studies research designs,
don’t indicate that high-tech investigate communication
is better than low-tech functions than requesting,
AAC. and conduct interventions
in natural settings.
Muharib et al. (2018). High-tech speech-generating High-tech SGD interventions Need more research on
devices as an have large effects on interventions in natural
evidence-based practice for manding, intraverbals, environments, using natural
children with ASD. multi-step tacting skills with communication partners,
children with ASD. programming for
generalization,
communication functions
other than manding.
Murray et al., (2014). AAC systems’ impact on Participants used AAC to Future research should
communicative alleviate frustration and compare treatment
effectiveness in children behavior problems due to approaches, should
with severe childhood communication failure. program for generalization
apraxia of speech. Aided AAC most effective and assess maintenance,
intervention. and compare whether AAC
interventions can promote
speech gains over
speech-based interventions.
Nam et al., (2018). Overview of reviews on Positive effects of using iPads Future research should evaluate
interventions using popular as AAC for individuals with and assess preferred type of
AAC systems with limited speech such as AAC for each child and
individuals with improved communication conduct more focused
developmental disabilities. skills. analyses to decrease
heterogeneity of
participants, designs, and
outcomes.
O’Neill et al., (2018). AAC interventions for Interventions using aided AAC Need further research on
individuals with CCN. input were highly effective long-term outcomes of
across participants and interventions, older
language skills. participants, effects on
comprehension skills, part-
ner use on communication
outcomes.
20 Journal of Developmental and Physical Disabilities (2022) 34:1–42

Table 2 (continued)

Review Intervention Outcomes Recommendations

Odom et al., (2015). Technology-aided Mobile tech as Need more research in

interventions for speech-generating device communication with
adolescents with ASD. increased communication technology for adolescents
skills for participants in with ASD and possible
school setting (n = 1). negative effects of
technology use.
Ok, (2018). Assistive technology for Use of iPads as AAC may be Need more research to replicate
students with disabilities, due to lower price effects of using iPads as
specifically iPads. compared to other assistive technology and
speech-generating devices. conduct research with
populations other than
individuals with
developmental disabilities.
Ostryn et al., (2008). PECS for individuals with Positive outcomes for Researchers should program
ASD. individuals with ASD, for generalization from the
particularly with manding beginning of intervention,
and generalizing manding. re-evaluate vocabulary and
icons because individual
needs change over time.
Østvik et al., (2017). Friendship between children Children who use AAC have Further research on indicators
who use AAC and peers. fewer friends and of social relationships,
acquaintance: Their different types of
parents’ friends are their relationships, characteristics
friends. Close family of friendships, models of
members are preferred friendship development,
communication partners. characteristics of
Conversations are limited friendships at different
by vocabulary on SGDs, ages/stages of development,
delayed communication, how children who use AAC
poor output volume, or poor establish friendships, and
voice quality. reciprocity in friendships
between children with AAC
and peers.
Pinto et al., (2009). Research on increasing Individuals with severe Researchers need to increase
communication for students disabilities can effectively programming for
with severe disabilities. communicate using generalization and
symbolic or idiosyncratic maintenance of outcomes,
communication forms. involve natural change
agents such as teachers and
parents, increase reporting
of treatment integrity, and
conduct research in natural
contexts.
Preston & Carter, PECS Preliminary evidence that Further research on component
(2009). PECS is readily learned by analysis of PECS, compare
most participants with to other AAC interventions,
positive effects on and studies should have
social-communication and higher methodological rigor
challenging behavior. Ef- to contribute to establishing
fects on speech dev unclear. evidence-based practices.
Most participants mastered
at least Phase I of PECS.
Ramdoss et al., (2011). Computer-based interventions Limited evidence to support Researchers should design
to deliver instruction on use of computer-based in- interventions to promote
speech and language terventions: few studies and generalization across
interventions to children small number of natural settings and natural
with ASD (n = 4). participants, but some im- consequences, investigate
provement in communica- prerequisite skills to use
tion. technology, and conduct
Journal of Developmental and Physical Disabilities (2022) 34:1–42 21

Table 2 (continued)

Review Intervention Outcomes Recommendations

more research with

individuals with severe
autism.
Rispoli et al., (2010). Speech-generating devices in Mostly positive outcomes Researchers should replicate
communication (86% of included studies), findings with additional
interventions for individuals 54% studies provide participants, investigate
with developmental conclusive evidence. communication functions
disabilities. Evidence base is promising. other than requesting, and
conduct group design
studies.
Roche et al., (2014). Tangible symbols as AAC Symbols mostly taught to Researchers should evaluate
option (e.g. 3D whole facilitate requesting, effects of symbol iconicity,
objects or partial objects participants learned to use realism, and concreteness
created uniquely and tangible symbols to on intervention outcomes;
individualized for the study) communicate (54% of compare advantages and
for individuals with participants). Tangible disadvantages of using
developmental disabilities. symbol use is promising standardized or
practice. individualized symbols; and
whether tangible symbols
are learned faster,
maintained better, and
preferred over other AAC.
Roche et al., (2015). Microswitches for Positive results for children for Researchers should investigate
self-enabling responding in accessing preferred stimuli, use of microswitches for
children with profound and for making choices, gaining more functions, compare
multiple disabilities. attention/social interaction. different types, replicate
Overall positive results and studies by other teams,
every participant learned to research into whether
activate microswitches. children with
profound/multiple disabil-
ities could learn to use
emerging new tech (e.g. eye
gaze control of computers).
Romski et al., (2015). AAC research in early Overall increase in number of Researchers should replicate
intervention (1985-2015). studies, positive effects of studies with children with
early AAC interventions on different
communication, language diagnoses/disabilities,
and speech outcomes. include families in
intervention development,
impact of multiple
languages and cultures,
assess long-term outcomes
of interventions, study inte-
gration of current and future
technology.
Schlosser & Wendt, AAC interventions effects on AAC does not impede speech Research hypotheses for why
(2008). speech production of production or result in a SGD may facilitate natural
children with ASD. decline in speech speech and research
production. Intervention whether there is a causal
results in modest gains. relation between AAC
interventions and speech
production.
Schlosser & Blischak, Role of speech output from Few studies with speech output Need more studies to
(2001). AAC systems and benefits as an independent variable. investigate synthetic speech
for people with ASD. Synthetic speech doesn't as receptive AAC method,
have intonation or prosody investigate digitized speech,
but might be more helpful investigate whether speech
for listeners with ASD output could support other
compared to natural speech.
22 Journal of Developmental and Physical Disabilities (2022) 34:1–42

Table 2 (continued)

Review Intervention Outcomes Recommendations

treatment methods (e.g.

spoken prompt).
Schlosser et al., (2014). Facilitated communication Messages generated through FC is not an EBP or valid
(FC) position statement. FC are authored by the method for communication.
facilitator and not the
individual with disabilities.
FC has no validity.
Outcomes support
assumption of facilitator
influence.
Sennott et al., (2016). AAC modeling in naturalistic Large changes in Researchers should expand
communication communication participant population,
interactions. performance from baseline. more contexts of
Gains in receptive and intervention, research
expressive language skills. across lifespan, include
Recommend using AAC adults who may have
modeling as foundation of acquired disabilities later in
AAC intervention. life, and research across
more communication
domains.
Shire & Jones, (2015). Communication partner Large effects and positive Researchers should clearly
interventions for partners of findings for partner skills delineate instructional
children who use AAC. and children's strategies to communication
communication that partners and report child
maintained over time. Most communication initiations
11 studies examined aided and responses.
AAC (n = 11).
Sievers et al., (2018). Child-related factors impacting Child characteristics include Need more research on
intervention effectiveness pre-intervention cognition, mediators of AAC
for AAC outcomes for severity of ASD, verbal intervention effectiveness,
children with ASD. imitation skills, vocabulary need high quality research
comprehension, object use. designs to determine
Emerging evidence for pre- causality, researchers
dictors. should make datasets more
readily available for
statistical analyses.
Smith & Iadarola, Evidence base update for ASD. PECS and SGDs have Need more research on
(2015). Communication outcomes: evidence to support positive mediators and moderators
individual focused applied effects. Applied behavior of individualized,
behavior analysis-based in- analysis-focused AAC is comprehensive
terventions with AAC. probably efficacious (needs interventions, having
more group design and lon- standardized outcome
ger follow up). Use of pic- measures would help with
ture symbols to make re- treatment comparisons,
quests was most frequently develop a standard for
reported outcome. reporting study procedures,
and develop a standardized
effect size reporting and
quality of evidence
measures.
Snell et al., (2006). AAC interventions for students Antecedent and consequence More research on natural
with severe disabilities. intervention components communication partners:
most effective to improve peers/siblings and less
AAC communication for adults, role of partner, con-
learners ages birth to 21. duct component analysis of
interventions, report treat-
ment integrity, examine ef-
fects of treatment
Journal of Developmental and Physical Disabilities (2022) 34:1–42 23

Table 2 (continued)

Review Intervention Outcomes Recommendations

intensity/dosage, and assess

students’ entry skill level.
Stauter et al., (2017). Literacy instruction: Modeling AAC in inclusive settings Research emergent literacy
AAC use, adapting increases children's development for young
materials, subvocal participation and children under 3, measure
rehearsal of words, engagement, children secondary measures
contextual learning, and demonstrated preferences (children motivation and
differentiated instruction. for adapted materials/books. participation, teacher
expectations, teacher
perceptions about
intervention feasibility),
report information about
home and social
environment, report
follow-up, clear definition
of emergent literacy
outcomes, and conduct
studies with larger sample
sizes.
Stephenson & Limbrick, Touchscreen mobile devices Very large positive effects for Researchers should investigate
(2015). with people with communication with mobile more apps, effectiveness of
developmental disabilities. touchscreen devices (e.g. dedicated device compared
iPod touch). to app, younger participants
Communication studies need to be included, and
used 3 apps: Proloquo2Go, research how people with
Pick a Word, Pixtalk and disabilities are using
focused on requesting. devices and apps outside of
Some participants learned formal intervention settings.
to activate device, navigate
across pages, make a
choice, and name pictures.
Still et al., (2014). High-tech AAC to teach SGDs most often used, most Researchers should conduct
functional requesting skills. frequent targets were more empirical research
requesting food or toys, across range of skills,
overall largely positive academic skills, requesting
results. Dedicated SGD info, conversation skills,
used more frequently than and the impact of feedback
tablet-based apps. on correct responding.
Sulzer-Azaroff et al., PECS: Whether PECS enables Improvement in Researchers should record
(2009). nonspeaking participants to communication for dates, times, settings,
initiate functional participants who used skills personnel, and materials as
communication, tested with teachers and well as correct/incorrect re-
adaptations due to mobility caregivers. Participants sponses during intervention,
needs, made icon 3D, tactile preferred using PECS. increase opportunities to
for vision impaired, PECS intervention promote generalization.
compare to other outcomes: resulted in
interventions. increased speaking and
social approaching,
decreases in disruptive or
dangerous bx.
Therrien et al., (2016). Interventions to promote peer Positive effects on interactions Researchers should conduct
interactions with children with peers, although results more studies on children
who use aided AAC. Most varied: Older participants with ASD, compare effects
frequently used: teaching had higher effect sizes than of two different
children with CCN how to younger, more gains in peer interventions, component
use AAC within social communicative interactions, analyses, training
interactions and teaching frequency of initiations, and paraprofessionals as
peers skills and strategies to frequency of facilitators of peer
promote interaction. communicative acts. interaction, and identify
variables that distinguish
24 Journal of Developmental and Physical Disabilities (2022) 34:1–42

Table 2 (continued)

Review Intervention Outcomes Recommendations

friendship from
acquaintance.
Tien, (2008). PECS as FCT for individuals PECS is effective for Further research with
with ASD. improving functional individuals with other
communication skills, diagnoses/disabilities.
increasing spontaneous
communication, and
increase in mean length of
utterances.
Tincani & Devis, (2011) PECS PECS is moderately effective Need more research to
in establishing mands up to establish efficacy of later
Phase IV. Higher levels of phases of PECS (most
manding found when PECS stopped at Phase III),
taught to individuals replicate operational
without ASD. For small definitions and settings of
subset of participants, current studies due to
PECS appears to facilitate variability in speech
speech. definitions and outcome
measured, and increase use
of natural change agents.
Van Der Meer & SGD interventions for children Overall positive outcomes: Future research should
Rispoli. (2010). with ASD. 87% positive outcomes, investigate teaching skills
13% mixed outcomes, no other than requesting, child
negative outcomes reported. preference for different
Most studies investigated AAC systems, and
requesting, used behavioral determining differential
strategies, and were effects of discrete trial
conducted in school training compared to
settings. naturalistic interventions.
Van der Meer et al., Preferences for AAC options in 67% of participants had some Research participant preference
(2011). communication degree of preference for for different AAC options
interventions by individuals using SGD compared to and whether preferences
with developmental 33% participants’ generalize across situations
disabilities. preference for picture and communicative
exchange. partners.
Walker & Snell, (2013). Effectiveness of AAC AAC intervention has positive Need additional research on
interventions on moderate effects on teaching typical
challenging behavior of decreasing CB for interventionists to conduct
individuals with disabilities. individuals with varying functional behavior
disabilities. assessments and increase
social validity data and
reporting.
Walker et al., (2018). Functional communication AAC interventions using FCT Researchers should make sure
training (FCT) implemented were effective in reducing behavior change maintains
in schools with children challenging behavior and over time and specific
who use AAC. promoting aided or unaided instructional procedures to
AAC use. provide guidelines for
practitioners.

intellectual and developmental disabilities who have complex communication needs. Data
from this overview of research literature indicate that review methodological quality is
improving slightly over time. Most of the research used single-case research designs, utilized
behavioral interventions, was conducted with participants using a speech-generating device,
was conducted with children diagnosed with autism spectrum disorder ages 5–18 in general
education settings, and is most frequently synthesized in systematic reviews of literature.
Journal of Developmental and Physical Disabilities (2022) 34:1–42 25

AMSTAR 2 Percentages by Publication Year

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%
2001 2003 2005 2 007 2009 2011 2013 2015 2017

Fig. 2 AMSTAR 2 scores in chronological order by publication year. Each review’s AMSTAR 2% achieved
is indicated by sections within each publication year bar

Thematic Issues Raised by Reviews as Areas of Need in Aided AAC Research

Assessing and reporting pre-intervention communication skills, particularly vocal

communication skills (Walker et al., 2018), intervening on younger children rather
than waiting for natural speech before beginning AAC interventions (Alper &

Table 3 Percent of Reviews Scoring Yes or Partial Yes for Each AMSTAR 2 Indicator

Item Indicator Percent of reviews

1 Research question and inclusion criteria a priori 85

2 Explicit statement of methods protocol 90
3 Explain selection of studies for inclusion 93
4 Comprehensive literature search 92
5 Study selection in duplicate 50
6 Data extraction in duplicate 63
7 List of excluded studies and why excluded 5
8 Adequate detail of included studies 89
9 Assess study risk of bias 15
10 Report study sources of funding 1
11 Meta analysis: appropriate statistics 33
12 Meta analysis: assess risk of bias of results 27
13 Risk of bias individual studies interpretation 26
14 Explain heterogeneity in results 25
15 Quantitative investigation of publication bias 1
16 Report review conflict of interests and funding 44

Note. Percent of reviews calculated by the total number of reviews with “Yes” or “Partial Yes” for that item
divided by 84 total reviews.
26 Journal of Developmental and Physical Disabilities (2022) 34:1–42

Table 4 AMSTAR 2 Scores by Each Included Review

Review AMSTAR 2 Items Percent

achieved
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Allen et al., (2017). Y Y Y Y N Y N N N N Y N N Y N Y 50%

Alper & Raharinirina, Y N N N N Y N Y N N n/a n/a N N N N 21%
(2006).
Alsayedhassan et al. (2016). Y Y Y Y Y N N Y N N n/a n/a N N n/a N 46%
Alwell & Cobb, (2009). Y Y Y Y N Y N Y N N Y N N N N N 44%
Alzrayer et al., (2014). Y Y Y Y Y N N Y N N Y Y N N n/a N 47%
Andzik et al., (2016). Y Y Y Y N Y N Y N N n/a n/a Y N N Y 64%
Anttila et al., (2012). Y Y Y Y N Y N Y N N n/a n/a N N N Y 50%
de Barbosa et al., (2018). Y Y Y Y Y Y N Y n/a Y n/a n/a n/a n/a n/a Y 82%
Barker et al., (2012). Y Y Y Y N N N Y N N n/a n/a N N N Y 50%
Barton et al., (2017). Y Y Y Y Y Y N Y Y N Y Y Y Y N Y 88%
Battaglia & McDonald, Y Y Y Y N N N N N N n/a n/a N N N N 29%
(2015).
Biggs et al., (2018). Y Y Y Y Y Y N Y Y N n/a n/a N Y n/a Y 77%
Boyle et al., (2017). N N N N N N N N N N n/a n/a N N N Y 14%
Branson & Demchak, N Y Y Y Y Y N Y N N Y n/a n/a N N N 50%
(2009).
Brunner & Seung, (2009). N Y Y Y N N N Y N N n/a n/a N N N Y 43%
Brunner et al., (2017). Y Y Y N N N N N N N n/a n/a N N N N 21%
Bryant et al., (2010). Y Y N Y N N Y Y N N n/a n/a N N N N 36%
Campbell et al., (2006). Y Y Y Y N Y Y n/a N N n/a n/a N N n/a N 50%
Chapin et al., (2018). Y Y Y Y Y Y N Y N N n/a n/a N Y n/a Y 69%
Chung et al., (2012). Y Y Y Y Y Y N Y N N n/a n/a N N N Y 90%
Cumming et al., (2017). Y Y Y Y N Y N Y N N Y N Y N N Y 63%
Desideri et al., (2013). N Y Y Y N Y N Y N N n/a n/a N N n/a N 38%
Douglas, (2012). Y Y Y Y N N N Y N N n/a n/a N N n/a N 38%
Dunst et al., (2013). Y Y Y Y N N N Y N N Y Y Y N N Y 63%
Erdem, (2017). Y Y Y Y N N N N N N n/a n/a N N n/a N 31%
Flippin et al., (2010). Y Y Y Y Y N N Y N N Y Y N N N N 50%
Ganz et al., (2012a). PECS Y Y Y Y Y Y N Y N N Y Y N N n/a N 60%
Ganz et al., (2012b). Aided Y Y Y Y Y Y N Y N N Y Y N N N N 56%
AAC
Ganz et al., (2014a). Partic- Y Y Y Y Y Y N Y Y N Y Y N Y N N 73%
ipant characteristics.
Ganz et al., (2017). Y Y Y Y Y Y N Y N N Y Y N N N N 56%
Ganz et al., (2014b). Y Y Y Y Y Y N Y Y N Y Y Y N N Y 81%
Ssetting and types.
Gevarter et al., (2013). Y Y Y Y Y Y N Y N N Y Y N N N Y 63%
Gilson et al., (2017). Y Y Y Y N Y N Y N N n/a n/a N N n/a N 46%
Hart & Banda, (2010). Y Y Y Y Y Y N Y N N n/a n/a N N n/a Y 69%
Heath et al. (2015). Y Y Y Y Y Y N Y N N Y Y Y N N Y 75%
Holyfield et al., (2017). Y Y Y Y Y Y N Y N N Y Y N N n/a N 60%
Y Y Y Y Y Y N Y N N Y N N N N N 56%
Journal of Developmental and Physical Disabilities (2022) 34:1–42 27

Table 4 (continued)

Review AMSTAR 2 Items Percent

achieved
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Hong et al., (2017).

Iacono et al., (2016). Y Y Y Y Y Y N Y N N Y Y N N N Y 69%
Kent-Walsh et al., (2015). Y Y Y Y Y N N Y N N n/a n/a N N n/a Y 62%
Kim & Kimm, (2017). Y Y Y Y N Y N Y N N Y Y Y Y N Y 69%
Lancioni et al. (2007). N Y Y Y N Y N Y N N Y Y Y Y N N 56%
Lancioni et al., (2001). Y Y Y Y N N N Y N N n/a n/a N N n/a N 38%
Logan et al., (2017). N N N N N N N Y N n/a n/a n/a n/a n/a N 10%
Lorah et al., (2015). Y Y Y Y Y Y N Y N N N n/a n/a Y N Y 71%
Lynch et al., (2018). Y Y Y Y Y Y N Y Y N n/a n/a N Y n/a N 69%
Machalicek et al., (2010). Y Y Y Y Y Y N Y N N n/a n/a Y Y n/a N 77%
Mancil (2006). Y Y Y Y Y Y N Y N N n/a n/a N Y n/a N 62%
Millar et al., (2006). Y Y Y Y N N N Y N N n/a n/a N N n/a N 38%
Morin et al., (2018). N Y Y Y Y Y N Y N N n/a n/a N N n/a N 46%
Muharib et al. (2018). Y Y Y Y N Y N Y Y N n/a n/a Y N n/a Y 77%
Murray et al., (2014). Y Y Y Y Y Y N Y N N Y Y N N n/a Y 67%
Nam et al., (2018). Y Y Y Y Y Y N Y Y N n/a n/a Y N n/a N 77%
O’Neill et al., (2018). Y Y Y Y Y Y N Y N N Y Y N Y N Y 67%
Odom et al., (2015). Y Y Y Y N N N Y N N n/a n/a N N n/a N 38%
Ok, (2018). N Y Y Y N N N N N N na n/a N N n/a N 31%
Ostryn et al., (2008). Y Y Y Y N N N Y N N n/a n/a N N n/a N 38%
Østvik et al., (2017). N N Y Y N N N Y N N n/a n/a N N N N 21%
Pinto et al., (2009). Y Y Y Y N Y N Y N N n/a n/a N N n/a Y 54%
Preston & Carter, (2009). N N N N N N N Y N N n/a n/a N N n/a N 8%
Ramdoss et al., (2011). Y Y Y Y N Y N Y N N Y Y N Y n/a N 60%
Rispoli et al., (2010). Y Y Y Y N Y N Y N N n/a n/a N N n/a N 46%
Roche et al., (2014). Y Y Y Y Y Y N Y N N n/a n/a n/a n/a n/a Y 80%
Roche et al., (2015). Y Y Y Y Y Y N Y N N n/a n/a Y Y Y Y 86%
Romski et al., (2015). Y Y Y Y Y Y N Y N N n/a n/a Y Y n/a Y 85%
Schlosser & Wendt, (2008). Y Y Y Y Y N N Y N N n/a n/a N N n/a Y 54%
Schlosser & Y Y Y Y Y Y Y Y N N Y Y N Y N N 69%
Blischak, (2001).
Schlosser et al., (2014). Y Y Y Y N N N Y N N n/a n/a N N n/a N 38%
Sennott et al., (2016). Y Y Y Y N N Y Y N N n/a n/a Y N n/a Y 69%
Shire & Jones, (2015). Y Y Y Y N Y N Y Y N n/a n/a Y Y n/a Y 85%
Sievers et al., (2018). N N Y Y N N N Y Y N n/a n/a Y N n/a Y 46%
Smith & Iadarola, (2015). Y Y Y Y Y Y N Y Y N Y Y Y Y N Y 88%
Snell et al., (2006). N Y Y Y N N N Y N N n/a n/a n/a N n/a N 33%
Stauter et al., (2017). Y Y Y Y Y Y N Y N N n/a n/a N N N N 50%
Stephenson & Y Y Y Y N Y N Y Y N n/a n/a Y N N N 57%
Limbrick, (2015).
Still et al., (2014). Y Y Y Y Y Y N Y Y N Y Y N Y N N 69%
28 Journal of Developmental and Physical Disabilities (2022) 34:1–42

Table 4 (continued)

Review AMSTAR 2 Items Percent

achieved
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Sulzer-Azaroff Y N Y Y N N N Y N N n/a n/a N N n/a Y 38%

et al., (2009).
Therrien et al., (2016). Y Y Y Y Y Y N Y N N n/a n/a N Y N N 57%
Tien, (2008). Y N Y Y N Y N Y Y N Y Y Y Y N Y 75%
Tincani & Devis, (2011) Y Y Y Y N N N Y N N n/a n/a n/a n/a n/a N 56%
Van Der Meer & Y Y Y Y Y Y N Y N N Y Y N Y N Y 75%
Rispoli. (2010).
Van der Meer et al., (2011). Y Y Y Y Y N N Y N N n/a n/a N N n/a Y 54%
Walker & Snell, (2013). Y Y Y Y Y Y N Y Y N n/a n/a Y N N Y 71%
Walker, V. L. et al. (2018). Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y 94%

Raharinirina, 2006), and training natural communication partners were most frequently
mentioned as areas of future research by review authors. Researching the impact of
different user interfaces was recommended in two reviews (Lorah et al., 2015; van der
Meer et al., 2011), and investigating symbol arrays on communication outcomes was
recommended in three reviews (Lynch et al., 2018; Morin et al., 2018; Roche et al.,
2014). Rapid developments and changes in technology, user interfaces, symbol lan-
guages, and specifically advances in multi-use mobile technology were mentioned as
reasons to research AAC devices other than dedicated SGDs. These review authors also
recommended investigating user experiences when interacting with technology and
exploring different designs and interfaces with various users to better meet their needs
(Lorah et al., 2015).
Another area of further research recommended by review authors was investigating
the effects of different types of speech output (Drager et al., 2010; Schlosser &
Blischak, 2001). Comparisons of intelligibility of digitized and synthesized speech
led to further questions about whether environmental noise impacts intelligibility of
AAC voices, and recommendations that researchers examine the intelligibility and
comprehension of AAC device voices by the user’s same age peers (Drager et al.,
2010).
Researching comparative effectiveness of types of AAC, (e.g., aided and unaided
AAC), was an area of future research recommended by authors of seven reviews
(Branson & Demchak, 2009; Brunner & Seung, 2009; Cumming & Draper Rodriguez,
2017; Logan et al., 2017; Lorah et al., 2015; Preston & Carter, 2009; Therrien
et al., 2016). While some reviews addressed comparing effectiveness of differ-
ent types of AAC (e.g., Ganz et al., 2012b; Ganz et al., 2017; Holyfield et al.,
2017; van der Meer et al., 2011), further research is warranted so that clinicians
and educators have an evidence based rationale for selecting specific types of
AAC for an individual’s needs and preferences. Recommendations included that
researchers perform comparison studies of different AAC modalities (Brunner &
Seung, 2009), mobile technology to more traditional AAC (Cumming & Draper
Rodriguez, 2017), and different AAC programs and apps (Lorah et al., 2015).
Journal of Developmental and Physical Disabilities (2022) 34:1–42 29

Multiple reviews recommended further investigation into interventions aimed

at training natural communication partners such as parents and teachers to
communicate using AAC with individuals who have complex communication
needs (Kent-Walsh et al., 2015; Logan et al., 2017; Mancil, 2006; Morin et al.,
2018; Shire & Jones, 2015; Snell et al., 2006; Stauter et al., 2017; Tincani &
Devis, 2011; Walker & Snell, 2013). Training communication partners other
than the researcher on interventions and using them as natural change agents
could lead to more socially valid intervention outcomes, more successful gen-
eralization, higher maintenance of communicative behaviors, and integrate AAC
interventions into natural contexts.
Research on effective dosage, or amount of treatment, of AAC interventions
was explicitly mentioned by one review (Sennott et al., 2016) with specific
recommendations to examine variables relating to service delivery by speech-
language pathologists in school settings. Sennott et al. (2016) recommended
that researchers examine the impact of language interventions across the
lifespan and how contextual and personal changes affect AAC intervention
needs, dosage, and communication skills such as vocabulary.
Further research on the effects of AAC interventions on academic skills was
recommended by 4 reviews (Ganz et al., 2014a; Ganz et al., 2017; Hong et al., 2017;
Still et al., 2014). Other reviews recommended further research on the impact of
technology aided instruction on literacy outcomes (Barker et al., 2012; Boyle et al.,
2017; Machalicek et al., 2010; Stauter et al., 2017).
Investigating the impact of AAC intervention on independence and social interac-
tions such as friendships was recommended in 6 reviews (Bryant et al., 2010; Chung
et al., 2012; Cumming & Draper Rodríguez, 2017; Holyfield et al., 2017; Østvik et al.,
2017; Therrien et al., 2016). While social interactions were identified as areas for future
research, the reviews included specific calls to action to explore the impact of AAC
interventions on peer interactions and supportive relationships for students with dis-
abilities in middle and high school settings (Chung et al., 2012). Areas of future
research specific to social relationships were developing indicators of social relation-
ships and operationalizing definitions of friendship (Østvik et al., 2017; Therrien et al.,
2016).
Integrating and increasing collaboration among parents, researchers, teachers, and
service providers throughout the research process was recommended by 5 reviews
(Alper & Raharinirina, 2006; Alquraini & Gut, 2012; Andzik et al., 2016; Logan et al.,
2017; Pinto et al., 2009). These authors called for increasing input from stakeholders
throughout all parts of the research process, which is a recommendation of participatory
research practices (Bailey et al., 2015). Increasing collaboration and participation by
stakeholders could also increase social validity and generalizability of empirical inter-
ventions to more natural settings (Alper & Raharinirina, 2006). Desideri and colleagues
(2013) recommended transitioning research away from the decontextualized experi-
ences of researchers to incorporate effective models for low incidence disabilities,
specifically children with multiple disabilities, and increasing collaboration with indi-
viduals with disabilities, hearing their experiences, and designing research with partic-
ipants to best meet their areas of need. They also recommend evaluating the cost
effectiveness of assistive technology interventions to address the financial burden on
the family.
30 Journal of Developmental and Physical Disabilities (2022) 34:1–42

Participant Demographics

Reviews reporting on included studies’ reporting of race and ethnicity data for partic-
ipants were very few (n = 4). Reporting this information is crucial not only to answer
the question of for whom does this intervention work, but also to assist researchers
working to identify mediators and moderators of intervention effectiveness. This
paucity of race/ethnicity reporting possibly reflects the need for greater participant
diversity in special education research (Sinclair et al., 2018). Non-binary gender
identifications were not reported in any of the reviews, further contributing to the
oppression and erasure of the identities of individuals with multiple sites for margin-
alization (Duke, 2011), or intersectionality (Crenshaw et al., 1996). Research partici-
pant demographics do not proportionately represent national demographics or reflect
school classroom populations, limiting generalizability and recommendations for di-
verse populations of students (Spear et al., 2013). Examining whether family poverty,
urban or rural environments, race and ethnicity, and specific factors related to disability
categories impact the effectiveness of interventions and best practices will be crucial as
educational policy and practices shift (Singer et al., 2017).
Researchers can create richer, more relevant, and more robust AAC interventions to
increase the field’s knowledge of different experiences with living with AAC and
increase points of entry and topics for intervention to increase communicative compe-
tencies and quality of life for individuals with complex communication needs (Chan &
Zoellick, 2011). Research on the experiences and outcomes of AAC interventions with
linguistically diverse individuals with disabilities who use aided AAC is a growing area
within the literature (Kulkarni & Parmar, 2017). Determining language preference for
instruction and language output of aided AAC (Aguilar et al., 2016; Kunze et al., 2019)
and incorporating cultural views of AAC users, their families, and stakeholders are
areas requiring exploration (Kulkarni & Parmar, 2017) in the field of AAC
interventions.
The predominance of single-case research designs in the field of special education
affords AAC researchers the ability to report more specific and individualized infor-
mation about participants to aid in direct and systematic replication of effective
interventions and increase the known pool of students for whom specific interventions
work (Horner et al., 2005). The cornerstone of the Individuals with Disabilities
Educational Improvement Act (2004) and the individualized education program em-
phasize the “individual” as the driving force behind development of interventions for a
student with disabilities. Understanding research as a practice in partnership with
participants and understanding that researchers bring their own theoretical frameworks,
implicit biases, and personal understandings of constructs including dis/ability, race,
gender, sexual orientation, and appropriate behavioral outcomes (Arzubiaga et al.,
2008), will help move research on AAC interventions forward.

Social Validity

One crucial area that the AMSTAR-2 does not address is the social validity of either the
studies included in the reviews and the reviews themselves. One way to improve social
and ecological validity is by increasing the participation of research subjects, their
families, educators, and other community stakeholders in the development of research
Journal of Developmental and Physical Disabilities (2022) 34:1–42 31

questions, selection of conceptual frameworks, types of interventions used, which

outcomes are measured, and what data is reported and through which channels. While
individual studies in the included reviews may have assessed and reported social
validity, many included reviews did not report on or discuss social validity
measures or findings. Without data on the acceptability of treatments and
interventions, researchers and practitioners may be reluctant to select interven-
tions that are not be acceptable to stakeholders, potentially leading to lack of
contextual fit, lower rates of intervention treatment fidelity, and lower rates of
treatment adherence (Spear et al., 2013).
For children who use AAC to communicate, assessing consumer satisfaction should
involve the AAC user to the greatest extent possible. A familiar adult and same age
peer could ask the AAC user for their input, providing the researcher with a richer
analysis of the user’s experience told to different and ecologically valid communication
partners. Directly asking the user about their experiences before, during, and after
intervention, especially involving the user from the beginning stages of research
development would increase targeting user-important skills and increase intervention
relevance to the user, possibly increasing buy-in and motivation to adhere to and
complete the intervention (Leko, 2014).

Generalization and Maintenance

Generalization and maintenance were identified by many review authors as

areas of need, both for study authors to program from inception and for
increased reporting out in manuscripts. Other researchers have analyzed and
offered suggestions for increasing programming for generalization and
collecting data on maintenance of skills at longer intervals after intervention
ends (Schlosser & Lee, 2000) yet underutilization or underreporting of both
persist. In AAC research, bringing functional communication skills under stim-
ulus control may require additional programming during intervention or follow
up interventions after the user has learned the communication skill to then teach
discrimination of under which conditions to exhibit that target behavior. Spe-
cifically, researchers could program for intervention in the natural environment
of the AAC user (Schlosser & Lee, 2000). Conducting an intervention session
in the school cafeteria, in the classroom with the general education teacher as
the interventionist, or on a field trip could decrease stimulus control of a
specific learning setting and increase behavioral momentum of the target skill
(Mace & Nevin, 2017). If changing intervention settings is not feasible, incor-
porating more communication partners such as the AAC user’s schoolmates and
teachers could increase generalization and increase the social validity of using
an AAC system across multiple communication partners.
Training the most frequent communication partners of individuals who use AAC
would enhance both generalization and maintenance of the newly acquired skills.
Generalization in the absence of reinforcement places the target behavior on extinction,
resulting in sharp decreases in responding and potential increases in problem behavior
(Mace & Nevin, 2017). Training communication partners on strategies such as sitting
close enough to the AAC user to see the communication system and signal their
availability as an audience, assessing and using the communication partner’s skills as
32 Journal of Developmental and Physical Disabilities (2022) 34:1–42

a jumping off point for coaching and intervention on responsiveness, and training the
communication partner to recognize and respond to the user’s communicative initia-
tions could increase the frequency of the AAC user’s communication behaviors and
opportunities to contact natural reinforcement (Calculator, 1988).

Communication Breakdown

Another aspect of programming for generalization and accounting for maintenance of

acquired skills over time would involve teaching the AAC user what to do in the event
of communication breakdown (Calculator, 1988). Speech-generating devices can be
unreliable (Baxter et al., 2012) and can run out of battery or be unavailable due to being
sent out for repair or updates (Cooper et al., 2009). AAC interventions incorporating
backup strategies for the user to employ if the high-tech communication device breaks
or is unavailable, or if the communication partner does not understand the communi-
cative act by the user (Calculator, 1988) would increase communicative opportunities
for the person who uses AAC. Teaching the AAC user to use picture symbols, gestures,
or other means of aiding the communication partner in understanding the message
(Halle et al., 2004) would increase generalization of the specific target behaviors across
novel contexts and communication partners. This in turn could increase maintenance of
the target skills over time since the user has multiple means of conveying their message
to others, thus reinforcing the behavior with natural consequences outside of the clinical
setting and with novel communication partners. Future research on increasing response
variability and use of alternate methods of communication are warranted.

Maintenance

When planning maintenance probes in coordination with school calendars, planning for
maintenance data collection further out than 1 to 2 weeks after an intervention ends
would help researchers and clinicians make decisions about effective interventions for
lasting behavior change. Just as teachers use maintenance data over fall and winter
breaks to assess whether students require extended school year services to maintain
skills gained during the school year, researchers could probe maintenance after students
return from holiday breaks.
With increased use, ease of access, and prevalence of technological communication
systems, researchers can check in with AAC users and stakeholders without much time
and cost investment. Researchers can check in via email, video teleconferencing
software, text message, or direct message through social media with links to online
surveys or conduct a telehealth-type consultation for data collection. Surveys or
interviews could also be used to inform future intervention development as well as
assist researchers with decision rules to re-teach the target skill or modify the original
intervention for re-teaching.
The use of videoconferencing software such as Zoom for Healthcare is an emerging
area within the evidence base made all the more important by recent school and clinic
closures due to the global pandemic. Telehealth intervention delivery can address
chronic shortages of trained and skilled professionals, provide services to families
living in remote areas or who cannot travel, and increase access to evidence based
practices by both families and practitioners. Clinicians and researchers can use
Journal of Developmental and Physical Disabilities (2022) 34:1–42 33

telehealth technology to provide direct services to individuals with complex commu-

nication needs, train parents/caregivers, and train practitioners to deliver evidence-
based practices. With the increasing reliance on telehealth technology due to the
COVID-19 global pandemic, rigorously designed research studies exploring distance
technology for direct service provision and communication partner intervention deliv-
ery is both warranted and sorely needed. Research into reducing disparities in access
and technology exacerbated by telehealth is also needed: reaching rural, remote, and
underresourced individuals with CCN remains an area of need for further research and
professional development for practitioners.

Vocabulary

AAC vocabulary is often selected by adults, particularly parents and professionals

(Trembath et al., 2007), who carefully curate frequently used or socially appropriate
vocabulary for the AAC user, potentially without considering what the user’s peers are
actually saying to each other. Observing the AAC user’s same age peers and collecting
language samples in a variety of contexts and with a variety of conversation partners
(teachers, parents, friends) would yield more ecologically valid communication targets
and vocabulary (Schwartz & Baer, 1991). Incorporating socially valid but not neces-
sarily school appropriate vocabulary (Ashby et al., 2016) such as potty-themed jokes
for a kindergartner, masturbation terms for a high schooler, or alcoholic beverages for
an adult is often ignored by parents and professionals who may find discussion of these
topics difficult and uncomfortable. These are topics the user may want to access to
increase social interactions and participation with peers (Bryen, 2009; Smith, 2015).

Limitations and Future Directions

This mega-review has several limitations, primarily that reviews of reviews have the
inherent weakness of relying on information provided about individual studies within the
review. Authors of prior reviews may have poorly defined their inclusion and exclusion
criteria, failed to correctly extract data from the articles, or may have inadequately
analyzed and reported on the findings across the reviewed studies. Reviews were not
excluded from analysis based on quality and summarized findings include poorly and
well-designed studies. Well-designed and highly rigorous literature reviews should be
positioned as potentially more inclusive of the literature and their evidence claims more
heavily weighted. Researchers and practitioners benefit from having an assessment of the
quality of the methods of reviews before making research-based decisions.
Additionally, this mega-review excluded grey literature, dissertations, articles writ-
ten in a language other than English, and articles in journals and databases not
accessible through those searched by the author. Articles identified during electronic
database searches that were not located in full manuscript format through the university
library systems, interlibrary loan, or Google Scholar® searches were also excluded. A
further limitation of electronic searches was the use of free term keywords rather than
each database’s recognized thesaurus search terms. This may have resulted in omission
of reviews that met inclusion criteria due to differences in indexing keywords, although
unlikely given the large number of documents acquired in the original electronic search
and the final number of reviews that were found and included. Exact overlap in
34 Journal of Developmental and Physical Disabilities (2022) 34:1–42

reviewed articles across included literature reviews was not assessed, therefore results
could have been inflated by potential double counting of article variables or author-
reported themes regarding effectiveness. A further limitation is the possibility that
literature reviews and meta-analyses pertaining to aided AAC intervention with chil-
dren with developmental disabilities were overlooked and not included in this review;
however, the use of hand searches and ancestral searches minimized this risk.
Due to the preponderance of single-case research design studies completed in this
area and few randomized control trial or group design studies analyzed in this mega-
review, we were limited in our ability to compare interventions, AAC devices and
programs, and dependent variables such as participant age, race, gender, disability,
setting of intervention, interventionist, and dosage of intervention. Effect sizes reported
by meta-analyses and systematic reviews were not comparable due to measuring
different dependent variables, using different measurement systems, and reporting
non-standardized effect sizes. We could not compare different designs or report
intervention effects across reviews. Researchers conducting meta-analyses could use
multilevel modeling and report design-comparable standardized effect sizes to facilitate
comparisons across single case studies and group designs. Due to the inability to
combine and compare effect sizes across designs and reviews, this mega-review only
reported the conclusions made by review authors.
Finally, the inability to evaluate the articles for publication bias might be considered
a limitation. Selection of studies for publication is possibly skewed toward studies with
positive results, particularly large effect sizes, resulting in omission of nonsignificant
results and studies with poor outcomes from inclusion in meta-analyses (Hedges, 1984;
Shadish et al., 2014). While single case designs are increasingly reporting statistical
effect sizes, decisions on whether to publish studies demonstrating strong functional
relations and not publishing weak or no effects could result in publication bias (Shadish
et al., 2014). Tests for publication bias assess whether studies with low precision have
different effects than studies with high: this does not actually assess publication bias.
Statistical tools cannot be used to evaluate publication bias for the reviews included in
the present mega-review because the included reviews focused on different types of
interventions and had different dependent variables that were impossible to aggregate
using current statistical measures and raw data were not provided in the reviews, which
precluded generating standardized data to calculate effect sizes.

Future Directions

There are many areas in which researchers can add to the knowledge base on aided AAC
interventions for individuals with developmental disabilities, including comparing inter-
ventions, programming for generalization throughout intervention phases, assessing
maintenance at longer intervals, using natural change agents and settings, and reporting
between case effect sizes. Another future direction for the field is to compose an evidence
and gap map to synthesize systematic reviews and primary intervention studies to
summarize the entire field of AAC research (Saran & White, 2018).
Establishing evidence-based practices is another future direction for the field.
Synthesizing well-designed and methodologically rigorous studies, applying criteria
for evidence-based practices, and disseminating this information across researchers,
clinicians, practitioners, and consumers is are areas of need. Many AAC interventions
Journal of Developmental and Physical Disabilities (2022) 34:1–42 35

are emerging or promising practices, but further efforts to establish evidence-based

practices will improve quality of life outcomes for consumer and clinician decision-
making and increase communication access for individuals with complex communica-
tion needs. AAC as an intervention practice was recently established as an evidence
based practice by the National Clearinghouse on Autism Evidence and Practice Review
Team (Steinbrunner et al., 2020), but further investigation into specific AAC interven-
tions for individuals with autism spectrum disorder and AAC as an evidence-based
practice for individuals with other categories of human difference is warranted.

Conclusion

This mega-review highlights steps toward improving the quality of procedures and
information provided by systematic literature reviews and meta-analyses and suggests
several areas of future research for interventions for children with developmental
disabilities and complex communication needs who use aided augmentative and
alternative communication. Increasing generalization and maintenance programming
before intervention begins, reporting out greater detail on participant demographics and
skills, and ensuring that lasting, socially important behavior change takes place will
improve quality of life for individuals who use AAC.

Funding This research was partially supported by a United States Department of Special Education Office
for Special Education Programs Leadership Grant #H325D150082, co-primary investigators Laura Lee
McIntyre, Kent McIntosh, and Wendy Machalicek.

Declarations

Conflict of Interest The authors have no conflicts of interest to report.

Ethical Approval This research was exempt from ethical approval by the Institutional Review Board at the
University of Oregon. No human participants were involved in this research synthesis. Non-published data
from this mega-review are available upon request, including original coding sheet and list of excluded reviews.

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