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Running Head: AAC AND SI FOR CHILDREN WITH AUTISM IN SCHOOLS

The Effects of Combining Augmentative and Alternative Communication with Sensory Integration on
Non-verbal Children with Autism Spectrum Disorder in School

Alicia Bollin

Kelsey Brooks

Emily Hannah

Benjamin Robison

Mckenzie St. Clair

University of Utah
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AAC AND SI FOR CHILDREN WITH AUTISM IN SCHOOLS

Introduction
Autism Spectrum Disorder (ASD) affects roughly 1 in every 59 children (Center for Disease
Control and Prevention [CDC], n.d.), and out of those children, about 85% have sensory
integration difficulties (Cheung & Siu, 2009), and 30% are nonverbal (CDC, n.d.). The inability
to properly regulate sensory information can decrease the child’s ability to participate socially,
emotionally, and academically. This can be further increased if the child is non-verbal. They are
at risk for social isolation and a lack of developmental opportunities (Barker, Akaba, Brady, &
Thiemann-Bourque, 2013).
Interventions such as Sensory Integration (SI) have been used to promote participation for
children, despite their sensory processing difficulties. These techniques focus on implementing
activities that challenge a child’s weak areas of sensory processing with the intention of
organizing and integrating various sensations to allow for functional participation.
Augmentative and Alternative Communication (AAC) is a term that is used to describe assistive
devices that allow those with communication difficulties to communicate more effectively by
pointing to pictures or pushing buttons to speak for them on the device (Trotier, Kemp, and
Mirenda, 2011). It is important to note that AAC intervention could also be effective in
supporting and promoting already established interventions, potentially making them more
potent.
Children with ASD face challenges due to difficulties with sensory processing and
communication, yet empirical research to support interventions that increase occupational
participation is lacking. While AAC has been found effective in improving communication in
children with ASD, and SI is shown to improve functional participation, there is no research to
determine if combining the two interventions can produce further positive results.We will
address this gap by implementing a within and between subjects experimental pilot study
comparing two groups (AAC+SI vs AAC only) with the following aims:
Aim 1: To determine the efficacy of AAC when coupled with SI in increasing the frequency
of communicative acts of children diagnosed with ASD within a school setting.
Hypothesis: AAC in combination with SI will be more effective than AAC alone in increasing
communicative acts in children with ASD in a school-based setting.
Aim 2: To determine the quality of communication through teacher perception of
participation in social, emotional, and academic domains.
Hypothesis: AAC in combination with SI will be more effective than AAC alone in improving
outcomes related to participation in social, emotional, and academic domains.
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Background
Prevalence and Effects of Autism Spectrum Disorder
Autism Spectrum Disorder (ASD) is a developmental disability that can affect the way a

child communicates and interacts with those around them. Studies show that nearly 1 in 59

children have been diagnosed with autism (CDC, n.d.). In addition, 30% of those children are

nonverbal, meaning they are unable to carry on a significant and meaningful conversation. These

children have a small collection of words that they employ, along with broken utterances that are

non-communicative (An, Feng, Bo, & Wang, 2017). In the United States, children who have

communication disorders are educated in separate classrooms and even separate schools about

90% of the time (Erikson & Geist, 2016). This approach can isolate individuals with

communication disorders and deprive them from the benefits of interacting with typically-

developing peers. This is to their developmental disadvantage as research shows that peer-

mediated communication between these groups improves the development of social-

communication skills (Barker et al., 2013). Along with communication disorders, 85% of those

with an ASD diagnosis have sensory processing difficulties, which decreases their ability to

regulate sensory information (Cheung & Siu, 2009). This can lead to difficulties completing

everyday activities due to the inability to organize and use sensory information appropriately

(Bodison & Parham, 2018) resulting in frustration, avoidance of specific stimuli, and decreased

social and academic participation (Reynolds, Bendixen, Lawrence & Lane, 2011).

Sensory Integration and Children with Autism

Sensory integration techniques focus on implementing activities that challenge a child’s

weak areas of sensory processing with the intention of organizing and integrating various

sensations to allow for functional participation (Bodison & Parham, 2018). This can include
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activities such as moving through an obstacle course, swinging, messy play, etc. in order to

provide opportunities for sensory input. Some therapists use specific Ayres Sensory Integration

(ASI) protocols focusing on individualized sensory experiences in order to change the way

individuals process sensory information at a neurological level. Others may use similar

techniques, but not the exact protocol, or strategies such as environmental modifications. These

techniques include immersing participants in playful activities that provide them with sensory

opportunities and comparing them to either routine OT, fine motor, or gross motor participant

groups. Examples of modifying the child’s environment to better meet their sensory needs might

include dimming lights or reducing auditory input through the use of noise cancelling

headphones (Bodison & Parham, 2018).

As demonstrated by systematic reviews, ASI as well as sensory-based techniques can

have positive outcomes in terms of increasing participation in children with ASD. This is

especially true when techniques focus on areas that improve performance in areas such as play,

sleep, ADLs, and social participation (Bodison & Parham, 2018; Schaaf, Dumont, Arbesman &

May-Benson, 2017).

Similarly, two separate studies examined the effects of SI programs on children between

the ages of 3-8 years old with a primary diagnosis of ASD. The results of both studies exhibited

an overall improvement in occupational performance and participation, especially in regard to

home and school participation. (Kashefimehr, Kayihan, & Huri, 2017; Hunt & Benevides, 2012).

Other studies focused more on sensory processing and peer interactions within a school

setting. One of the studies found that sensory-based interventions in combination with other

strategies such as daily yoga, self-regulation techniques, social stories, and social skill group
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activities led to increased peer interactions (Clark, Watling, Parham & Schaaf, 2019). Similarly,

Tomcheck, Little and Dunn (2015) explored how sensory processing responses impact children’s

behaviors and developmental skills, with a focus on social communication and adaptive

functioning. Findings showed that in general, children that were hyper-responsive to sensory

input were associated with language limitations, and those that were hyporesponsive were

associated with better language skills. These sensory processing responses affected how

frequently they participated in peer/social interactions (Tomcheck et al., 2015).

Augmentative and Alternative Communication

Augmentative and Alternative Communication involves using a device to enable or

augment communication. Examples of devices used in populations with communication

disorders include iPad applications, speech generating devices, the Picture Exchange

Communication System (PECS), smart phones, and language mastery skills programs. Evidence

across the literature supports the efficacy of these devices in increasing successful

communicative acts in these populations (An et al., 2017). Devices can be used stand-alone or

are sometimes used in combination. Devices can present pictures of various objects or places,

generate language for the user to communicate with others, use predictive technology to increase

the speed of communication, and can track intentional movement and transcribe it into language.

Evidence shows that AAC can improve outcomes for those with an ASD diagnosis in a

few different ways. An et al. (2017) and Strasberger and Ferreri (2014) both show evidence

supporting AAC in increasing request productions such as asking for help or for requesting a

desired object/outcome. Strasberger and Ferreri (2014) also shows that AAC can increase the

initiation of social communication. Implementing AAC has also been shown to significantly
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improve expressive- and receptive-language scores (Fteiha, 2017) and increase turn taking

(Therrien & Light, 2018). Results are mixed when it comes to matching and verbal imitation.

Fteiha (2017) found significant improvement in this area while Parsons, Cordler, Lee, Falkmer,

and Vaz (2019) failed to observe a significant change, due largely to low-level evidence. This is

an area where further research is still needed. Finally, there is solid evidence that AAC increases

the outcomes of joint attention or engagement. Graham et al. (2016) and Thiemann-Bourque,

McGuff, and Goldstein (2017) both found evidence that AAC is efficacious with these outcomes.

While the research generally indicates the efficacy of AAC, there is a paucity of

randomized controlled trials in the literature that would cement AAC as an efficacious tool.

However, the broad picture paints AAC as worthy of clinical pursuit. Multiple studies provide

evidence for the efficacy of using iPad applications in increasing communication-outcomes with

those diagnosed with ASD (Flores et al., 2012; Parsons et al., 2019; Therrien et al., 2018).

Research Combining AAC and Sensory Integration

Research shows that ASI/sensory-based interventions and AAC implemented

independently can be beneficial in increasing participation in those diagnosed with ASD.

However, there is a lack of empirical research exploring how the use of sensory integration in

combination with AAC might affect non-verbal children with ASD. This study will determine if

SI as a preparatory method will regulate children to maximize their engagement with AAC

intervention. By maximizing engagement, researchers seek to maximize outcomes of AAC, such

as occupational and societal participation. Therefore, the purpose of this study is to explore if

AAC is more effective in combination with SI than AAC alone in increasing communicative acts

in non-verbal children within a school setting. Data collected from this study will advance the
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practice of occupational therapy by providing significant information regarding how AAC

combined with SI will affect participation within a school setting.

Methods

Design

This pilot study is a randomized control trial that will consist of a control group and an

experimental group, each with pre- and post-testing on outcomes. Participants in the control

group will receive AAC intervention alone while the experimental group will receive SI

treatment as a preparatory method in addition to AAC intervention. Pre-tests will identify

similarities between groups at baseline and post-tests will measure changes in measured

outcomes within and between groups.

Participants

Children must meet the inclusion criteria that they have a professional and primary

diagnosis of Autism Spectrum Disorder, sensory processing problems (atypical sensory profile),

nonverbal communication, and are enrolled in an official school program Kindergarten to 6th

grade. Individuals will be excluded if they do not meet inclusion criteria or cannot physically

manipulate the AAC device or have prior use of the AAC device being used in the study.

Participant recruitment (n=50) will start the Spring prior to the study and will entail sending an

email to each school district and private school in Utah, providing them with information about

the study, our goals, and inclusion/exclusion criteria. Teachers or school professionals will

nominate students they believe to be good candidates. These students will have a Sensory Profile

(SP) completed by their teacher and if the SP results are atypical and they meet the rest of the

inclusion criteria, the student will be added to our group of potential participants. If selected, the
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guardians of the participants will be provided with detailed information about the study

procedures and if interested in participating, written consent will be obtained.

Procedures

Each group will receive introductory training and will have one week to become familiar

with the AAC device known as the Proloquo2Go, which is highly customizable and is intended

to build various language skills and increase overall communication. This app includes over

25,000 different symbols, and allows users to take and upload personal pictures to the app to

increase familiarity with individual environments. The app also includes 10,000+ words, with the

option to add any additional desired words. There are various features included in the app to

build language skills such as word games, text entry and speak, creating simple sentences, and

supports bilingual use if so desired. The ability to customize the program will better meet the

personal needs of the participants, increasing the congruency between the device and the child,

and allowing for optimal engagement. After the one-week period, trained research assistants will

go into the schools at the beginning of the school year and observe students for two days during

school hours. Assistants will report the frequency of communicative acts based on definitions set

by the study: request production, initiating/responding to social interaction, reciprocal interaction

and turn taking, receptive/expressive language, and joint attention/engagement in social

interaction with another individual(s). This will establish a baseline of communicative acts for

each of the groups. Once the baseline information has been obtained, the experimental group will

begin receiving sensory integration treatment for 1 hour, 2 times per week, for 8 weeks. This will

include activities that allow children to receive tactile, vestibular, and proprioceptive input that

help regulate their sensory systems. The solo AAC group will continue to use and implement the

AAC device in their daily communications. After 8 weeks, the research assistants will return to
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observe the participants in their school environment and measure the frequency of

communicative acts over a 2-day period.

Human Participants Protection

Prior to study initiation, University of Utah Institutional Review Board (IRB) will be

obtained. To protect all participants in the study, parents or caregivers will receive an

informational packet detailing all study procedures before signing the required consent form.

They have the right to discontinue at any time.

Measures (Instrumentation)

The Sensory Profile 2 (SP), created by Winnie Dunn, will be used as a screening tool for

atypical sensory processing problems, which is necessary for participants to be included in the

study. It looks at all the senses and categorizes sensory responses into seeking, sensitive,

avoidant, and registration. This measure has been proven valid and reliable (Dunn, 2014).

Observations of frequency of communicative acts will be used in the classroom setting to

obtain meaningful communication data. Trained research assistants will be noting each time a

participant displays one of the following: request production, initiating/responding to social

interaction, reciprocal interaction and turn taking, receptive/expressive language, and joint

attention/engagement in social interaction with another individual(s).

We will administer a pre- and post-questionnaire to participants’ teachers with questions

relating to perception of progress (see Appendix I). Questions will have a 1-5 scale rating to

determine social participation, emotional regulation and academic performance.

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Data Analysis Plan

Quantitative statistics will be used to analyze the data. We will utilize multiple

ANCOVAs to analyze the data and compare the outcomes of our different aims. We will include

baseline scores from each group as a covariate. We can assume that a p-value of <.05 may

signify that children with ASD will demonstrate an increase in communicative acts when

receiving AAC and SI combined compared to receiving AAC alone.

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References

An, S., Feng, X., Dai, Y., Bo, H., Wang, X., Li, M., & Wei, L. (2017). Development and evaluation of a

speech-generating AAC mobile app for minimally verbal children with autism spectrum disorder

in Mainland China. Molecular Autism, 8(52), 1-12. doi:10.1186/s13229-017-0165-5.

Barker, R.M., Akaba, S., Brady, N.C., & Thiemann-Bourque, K. (2013). Support for AAC

use in preschool and growth in language skills for young children with developmental

disabilities. Augmentative and Alternative Communication, 29(4), 334-46.

Bodison, S. C., & Parham, L. D. (2018). Specific sensory techniques and sensory environmental

modifications for children and youth with sensory integration difficulties: A systematic review.

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Clark, G.F., Watling, R., Parham, L. D., & Schaaf, R. (2019). Occupational therapy interventions for

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Dunn, W. (2014). Sensory Profile 2: User’s manual. San Antonio, TX: Pearson.

Flores, M., Musgrove, K., Renner, S., Hinton, V., Strozier, S., Franklin, S., & Hil, D. (2012). A

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Fteiha, M. A. (2017). Effectiveness of assistive technology in enhancing language skills for children

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Parsons, D., Cordler, R., Lee, H., Falkmer, T., & Vaz, S. (2019). A randomised controlled trial of an

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Schaaf, R.C., Dumont, R.L., Arbesman, M., & May-Benson, T.A. (2017). Efficacy of occupational

therapy using Ayres Sensory Integration: A systematic review. American Journal of

Occupational Therapy, 72, 7201190010. doi:10.5014/ajot.2018.028431.

Schaaf, R. C., Hunt, J., & Benevides, T. (2012). Occupational therapy using sensory integration to

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Appendix I

Teacher perception of student performance

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