JSLHR
Review Article
Effects of Interventions That Include Aided
Augmentative and Alternative Communication
Input on the Communication of Individuals
With Complex Communication Needs:
A Meta-Analysis
Tara O’Neill,a Janice Light,a and Lauramarie Popea
Purpose: The purpose of this meta-analysis was to
investigate the effects of augmentative and alternative
communication (AAC) interventions that included aided
AAC input (e.g., aided AAC modeling, aided language
modeling, aided language stimulation, augmented input)
on communicative outcomes (both comprehension and
expression) for individuals with developmental disabilities
who use AAC.
Method: A systematic search resulted in the identification
of 26 single-case experimental designs (88 participants)
and 2 group experimental designs (103 participants).
Studies were coded in terms of participants, intervention
characteristics, dependent variables, outcomes, and
quality of evidence.
Results: AAC interventions that included aided AAC input
in isolation, or as part of a multicomponent intervention,
were found to be highly effective across participants of
various ages, disabilities, and language skills. The
A
lmost four million individuals living in the United
States have developmental disabilities such as
autism spectrum disorder (ASD), cerebral palsy,
or intellectual disability (U.S. Census Bureau, 2010). These
individuals often cannot rely on speech to meet their
communication needs, and they benefit from aided aug-
mentative and alternative communication (AAC) such as
communication boards, speech-generating devices (SGDs),
and/or mobile technologies with AAC apps (Light &
a
Department of Communication Sciences and Disorders,
The Pennsylvania State University, University Park
Correspondence to Tara O’Neill: tao5012@psu.edu
Editor-in-Chief: Sean Redmond
Editor: Joe Reichle
Received April 12, 2017
Revision received August 8, 2017
Accepted February 5, 2018
https://doi.org/10.1044/2018_JSLHR-L-17-0132
Journal of Speech, Language, and Hearing Research • Vol. 61 • 1743–1765 • July 2018 • Copyright © 2018 American Speech-Language-Hearing Association
interventions typically included aided AAC input in
conjunction with expectant delay, direct prompting (e.g.,
spoken, gestural), contingent responding, and open-
ended questions. The interventions were found to be
highly effective in supporting both comprehension and
expression across the domains of pragmatics, semantics,
and morphosyntax. Outcomes related to expression
were reported more often than outcomes related to
comprehension.
Conclusion: Aided AAC input may reduce input–output
asymmetry and enhance expression and comprehension
for individuals who use AAC; the evidence suggests that
partners should utilize this strategy. Future research is
needed to investigate the effects of AAC input (aided and
unaided) on long-term language development for individuals
who require AAC.
Supplemental Material: https://doi.org/10.23641/asha.
6394364
McNaughton, 2012). One important component of AAC
interventions for individuals with developmental disabilities
who experience complex communication needs is the lan-
guage input provided by their communication partners.
The primary channel of language input provided
to most individuals who use aided AAC systems is spoken
language (Light, 1997; Smith & Grove, 2003). However,
individuals who experience complex communication needs
and use multimodal AAC as their primary channel of ex-
pression experience an asymmetry between the input mode
and the expected output mode (Light, 1997). Aided AAC
input has been described as one way to rebalance this input–
output asymmetry by providing linguistic input using
both speech and the AAC systems that individuals with
complex communication needs use to communicate (Smith
& Grove, 2003).
Disclosure: The authors have declared that no competing interests existed at the time
of publication.
1743
 The term “aided AAC input” describes interventions
in which partners point to (or activate) aided AAC sym-
bols (on communication boards, SGDs, or mobile technol-
ogies with AAC apps) while speaking with an individual
who uses AAC. Aided AAC input is conceptually similar
to simultaneous communication (also referred to as total
communication or key word signing) in which partners
produce manual signs while speaking (e.g., Remington &
Clarke, 1983; X. Y. Tan, Trembath, Bloomberg, Iacono,
& Caithness, 2014); however, these methods model the use
of unaided AAC, and the focus of the current review is
aided AAC. A number of different terms have been used
in the literature to describe aided AAC input including
augmented input (e.g., Romski & Sevcik, 1996), aided
AAC modeling (e.g., Binger & Light, 2007), aided lan-
guage modeling (e.g., Drager et al., 2006), aided language
stimulation (e.g., Goossens, 1989), partner-augmented input
(Senner & Baud, 2017), and natural aided language (e.g.,
Cafiero, 2001).
Although these approaches have significant overlap,
they vary on a continuum from more structured interven-
tions to stimulation that is infused within daily activities.
The goals (i.e., support comprehension or expression) and
the type of aided AAC used (e.g., SGD or non-SGD) may
also vary across approaches. Table 1 provides a brief sum-
mary of the characteristics of each intervention and high-
lights the similarities and differences between interventions.
In this article, the term “aided AAC input” is used to refer
only to the indication of aided AAC symbols by the partner
in conjunction with speech on an ongoing basis during in-
teractions; the term does not include other components of
intervention (e.g., time delay) nor does it include the use of
aided AAC as a consequential prompt in intervention (i.e.,
providing aided input to prompt a specific response by
demonstrating the target response within a most-to-least
or least-to-most prompting hierarchy).
Aided AAC input has been described in the litera-
ture and utilized clinically as a mechanism to facilitate
two communicative outcomes: (a) supporting the learner’s
comprehension (e.g., Dada & Alant, 2009; Drager et al.,
2006) and/or (b) modeling expressive output for the learner
(e.g., Binger & Light, 2007; Kent-Walsh, Binger, &
Hasham, 2010). A complex relationship exists between
the modalities available for input–output and the compre-
hension and expression of individuals who use AAC (Smith
& Grove, 2003). Although the precise mechanisms are
unknown, there are several ways in which aided AAC input
may support comprehension. First, aided AAC input pairs
aided symbols with spoken input, thus providing individ-
uals who use AAC with an alternative channel of input. If
individuals who use AAC know the meaning of the aided
symbols, the pairing of the aided symbol with the spoken
input may serve to improve comprehension of the partner’s
message (Romski & Sevcik, 1993). In addition, aided AAC
input may actually serve to alter the spoken input pro-
vided. Given the effort required for partners to locate
aided symbols on the AAC display, partners may simplify
the input they provide. In addition, partners may be more
apt to use vocabulary available on the AAC display and
known by the individuals who use AAC. Using familiar
vocabulary and simple sentence structures may promote
comprehension for at least some individuals with develop-
mental disabilities (Sevcik & Romski, 2002). Finally, aided
AAC input may affect the rate of spoken input; partners

Table 1. Description of interventions that include aided AAC input.

Specific intervention Unique characteristics as described by the authors

Augmented input (Romski & Sevcik, 1996)
Aided AAC modeling (Binger & Light, 2007)
Aided language modeling (Drager et al., 2006)
Aided language stimulation (Goossens, 1989)
Natural aided language (Cafiero, 2001)
• Described as an intervention primarily to support development of speech comprehension
by providing combined visual and auditory input
• Included in packaged System for Augmenting Language intervention that is implemented
in natural environments with actual communication partners and includes partner use
of AAC with voice output
• Included an expanded spoken model following the aided AAC model
• Involved modeling two symbols
• Specified dosage (i.e., minimum of 30 AAC models during a 15-min session)
• Included pointing to a referent in the environment before pointing to an aided
AAC symbol
• Used with low-technology language boards in naturalistic play activities
• Specified frequency (i.e., model each target word four times)
• Described as analogous to total communication approach in manual signing literature
• Provided with all ongoing language stimulation
• Used with any display type or selection technique
• Commonly used with non–speech-generating devices
• Combined aided language stimulation with naturalistic strategies of natural language
paradigm
• Implemented in natural environments using activity-specific language boards with
various natural communication partners
• Included individuals with ASD

Note. All interventions involve the partner’s use of aided augmentative and alternative communication (AAC) input; specifically, the partner
points to (and/or activates) aided AAC symbols while he or she speaks with an individual who uses AAC. ASD = autism spectrum disorder.

1744 Journal of Speech, Language, and Hearing Research • Vol. 61 • 1743–1765 • July 2018
may slow down their rate of speech as they search for the
symbols to indicate on the display, thus allowing individuals
who use AAC more time to process the input (Smith, 2015).
Beyond the impact on comprehension, aided AAC input
may also serve to model expressive output for the learner.
It allows partners to validate the aided system as an accept-
able and effective mode of communication, while providing a
model of how the system can be used, in what contexts, and
for what purposes (Sevcik, Romski, Watkins, & Deffebach,
1995).
Because the exact mechanisms are unknown, it is
also possible that aided AAC input may not benefit some
individuals, or it could have limitations for some. For ex-
ample, individuals with autism who are presented with
competing stimuli from multiple modalities (e.g., auditory
and visual) may only attend to one of the stimuli (e.g.,
Carr, Binkoff, Kologinsky, & Eddy, 1978). Therefore, it is
possible that they may not receive additional benefits from
pairing speech (i.e., auditory input) with graphic symbols
(i.e., visual input). Furthermore, the dual auditory stimula-
tion (i.e., speech and voice output) provided when partners
use aided input could actually be counterproductive, due
to the frequent presence of auditory hypersensitivity
among individuals with autism (Y. H. Tan et al., 2012).
Finally, it has been suggested that the ability to imitate
others may play a role in the effectiveness of aided AAC
input, and imitation is often an area of difficulty for indi-
viduals with autism (e.g., Toth, Munson, Meltzoff, &
Dawson, 2006). Therefore, although pairing speech with
graphic symbols is advantageous in facilitating communi-
cation for some learners, it may not be advantageous
for all, and whether having good imitation skills represents
a pivotal skill in achieving this outcome requires further
study.
Given the potential benefits and possible limitations
of aided AAC input, it is critical to investigate the effects of
aided AAC input on the comprehension and expression
of individuals with developmental disabilities who use AAC.
Systematic reviews are a well-established method used to
synthesize empirical evidence related to a specific research
question. They use systematic methods to minimize bias
to provide more reliable findings from which conclusions
can be drawn regarding the use of evidence-based practices
(Littell, Corcoran, & Pillai, 2008; Petticrew & Roberts,
2006). In addition, they can identify areas where there is a
lack of research to provide directions for future research.
The use of meta-analysis within systematic reviews pro-
vides a quantitative summary of effects in several domains
by using a moderator analysis to assess influences of partic-
ipant and intervention characteristics on variations in effect
size. This type of analysis allows researchers and clinicians
to identify for whom and under what circumstances an inter-
vention is effective, which can enhance efforts to target in-
terventions to the individuals who are most likely to benefit
and to identify intervention approaches that are most likely
to result in positive outcomes (Littell et al., 2008).
Two previous reviews investigated the effects of in-
terventions that included aided AAC input on language
acquisition of individuals who use AAC (Allen, Schlosser,
Brock, & Shane, 2017; Sennott, Light, & McNaughton,
2016). Sennott et al. (2016) identified and summarized nine
single-subject studies involving 31 participants under the
age of 12 years as well as one group study, and the authors
provided evidence that children who use AAC make observ-
able gains in both expressive and receptive language when
provided with aided AAC input packaged with various
intervention components. Another recent review by Allen
and colleagues (2017), which identified and summarized
19 single-case studies involving 56 participants and two
group studies involving 75 participants, found that augmented
input can improve expression (i.e., single-word vocabu-
lary, multisymbol utterances) for individuals with develop-
mental disabilities who use AAC. However, there are several
limitations to these reviews. The review by Sennott et al.
included only a limited number of studies, all of which were
published before 2014. In addition, the review did not iden-
tify the specific components included within each interven-
tion, making it impossible to evaluate the key components
of interventions utilizing aided input. Furthermore, the review
did not evaluate the quality of evidence provided by the
studies considered. A notable limitation of both the Sennott
et al. and the Allen et al. reviews was that neither con-
ducted a meta-analysis to quantitatively summarize effects
by participant, intervention, or outcome characteristics.
Therefore, the conclusions that could be made regarding
the effectiveness of aided AAC input with different partici-
pants and intervention characteristics were limited.
Given these limitations, there is a need for a more
current and comprehensive meta-analysis of the effects of
aided AAC input. The goals of this systematic review are
(a) to determine the effect of interventions including aided
AAC input on the expression and comprehension of indi-
viduals with developmental disabilities who use AAC;
(b) to evaluate how effects may differ by variables related
to participant, intervention, or outcome characteristics;
(c) to assess the strengths and limitations of the existing
evidence; and (d) to consider clinical implications and direc-
tions for future research.
Method
The protocol for this review was developed in accor-
dance with procedures delineated by the Cochrane Collabo-
ration (http://www.cochrane.org). The protocol was used to
guide all aspects of the investigation. The full protocol
and codebook are available upon request.
Inclusion and Exclusion Criteria
For inclusion, studies had to meet the following cri-
teria: (a) All participants in the study were individuals with
developmental disabilities who used AAC before the study
onset or who were provided with AAC as part of the inter-
vention; (b) the study included documentation of progress
in the use of AAC in the context of an intervention that
included aided AAC input in isolation or in combination
O’Neill et al.: Effects of Aided AAC Input 1745
with other intervention components; (c) the study used Figure 1. Search strategy used to locate studies. Adapted from
“The PRISMA statement for reporting systematic reviews and meta-
an experimental or quasi-experimental design to evaluate analyses of studies that evaluate healthcare interventions: Explanation
the intervention; (d) the study reported outcome data on and elaboration,” by A. Liberati, D. G. Altman, J. Tetzlaff, C. Mulrow,
comprehension and/or expression after the intervention, P. C. Gøtzsche, J. P. A. Ioannidis, … D. Moher, 2009, British Medical
such that effect sizes could be calculated (i.e., time series Journal, 339, p. b2700. Copyright © Liberati et al.
data for baseline and intervention phases for single-case
studies or comparison of control and treatment groups for
group-design studies); (e) the study was published in a peer-
reviewed journal or approved as a dissertation or thesis
before May 2017; and (f ) the study was published or trans-
lated into English.
Studies that included unaided AAC input (i.e., simul-
taneous communication, total communication, key word
signing) were excluded (e.g., Remington & Clarke, 1983;
X. Y. Tan et al., 2014). Group studies were excluded when
outcome data were not reported for individuals who used
AAC (e.g., Jonsson, Kristoffersson, Ferm, & Thunberg, 2011),
a control group was not included that allowed for compu-
tation of an effect size (e.g., Sevcik et al., 1995), or a pretest–
posttest design was used (e.g., Bruno & Trembath, 2006).
Single-case studies with an AB design were also excluded
(e.g., Cafiero, 2001). Studies were also excluded if the part-
ner only provided aided AAC input as a consequential
prompt within a least-to-most or most-to-least prompt-
ing hierarchy (e.g., if the learner did not produce the target
skill after a time delay; e.g., van der Meer et al., 2013).
This was to ensure that aided input was provided on an
ongoing basis as an integral part of the intervention, rather
than only under certain conditions, dependent on the
performance of the learner. Theses and dissertations were
excluded that were later published in a peer-reviewed
journal. resulted in the use of three primary search terms with
several synonyms and related terms for each primary
term.
The first primary search term used was “modeling”
Search Strategy to locate studies with the intervention of interest (i.e., aided
The search process is illustrated in Figure 1. A search AAC input). Aided AAC input has been referred to as a
of electronic databases including ProQuest dissertation variety of names including aided language modeling, aided
and theses, Education database, ERIC, Linguistics and AAC modeling, augmented input, aided language stimula-
Language Behavior Abstracts, PubMed, and PsycINFO tion, and natural aided language. Terms have also been
was completed. These databases were chosen to yield results used to refer to unaided AAC input including simultaneous
from various subject areas including education, social sci- communication (Remington & Clarke, 1983), total com-
ences, and medicine. In addition, an examination of recent munication (Barrera, Lobato-Barrera, & Sulzer-Azaroff,
reviews from the AAC field (e.g., Kent-Walsh, Murza, 1980), and key word signing (X. Y. Tan et al., 2014). These
Malani, & Binger, 2015; Schlosser & Wendt, 2008) revealed terms related to unaided AAC input were not used because
precedence for the selection of these databases. The dis- the focus of the current investigation was partner model-
sertations and theses database was included in an attempt ing of aided AAC. Therefore, the first search term (i.e.,
to reduce potential publication bias (Rothstein, Sutton, & “modeling”) included the variants “aided language model-
Borenstein, 2005). ing,” “aided language stimulation,” “natural aided language,”
Different combinations of key words related to the “aided AAC modeling,” “augmented input,” “partner
inclusion and exclusion criteria were tested to assess the aided modeling,” or “model*.” The second primary search
breadth and depth of results. Search terms were refined by term used was “augmentative and alternative communica-
examining the resulting articles for relevance. Following tion,” including “speech generating device,” “voice output,”
recommendations from the Cochrane Collaboration for or “picture symbol.” The term “AAC” was used to ensure
systematic reviews (Higgins & Green, 2008), an effort was that the results would pertain to individuals with com-
made to reduce the number of different search terms used. plex communication needs. Variants were used to cover
Instead, a variety of synonyms and related terms were a range of terms that have been used in the literature to
used and combined with “OR” within each concept. This refer to AAC. The final search term was “intervention,”

1746 Journal of Speech, Language, and Hearing Research • Vol. 61 • 1743–1765 • July 2018
including “treatment” and “treat*.” The search term “model-
ing” (and its variants) included a limiter to appear in the
abstract.
The database search with these search terms resulted
in 731 records that were screened for relevance by reading
the title and abstract. Records related to individuals with
developmental disabilities and aided AAC input were retained
for further review, and records on unrelated topics were
excluded (n = 619). The remaining 112 articles were reviewed
at the full-text level. Ancestral searches were conducted by
handsearching the reference lists of the 112 articles that
were reviewed at the full-text level. The ancestral search
resulted in the identification of an additional 12 records for
review. The search ultimately yielded 28 studies that were
identified for inclusion. To ensure the reliability of the in-
clusion decisions, a doctoral student in communication sci-
ences and disorders reviewed a randomly selected sample
of 20% of the 112 articles assessed for eligibility at the full-
text level (i.e., 22 articles); agreement (i.e., number of agree-
ments divided by total number of articles) with the first
author for inclusion was 100%.
Coding Procedures
All 28 studies that met the inclusion criteria were
thoroughly reviewed and coded according to the following
coding categories: (a) study design; (b) participants (num-
ber, age, gender, disability, and receptive language skills);
(c) independent variable (i.e., intervention, nature of input,
and components); (d) intervention intensity (i.e., num-
ber, length, and frequency of sessions; rate of modeling);
(d) type of AAC used; (e) partner, context, and location;
(f ) dependent variable; (g) outcomes; and (h) quality of
evidence. See the Supplemental Material for definitions
and examples for each coding category.
The independent variable was coded according to the
nature of the input (i.e., relationship between aided input
and spoken input). The nature of the input was categorized
as (a) key word input (i.e., partners indicated aided AAC
symbols for one to two key words from a spoken phrase),
(b) full-phrase multisymbol input (i.e., partners indicated
multiple aided symbols that each corresponded with one
spoken word or morpheme), or (c) full-phrase single-symbol
input (i.e., partners indicated one aided symbol that corre-
sponded to an entire spoken phrase or sentence). In addition
to the spoken and graphic (i.e., indicated symbol) input,
there was additional input from the voice output when the
intervention involved an SGD. The timing of the input was
also characterized as simultaneous or asynchronous with
the spoken input provided by the partner. Examples of each
type of input are provided in Table 2. The specific compo-
nents of intervention in addition to aided input were also
coded (e.g., expectant delay, contingent responding; see
the Supplemental Material). The interventions were then
categorized into one of the following two categories:
(a) multicomponent interventions that included aided AAC
input along with one or more other intervention compo-
nents or (b) isolated interventions that included aided
AAC input as a single technique. In addition, the terminol-
ogy used by the authors of the study to describe the inter-
vention was noted (e.g., aided AAC modeling, augmented
input).
To ensure the reliability of the coding, the first author
and a graduate student in communication sciences and dis-
orders independently coded all of the included studies
based on the operational definitions found in the coding
manual. Reliability calculations were completed for all
coded variables within each study by taking the number
of agreements divided by the number of agreements plus
disagreements and multiplying by 100. Overall agreement
was 94% across coding categories across studies (range =
78%–100%). The study with 78% agreement reported inter-
vention components in an appendix that were unaccounted
by one coder; consensus was reached for coding this study
after reviewing the appendix together. All other disagree-
ments were resolved through discussion and clarification
of definitions until consensus reached 100% for all codes
across all studies.
Two effect size calculations were used to determine
outcomes of single-case studies: Tau-U (Parker, Vannest,
Davis, & Sauber, 2011) and gain scores. Tau-U is one of
the effect size indices for single-case designs with the most
power; it estimates nonoverlap between baseline and
intervention (Parker et al., 2011). Tau-U provides a statis-
tic that ranges from 0 to 1 and represents the proportion
of data that improved between baseline and treatment
phases, after controlling for undesirable baseline trend. A
Tau-U value from 0 to .19 is considered small, a value
from .20 to .59 is considered moderate, a value of .60–.79
is considered large, and a value above .80 is considered
very large (Vannest & Ninci, 2015). Tau-U effect sizes were
calculated using a free online calculator (Vannest, Parker,
& Gonen, 2011). Gain scores were also calculated to pro-
vide a measure of the magnitude of effects (i.e., the amount
of change that occurred from baseline to intervention).
Two interventions with 100% nonoverlapping data appear
equally effective using Tau-U; however, the intervention
data for the first study may minimally exceed baseline,
whereas the intervention data for the second study may
indicate a large improvement between baseline and inter-
vention (Wendt, 2009). Gain scores were calculated as the
difference between average performance during the final
three intervention sessions and average performance during
baseline. Data from the final three intervention sessions
were used because it was expected that participants would
require several exposures to symbols before demonstrating
comprehension or using them expressively (Dunham &
Dunham, 1992).
For group studies, Cohen’s d was the effect size
used. It was computed using an online calculator (Ellis,
2009). Effect sizes for d range from −3.0 to 3.0. The
following guidelines are recommended for interpreting
these effect sizes: An effect size below 0.20 is considered
small, an effect size from 0.20 to 0.49 is considered
medium, and anything above 0.80 is considered large
(Cohen, 1988).
O’Neill et al.: Effects of Aided AAC Input 1747
Table 2. Relationship of aided AAC input and spoken input: description and examples.

Category Description Examples

Key word aided Partners point to or activate aided AAC symbol(s) Simultaneous: “That’s a noisy VAN.” (Harris & Reichle, 2004, p. 158)
input for one to two key words from a spoken phrase. Asynchronous: “Who is flying the helicopter WHO + FLY” (Binger,
Could be simultaneous with spoken input or Kent-Walsh, Ewing, & Taylor, 2010, p. 112)
asynchronous. Asynchronous: “DOG + SPILL The dog spilled the tea!”(Binger &
Light, 2007, p. 34)
Full-phrase Partners point to or activate aided AAC symbols Simultaneous: “IS + MICKEY + JUMPING?” (Kent-Walsh, Binger, &
multisymbol to compose an entire phrase. Each symbol Buchanan, 2015, p. 225)
aided input corresponds with one spoken word or morpheme. Asynchronous: “Scooby Doo is eating Scooby snacks HE + IS +
Could be simultaneous with spoken input or EAT + ING” (Binger, Maguire-Marshall, & Kent-Walsh, 2011,
asynchronous. p. 166)
Full-phrase single- Partners point to or activate one aided AAC symbol Partner indicates graphic symbol for singing, which corresponds
symbol aided that corresponds to an entire phrase or sentence. to the phrase “MORE SINGING PLEASE” ( Johnston, McDonnell,
input Nelson, & Magnavito, 2003, p. 268)
Partner indicates graphic symbol for match, which corresponds
to the phrase “I GOT A MATCH” (Trottier, Kamp, & Mirenda,
2011, p. 32)

Note. Capitalized words indicate aided input. Italicized words indicate spoken input. Words that are both italicized and capitalized indicate
simultaneous spoken and aided input. Plus signs (+) between words indicate that the phrase was composed of more than one symbol.
AAC = augmentative and alternative communication.

To calculate the effect size for the group studies, the
intervention group that included aided AAC input was
compared with the control group. In one study ( Romski
et al., 2010), the group that included aided AAC input
(augmented communication input group) was compared
with the control group (spoken communication group).
There was a third intervention group (augmented commu-
nication output) that did not include aided AAC input
as an independent variable; therefore, this group was not
included in the analyses. The other group study (Kasari
et al., 2014) included only two groups (i.e., behavioral inter-
vention with or without augmentation with an SGD) that
formed the basis for comparison in the analyses.
Interrater reliability for the effect size computations
was calculated for 20% of dependent variable values (i.e.,
24 randomly selected measures of 122 total measures across
studies and participants). Tau-U values within .05 points
and gain scores within 5% were considered to agree. This
agreement standard was used in a recent meta-analysis in
the field (Kent-Walsh, Murza, Malani, & Binger, 2015).
Calculations yielded 95% agreement for gain scores and
91% agreement for Tau-U. Differences were related to
variability in reading values depicted in graphs printed in
the papers that were sometimes difficult to read with ex-
act precision; all disagreements were resolved through dis-
cussion before the completion of final analyses.
The quality markers from Horner et al. (2005) were
used to evaluate the certainty of evidence provided within
each single-case study, and the quality markers from
Gersten et al. (2005) were used to evaluate the certainty
of evidence provided within each group study. Each study
was analyzed based on the internal validity, reliability of the
dependent variable, and procedural integrity. Considering
these factors, each study was given a quality of evidence
rating of inconclusive, preponderant, suggestive, or incon-
clusive (see the Supplemental Material for definitions).
These ratings were developed by Simeonsson and Bailey
(1991) and have been used in multiple reviews within
the field (e.g., Kent-Walsh, Murza, Malani, & Binger, 2015;
Schlosser & Wendt, 2008).
Meta-Analysis Procedures
To evaluate findings of single-case studies by partici-
pant, intervention, and outcome characteristics, effect
sizes were aggregated by taking the average of a set of effect
sizes associated with a particular coded variable (e.g., par-
ticipant diagnosis, type of AAC, language domain). This
average provided a summary statistic of the intervention’s
effectiveness for that particular measure (Lipsey & Wilson,
2001).
Results
Twenty-six single-case studies and two group studies
met the inclusion criteria. Tables 3 and 4 provide a sum-
mary of the coded variables for the single-case studies and
group studies, respectively. Results for the main coding
categories are summarized below, first for the single-case
studies and then for the group designs.
Participant Characteristics
The single-case studies involved 88 participants, and
each study included between one and six participants,
with a mean age of 9;5 years;months. Of these participants,
66% (n = 58) were male, and 34% (n = 30) were female.
Participants included individuals from preschool through
adult, ranging from 3 to 59 years old. Most participants
were preschoolers (42%, n = 37) or elementary-age children
(40%, n = 35), whereas fewer participants were toddlers (6%,
n = 5), adolescents (5%, n = 4), or adults (8%, n = 7). The

1748 Journal of Speech, Language, and Hearing Research • Vol. 61 • 1743–1765 • July 2018
 Table 3. Summary of coded variables for single-case studies.

Intervention characteristics DV
Participant’s IV category: Partner/ Expression/ Outcomes
Study authors name/CA/ IV, nature context/ Type comprehension, Certainty of
and design gender/Dx of input location of AAC DV domain: DV Tau-Ua Gain score evidence

Acheson (2006): Zane, 4;5, Multicomponent: Teacher/ Non-SGD Expression, pragmatic: .50 +3.0 Inconclusive
multiple probes M, ASD aided language natural number of requests • Failed to
across participants Damian, 4;9, stimulation, routine/ Non-SGD .75 +6.0 establish
M, ASD key word school control;
Andrew, 4;10, Non-SGD 1.00 +6.0 missing
M, ASD procedural
integrity
Beck, Stoner, & Dennis Jane, 35, Multicomponent: SLP or SGD Expression, pragmatic: .18 +3.1 Suggestive
(2009): ABAB F, IDD aided language researcher/ number of turns • Some
James, 25, stimulation, group/ SGD .20 +0.1 instability
M, IDD key word workshop in baseline;
Robbie, 38, Non-SGD −.18 −0.1 IV not well
M, IDD described
Craig, 43, Non-SGD .51 −0.8
M, IDD
Jennifer, 50, Non-SGD .27 +1.3
F, IDD
Rita, 45, Non-SGD .61 +2.6
F, IDD
Binger & Light (2007): Valerie, 4;3, Multi component: Researcher/ SGD Expression, 1.00 +13.0 Conclusive
multiple probes F, other aided AAC play/school morphosyntactic:
across participants Timmy, 3;5, modeling, and home SGD frequency of 1.00 +22.0
M, other key word multisymbol
Robin, 4;6, SGD messages .81 +1.0
F, DS
Nathan, 4;4, Non-SGD 1.00 +18.0
O’Neill et al.: Effects of Aided AAC Input

M, DD
Richard, 4;2, Non-SGD .80 +16.0
M, DD
Binger, Kent-Walsh, Antonio, 4;1, Multicomponent: Parents/book SGD Expression, 1.00 +9.0 Conclusive
Berens, Del Campo, M, other aided AAC reading/NR morphosyntactic:
& Rivera (2008): Angela, 3;4, modeling, Non-SGD frequency of 1.00 +18.0
multiple probes F, other key word multisymbol
across participants Julia, 2;11, SGD messages 1.00 +14.0
F, other
Binger et al. (2010): Oscar, 6;4, Multicomponent: EA/book SGD Expression, 1.00 +11.0 Conclusive
multiple probes M, DD aided AAC reading/ morphosyntactic:
across participants Adam, 4;6, modeling, school SGD frequency of 1.00 +11.0
M, DD key word multisymbol
Valerie, 5;8, SGD messages .80 +11.0
F, CP
(table continues)
1749
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Table 3. (Continued).
Journal of Speech, Language, and Hearing Research • Vol. 61 • 1743–1765 • July 2018

Intervention characteristics DV
Participant’s IV category: Partner/ Expression/ Outcomes
Study authors name/CA/ IV, nature context/ Type comprehension, Certainty of
and design gender/Dx of input location of AAC DV domain: DV Tau-Ua Gain score evidence
Binger et al. (2011): Alex, 11, Multicomponent: Researcher/ SGD Expression, 1.00 +93.0% Conclusive
multiple probes M, CP aided AAC book morphosyntactic:
across morphemes Jessie, 6, modeling, reading/ SGD percent correct .85 +96.0%
F, CAS full-phrase school and use of morphemes
Ian, 9, multisymbol home SGD .84 +90.0%
M, CP
Dada & Alant A, 8;5, Isolated: aided SLP/group/ Non-SGD Comprehension, .72 +4.0 Conclusive
(2009): multiple M, CP language school semantic: number
probes across B, 10;1, stimulation, Non-SGD of correctly .84 +4.0
activities F, CP key word identified words
C, 8;1, F, Non-SGD .76 +4.0
CP
D, 12;1, Non-SGD .62 +3.0
F, DS
Dexter (1998): Andre, 8;1, Multicomponent: Researcher/ Non-SGD Expression, pragmatic: 0.79 +10.0 Inconclusive
multiple baseline M, ASD aided language book frequency of .47 +50.0 • Failed to
across participants Tony, 9;2, stimulation, NR reading/ Non-SGD spoken output, 1.00 +28.0 establish
M, ASD school and frequency of aided 1.00 +83.0 control;
Peter, 9;3, home Non-SGD AAC use .91 +12.0 missing
M, ASD 1.00 +80.0 procedural
Carl, 9;0, Non-SGD 1.00 +22.0 integrity
M, ASD .88 +27.0
Sam, 7;2, Non-SGD .65 +12.0
M, ASD .16 +0.1
Brad, 6;5, Non-SGD .82 +18.0
M, ASD .84 +35.0
Drager et al. (2006): Maggie, 4;5, Isolated: aided SLP or Non-SGD Expression, semantic: .60 +3.0 Suggestive
multiple probes F, ASD language researcher/ number correct for • Experimental
across sets modeling, play/day symbol expression control not
key word care Comprehension, .78 +6.0 maintained
Sam, 4;0, Non-SGD semantic: number .80 +6.0 across all
M, ASD correct for symbol .68 +7.0 sets because
comprehension of timing of
baseline data
collection
Hall (2014): ABAB 1, 7, F, ASD Multicomponent: Researcher/ Non-SGD Expression, semantic: .72 +32.0 Inconclusive
aided language clinic/book number of spoken 1.00 +24.0 • Only one
stimulation, reading and words .81 +12.0 demonstration
key word play Morphosyntactic: of effect
number of symbol
and symbol–spoken
combinations
(table continues)
 Table 3. (Continued).

Intervention characteristics DV
Participant’s IV category: Partner/ Expression/ Outcomes
Study authors name/CA/ IV, nature context/ Type comprehension, Certainty of
and design gender/Dx of input location of AAC DV domain: DV Tau-Ua Gain score evidence
Harris & Reichle Jennie, 3;10, Isolated: aided Researcher/ Non-SGD Expression, semantic: .64 +47.0% Preponderant
(2004): multiple F, DS language preferred percent correct for .82 +63.0% • Some instability
probes across stimulation, activity/ symbol expression in baseline,
sets Niles, 5;4, key word school or Non-SGD Comprehension, .84 +69.0% generally
M, DS home semantic: percent .79 +50.0% stabilized
Edie, 4;2, Non-SGD correct for symbol 1.00 +67.0% before
F, IDD comprehension 1.00 +97.0% intervention
Ho (2000): multiple 1, 7;8, M, Isolated: aided Researcher/ Non-SGD Comprehension, .30 +2.0 Inconclusive
probes across CP AAC modeling, book semantic: number • Failed to
sets 2, 4;7, key word reading/ Non-SGD of correctly .91 +2.0 establish
M, other school identified symbols stable
3, 5;10, Non-SGD 1.00 +3.0 baselines
M, CP
Hughes et al. Justin, 17, Multicomponent: Peer/direct Non-SGD Expression, pragmatic: .64 +4.9 Conclusive
(2000): multiple M, ID communication teaching/ frequency of
probes across Jack, 16, book training, school Non-SGD conversation .95 +2.2
participants M, ID full-phase initiations
Jerome, 16, one-symbol Non-SGD .86 +2.9
M, ID
Thomas, 18, Non-SGD 1.00 +5.7
M, ID
Sarah, 16, Non-SGD 1.00 +6.7
F, ID
Iacono & Duncum Lisa, 2;8, Multicomponent: Researcher/ SGD Expression, pragmatic: .78 +6.0 Inconclusive
(1995): alternating F, DS sign + Dynavox + play/clinic number of words • Only one
O’Neill et al.: Effects of Aided AAC Input

treatments speech, key word Semantic: number of .94 +4.0 demonstration

different words of effect
Johnston, McDonell, Sallie, 3;10, Multicomponent: Peer and Non-SGD Expression, pragmatic: .86 +92.0% Conclusive
et al. (2003): multiple F, DD four-step teacher/ percent correct
baseline across Jason, 4;6, strategy natural SGD use of symbolic .90 +100.0%
participants M, CP with aided routines/ communication
Maddie, 3;3, modeling, school SGD .33 +75.0%
F, MD full-phrase
one-symbol
Johnston, Nelson, Evans, Brad, 4;3, Multicomponent: Peer and Non-SGD Expression, pragmatic: .42 +60.0% Conclusive
& Palazolo (2003): M, ASD four-step teacher/ percent correct
multiple probes Alex, 5;3, strategy with play/school Non-SGD use of symbolic .23 +80.0%
across participants M, ASD aided modeling, communication
Billy, 5;1, full-phrase Non-SGD .45 +95.0%
M, ASD one-symbol
(table continues)
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Table 3. (Continued).

Intervention characteristics DV
Participant’s IV category: Partner/ Expression/ Outcomes
Study authors name/CA/ IV, nature context/ Type comprehension, Certainty of
and design gender/Dx of input location of AAC DV domain: DV Tau-Ua Gain score evidence
Kent-Walsh (2003): Adam, 4;3, Multicomponent: EA/book Non-SGD Expression, pragmatic: 1.00 +48.0 Conclusive
multiple baseline M, CAS aided AAC reading/NR number of turns 1.00 +26.0
across participants Betty, 12;7, modeling, Non-SGD Semantic: different 1.00 +38.0
F, DS key word concepts expressed 1.00 +22.0
Caleb, 3;0, Non-SGD 1.00 +34.0
M, CAS 1.00 +26.0
Dave, 11;5, SGD 1.00 +54.0
M, DS 1.00 +31.0
Emma, 9;0, Non-SGD 1.00 +36.0
F, ID 1.00 +28.0
Kent-Walsh et al. (2010): Abby, 8;0, Multicomponent: Parents/book SGD Expression, pragmatic: 1.00 +21.0 Conclusive
multiple probes F, CP aided AAC reading/ number of turns 1.00 +5.0
across participants Brian, 5;4, modeling, home SGD Semantic: different 1.00 +54.0
M, DS key word concepts expressed 1.00 +18.0
Clea, 5;0, SGD 1.00 +43.0
F, CP 1.00 +17.0
Dale, 8;3, SGD .67 +9.0
M, CP .67 +21.0
Evan, 4;7, SGD 1.00 +19.0
M, DS 1.00 +32.0
Freddy, 5;11, SGD 1.00 +29.0
M, DS 1.00 +23.0
Kent-Walsh, Binger, & Adam, 4;10, Multicomponent: Researcher SGD Expression, .93 +97.0% Conclusive
Buchanan (2015): M, CAS aided AAC and parent/ morphosyntactic:
multiple probes Bella, 6;2, modeling, play/clinic SGD percent use of target .93 +95.0%
across participants F, DS full-phrase sentence forms
Clay, 4;9, multisymbol SGD .48 +90.0%
M, DD
Pitman (2015): Kacey, 6;6, Multicomponent: EA/book SGD Expression, pragmatic: 1.00 +16.0 Inconclusive:
multiple baseline F, IDD aided AAC reading/ number of single- 1.00 +10.0 • Missing
across participants Isaac, 7;4, modeling, school SGD symbol messages 1.00 +3.0 reliability and
M, IDD key word Morphosyntactic: 1.00 +42.0 procedural
Austin, 8;8, SGD number of multisymbol .00 +8.0 integrity
M, ASD messages .89 +6.0
Rosa-Lugo & Kent- Alexis, 6;10, Multicomponent: Parent/book SGD Expression, pragmatic: 1.00 +29.0 Preponderant
Walsh (2008): F, other aided AAC reading/NR number of turns 1.00 +14.0 • Only two
multiple probes Bernardo, 6;8, modeling, SGD Semantic: different 1.00 +48.0 replications
across participants M, DD key word concepts expressed 1.00 +21.0 of effect
(table continues)
 Table 3. (Continued).

Intervention characteristics DV
Participant’s IV category: Partner/ Expression/ Outcomes
Study authors name/CA/ IV, nature context/ Type comprehension, Certainty of
and design gender/Dx of input location of AAC DV domain: DV Tau-Ua Gain score evidence
Sennott (2013): Ava, 4;7, Multicomponent: EA/book SGD Expression, pragmatic: 1.00 +2.0 Conclusive
multiple probes F, ID aided AAC reading/ number of turns
across participants Ben, 4;4, modeling, school SGD 1.00 +2.0
M, ASD full-phrase
Cassie, 3;9, multisymbol SGD 1.00 +2.0
F, ASD
Solomon-Rice & Karl, 2;3, Multicomponent: SLP/play/ Non-SGD Expression, semantic: 1.00 +67.0% Conclusive
Soto (2014): M, DD augmented community percentage of target
alternating Carol, 2;4, input, or home Non-SGD vocabulary produced 1.00 +63.0%
treatments F, DD key word
Mick, 2;2, Non-SGD .69 +30.0%
M, DD
Tönsing (2016): 1, 11;3, Multicomponent: Researcher/ Both Expression, 1.00 +11.0 Conclusive
adapted M, CP aided AAC book morphosyntactic: 1.00 +11.0
alternating 2, 11;4, modeling reading/ Both number of correct 1.00 +11.0
treatments M, other on SGD vs. school two-word 1.00 +7.0
3, 8;0, non-SGD, or home Both combinations .83 +11.0
F, CP key word .89 +11.0
4, 6;11, Both .90 +8.0
M, CP .89 +7.0
Trembath, Balandin, Jeremy, 4, Isolated: peer- Peers/play/ SGD Expression, pragmatic: .60 +0.5 Suggestive
Togher, & Stancliffe M, ASD mediated school frequency of • Missing
(2009): multiple Aaron, 5, teaching SGD communication .86 +0.3 procedural
baseline across M, ASD with aided acts per minute integrity
participants Shane, 3, modeling, SGD 1.00 +0.6
O’Neill et al.: Effects of Aided AAC Input

M, ASD key word

Trottier et al. (2011): Ian, 11;4, Multicomponent: Peers/play/ SGD Expression, pragmatic: .67 +0.7 Preponderant
multiple baseline M, ASD peer-mediated school frequency of • Only two
across participants Max, 11;2, instruction, SGD communication 1.00 +0.8 replications
M, ASD full-phrase acts per minute of effect
one-symbol

Note. AAC = augmentative and alternative communication; ASD = autism spectrum disorder; CA = chronological age (years;months); CAS = childhood apraxia of speech; CP =
cerebral palsy; DD = developmental delay; DS = Down syndrome; DV = dependent variable; Dx = diagnosis; EA = educational assistant; F = female; ID = identification; IDD =
intellectual or developmental disability; IV = independent variable; M = male; MD = multiple disabilities; non-SGD = non–speech-generating device; NR = not reported; SGD = speech-
generating device; SLP = speech-language pathologist.
a
For studies with more than one DV, Tau-U and gain scores are listed separately for each DV by participant in order of listed DVs.
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Journal of Speech, Language, and Hearing Research • Vol. 61 • 1743–1765 • July 2018

Table 4. Summary of coded variables for group studies.

Intervention characteristics DV Outcomes

Expression/
Study authors Participants, IV category: IV, Partner/context/ Type comprehension, Effect Certainty of
and design N (CA), Dx nature of input location of AAC DV domain: DV M (SD) size evidence

Kasari et al. (2014): 61 (6;4), ASD Multicomponent: Trained interventionists SGD Expression, pragmatic: TSCU: TSCU: Conclusive
sequential, multiple- (a) JASP + EMT and parents/play/ number of spontaneous 1 T1a: 35.3 d = 0.57
assignment, vs. (b) JASP + clinic communicative 2 T1: 54.4
randomized trial EMT + aided utterances (TSCU); 1 T2: 40.3 d = 0.62
AAC input, NR total number of 2 T2: 61.9
comments (TCOM) 1 T3: 45.4 d = 0.22
2 T3: 52.7
Semantic: total TCOM: TCOM:
different root 1 T1: 8.10 d = 0.51
words (TDRW) 2 T1: 14.1
1 T2: 8.1 d = 0.44
2 T2: 14.1
1 T3: 8.1 d = 0.54
2 T3: 14.1
TDRW: TDRW:
1 T1: 24.3 d = 0.34
2 T1: 33.1
1 T2: 25.6 d = 0.29
2 T2: 33.1
1 T3: 26.9 d = 0.21
2 T3: 33.1
Romski et al. 42 (2;6), DD Isolated: (a) SC Trained interventionists SGD Expression, semantic: 1 T1: 1.4 (0.5) d = 0.71 Conclusive
(2010): RCT vs. (b) AC-I, and parents/play, number of different 2 T1: 2.3 (1.8)
key word book reading, and spoken words used 1 T2: 2.3 (2.2) d = 0.52
snack/laboratory 2 T2: 4.2 (5.7)
and home

Note. AAC = augmentative and alternative communication; AC-I = augmented communication input; ASD = autism spectrum disorder; CA = chronological age (years;months);
d = Cohen’s d; DD = developmental delay; DV = dependent variable; Dx = diagnosis; IV = independent variable; JASP + EMT = joint attention symbolic play plus enhanced milieu
teaching; N = number; NR = not reported; RCT = randomized controlled trial; SC = spoken communication; SGD = speech-generating device.
a
Refers to the time of testing ( T1 = Measurement Occasion 1; T2 = Measurement Occasion 2; T3 = Measurement Occasion 3).
participants included individuals with a range of diagnoses:
26% were identified as having ASD (n = 23); 17%, as having
cerebral palsy (n = 15); 18%, as having intellectual or develop-
mental disabilities (n = 16); 13%, as having Down syndrome
(n = 11); 10%, as having a developmental delay (n = 9); and
the remaining 10%, as having other disabilities (n = 9; e.g.,
Prader–Willi syndrome, childhood apraxia of speech).
Receptive language standard scores were reported
for 74 participants (84%). Most participants were assessed
using receptive language assessments such as the Test of
Auditory Comprehension of Language (Carrow-Woolfolk,
1999) or the Peabody Picture Vocabulary Test (Dunn &
Dunn, 2007), although several studies included more global
measures of language skills such as the Vineland Adaptive
Behavior Scale–Second Edition communication subdomain
scores (Sparrow, Cicchetti, & Balla, 2005). According to
the reported scores, the receptive language skills of the par-
ticipants varied significantly. Of the 74 participants for whom
receptive language scores were reported, 57 (77%) were
reported to have below-average receptive language skills,
and 17 (23%) were reported to have receptive language
skills within normal limits. Receptive language ages were
reported for fewer participants (n = 47, 53%). Of these par-
ticipants, 16 (34%) had a language age between 36 and
48 months, and 15 (32%) had a language age between 24
and 36 months. Fewer participants had a language age score
from 1 to 24 months (n = 8, 17%) or greater than 48 months
(n = 8, 17%).
The group studies included 103 participants, with
mean ages of 6;5 and 2;6 years;months, respectively. The
participants included young children with ASD (Kasari et al.,
2014) and toddlers with developmental delays (Romski
et al., 2010). All participants were reported to have below-
average receptive language skills. The participants in the
Kasari et al. (2014) study were reported to have an aver-
age receptive language age of 2;8 years;months, and the par-
ticipants in the Romski et al. (2010) study were reported to
have an average receptive language age of 18 months.
Intervention Characteristics
Partners
In the single-case studies, the partners who provided
aided input were most often the researcher (n = 31, 35%)
or multiple partners (n = 17, 19%). Paraprofessionals (n =
14, 16%), parents (n = 11, 13%), and peers (n = 9, 10%)
were partners in some studies, whereas speech-language pathol-
ogists (n = 3, 3%) and teachers (n = 3, 3%) were partners
less often. For both of the group studies, the partners were
trained interventionists during the first phase of each study;
and parents, during the second phase.
Location and Context
The participants in the single-case studies most often
received intervention at school (n = 48, 55%); fewer were
seen at home (n = 12, 14%), in the community (n = 6, 7%),
or in a clinic setting (n = 8, 9%). The group studies occurred
primarily in controlled settings (e.g., laboratory, clinic).
In the Romski et al. (2010) study, the initial 18 weeks
of intervention occurred in the clinic, and the final 6 weeks
of intervention occurred at home. The interventions in
the single-case studies took place most often in the context
of reading (n = 41, 47%) or play (n = 19, 22%), although
some interventions took place during preferred activities
(n = 15, 17%) or natural routines (n = 8, 9%) or in multiple
contexts (n = 5, 6%). The group studies took place in the
context of play (Kasari et al., 2014) or multiple naturalistic
routines (i.e., play, book reading, snack; Romski et al., 2010).
Type of AAC
In the single-case studies, 51% of the participants
(n = 45) used a non-SGD such as communication board
or single picture symbol, and 49% (n = 43) used an SGD
such as a dedicated AAC device or tablet with an AAC
application. Of the participants who used SGDs, 53%
(n = 23) used SGDs with synthesized voice output, 26%
(n = 11) used devices with digitized speech output, and the
type of voice output was not reported for 21% (n = 9). All
participants in the group studies used SGDs. The Romski
et al. (2010) study used digitized speech, and the Kasari
et al. (2014) study used synthesized speech.
Nature of Input
The interventions varied in terms of the correspon-
dence between the aided input and the spoken input provided
by the partners. See Table 2 for specific examples. Eighteen
single-case studies involving 60 participants (68%) included
key word aided input. Fewer studies included full-phrase
aided input associated with one symbol (i.e., four single-case
studies involving 13 participants). The smallest number of
studies (three studies, nine participants) included full-phrase
aided input composed of multiple symbols. For participants
using SGDs, in addition to the indicated symbol and the
spoken input, they also received auditory input from the voice
output on the device. In regard to the timing of the aided
input relative to the spoken input, 42 participants (48%)
received simultaneous spoken and aided input, and 34 par-
ticipants (39%) received asynchronous spoken and aided
input (i.e., spoken input preceded or followed by aided input).
Specific information regarding the timing of spoken and
aided input was not available for 14% of the participants
(n = 12). The Romski et al. (2010) study used key word
aided input that was simultaneous with spoken input. Spe-
cific information regarding the nature of input was not pro-
vided for the Kasari et al. (2014) study.
Intervention Components
Twenty-one single-case studies involving 73 partici-
pants (83%) included multicomponent interventions, and five
single-case studies involving 15 participants (17%) included
aided AAC input in isolation. As indicated in Table 5, the
multicomponent interventions included various combinations
of the following components in addition to aided AAC
input: (a) expectant delay, (b) open-ended questions, (c) con-
tingent responding, (d) prompting (spoken, gestural, or
physical), and (e) expansions or recasts. The greatest
O’Neill et al.: Effects of Aided AAC Input 1755
Table 5. Specific intervention components of included studies in addition to aided AAC input.

Expectant Open-ended Contingent Direct Expansion

Study delay question responding prompting or recast

Acheson (2006)a X X X X
Beck et al. (2009) X X X
Binger & Light (2007) X X
Binger et al. (2008)a X X X
Binger et al. (2010)a X X X X
Binger et al. (2011) X
Dada & Alant (2009)
Dexter (1998) X X
Drager et al. (2006)
Hall (2014) X X
Harris & Reichle (2004)
Ho (2000)
Hughes et al. (2000)a X X X
Iacono & Duncum (1995) X X X
Johnston, McDonnell, et al. (2003)a X X X
Johnston, Nelson, et al. (2003)a X X X
Kasari et al. (2014)a X X X X
Kent-Walsh (2003)a X X X
Kent-Walsh et al. (2010)a X X X
Kent-Walsh, Binger, & Buchanan (2015)a X X X X X
Pitman (2015)a X X X X
Romski et al. (2010)a X
Rosa-Lugo & Kent-Walsh (2008)a X X X
Sennott (2013)a X X
Solomon-Rice & Soto (2014) X X
Tönsing (2016) X X X X
Trembath et al. (2009)a X
Trottier et al. (2011)a X X
Total number of studies (28) 20 13 16 12 6

Note. AAC = augmentative and alternative communication.

a
The study that included instruction for natural partners to implement aided AAC input.

number of studies included the following components in
addition to aided AAC input: expectant delay (n = 20,
77%), contingent responding (n = 16, 62%), and/or open-
ended questions (n = 13, 50%). The interventions were also
categorized according to whether or not partner instruction
was a component of the intervention. Fourteen single-
case studies involving 44 participants included instruction
for natural partners (e.g., parents, teachers, paraprofessionals)
to provide aided AAC input (see Table 5); the remain-
ing studies utilized researchers or other professionals
who had already been instructed in this technique. In the
multicomponent interventions that included partner in-
struction (e.g., Binger et al., 2008), partners were often
instructed to use several intervention techniques in addi-
tion to aided AAC input. Both group studies included
multicomponent interventions and instruction for natural
partners.
Intervention Intensity
Studies were also coded for the length, frequency,
and number of intervention sessions as well as the rate
of aided AAC input within each intervention. Eighty-five
percent of the single-case studies involving 74 partici-
pants (84%) reported data on the length of intervention
sessions, which ranged from 5 to 60 min per session. To
calculate the overall time spent in intervention for each
participant, the number of sessions per participant was
multiplied by the reported length of session. Of the stud-
ies that reported time spent in intervention, the greatest
proportion of participants (n = 24, 32%) spent 1–2 hr in
intervention across the length of the study, 31% (n = 23)
spent 1 hr or less, 22% (n = 16) spent between 2 and 5 hr
in intervention, and 15% (n = 11) spent 5 hr or more.
Seven studies (27%) reported data on the frequency of
intervention sessions per week, which ranged from one
time per week to daily across these studies. The exact
number of aided AAC inputs during intervention sessions
was provided for eight studies (29%), and it ranged from
10 aided AAC models per 15-min session (e.g., Binger
et al., 2011) to 100 per 20-min session (e.g., Solomon-
Rice & Soto, 2014), that is, rates of less than one aided
AAC model per minute to approximately five models per
minute.
Participants in the Romski et al. (2010) study spent
12 hr in intervention, whereas participants in the Kasari
et al. (2014) study spent 48 hr in intervention. The Kasari
et al. study reported that a minimum of 50% of all spoken
language was modeled, whereas the Romski et al. study did
not specify the rate of modeling.

1756 Journal of Speech, Language, and Hearing Research • Vol. 61 • 1743–1765 • July 2018
Dependent Variables
Data were extracted for outcomes related to both
comprehension and expression. In addition, outcomes were
classified according to language domain (i.e., pragmatic,
semantic, or morphosyntactic). Outcomes were reported
for expression (n = 110, 90%) much more frequently than
for comprehension (n = 12, 10%). Only four single-case
studies (Dada & Alant, 2009; Drager et al., 2006; Harris
& Reichle, 2004; Ho, 2000) reported outcomes related to
comprehension. In terms of language domain, outcomes
related to pragmatics were reported most often (41%; e.g.,
number of communicative turns; e.g., Kent-Walsh et al.,
2010). Fewer participants had outcomes reported related
to semantics (29%; e.g., number of symbols correctly pro-
duced; e.g., Drager et al., 2006) or morphosyntax (25%;
e.g., percent correct use of target morphemes; e.g., Binger
et al., 2011).
Both group studies reported outcomes related to
expression only. The Kasari et al. (2014) study reported
outcomes related to both pragmatics (e.g., number of
utterances) and semantics (e.g., different root words).
The Romski et al. (2010) study reported outcomes primar-
ily related to semantics (e.g., vocabulary size).
Effect Size Findings for Single-Case Studies
Currently, there are no accepted methods to aggre-
gate data from group and single-case designs (Schlosser
& Wendt, 2008); therefore, effect sizes are presented sepa-
rately here.
Overall Effects
The mean effect size (Tau-U) aggregated across the
single-case studies was .83 (SD = .24, range = −.18 to 1.0),
indicating a very large overall effect (Vannest & Ninci,
2015) of interventions that included aided AAC input on
the communication of individuals with developmental dis-
abilities who used AAC. Table 3 provides the gain scores
and Tau-U values for individual participants by study.
Table 6 provides the mean Tau-U values and standard devi-
ations by participant, intervention, and outcome characteris-
tics aggregated across studies when comparing baseline
with intervention phases. It was not possible to calculate
effect sizes across maintenance and generalization phases
because many studies did not include the data required
to make these calculations. Most aggregated Tau-U scores
for participant, intervention, and intervention outcome char-
acteristics indicated large or very large effect sizes.
Participant Characteristics
The interventions including aided AAC input had a
very large effect size for children and adolescents (range =
.83–.90) and a moderate effect size (Tau-U = .37) for adults
with developmental disabilities. The aggregated effect
sizes indicated large effect sizes for interventions across
participants with diagnoses of ASD and intellectual or
developmental disability, with very large effect sizes for
interventions with participants with Down syndrome, cere-
bral palsy, and other diagnoses. Effect sizes were large
to very large across participants with varying levels of lan-
guage skills (range = .68–.92).
Intervention Characteristics
Interventions that investigated aided AAC input
implemented by partners who were researchers, parents,
peers, paraprofessionals, or speech-language pathologists
all resulted in very large effect sizes (range = .84–.97). A
moderate effect size (.52) resulted for interventions that
included multiple communication partners. Outcomes
yielded a very large effect size for interventions using SGDs
(.88) and a large effect size for interventions using non-
SGDs (.79). Interventions that included key word aided in-
put or full-phase aided input composed of multiple aided
symbols resulted in very large effect sizes (.84–.91), whereas
full-phrase input associated with a single symbol resulted in
a large effect size (.72). Providing aided input simultaneously
with speech resulted in a large effect size (.77), whereas pro-
viding aided input in an asynchronous manner resulted in
a very large effect size (.93). Interventions including one
or more components in addition to aided AAC input had a
very large effect size (.84), whereas interventions that only
included aided AAC input had a large effect size (.77). With
regard to partner instruction, interventions that included
partner instruction had a very large effect size (.88), whereas
interventions that did not include partner instruction had a
large effect size (.78). The amount of time spent in inter-
vention was associated with very large effects for the fol-
lowing durations: 1 hr or less, and 1–2 and 2–5 hr (range =
.84–.91). A moderate effect (.54) resulted from cases in which
more than 5 hr was spent in intervention.
Intervention Outcome Characteristics
Outcomes related to expression resulted in a very
large effect size (.84), and outcomes related to compre-
hension resulted in a large effect size (.76). Across the
language domains of pragmatics, semantics, and morpho-
syntax, interventions yielded large to very large effect sizes
(range = .76–.93).
Effect Size Findings for Group Studies
Table 4 lists effect sizes calculated for each of the
group studies. In the Kasari et al. (2014) study, the effect
sizes were medium across the three dependent variables
(i.e., spontaneous communicative turns, total number of
comments, and total different root words) across the three
measurement occasions at Weeks 12, 24, and 36 (i.e., range
d = 0.21–0.62), with an overall trend for higher performance
in the condition that included aided AAC input in com-
bination with the naturalistic behavioral intervention com-
pared with the group that received the naturalistic behavioral
intervention in isolation. In the Romski et al. (2010) study,
there were medium effect sizes on the first measurement
occasion at Session 18 (i.e., d = 0.71) and the second measure-
ment occasion at Session 24 (i.e., d = 0.52), with participants
O’Neill et al.: Effects of Aided AAC Input 1757
Table 6. Results of single-case studies by participant, intervention, and intervention outcome characteristics.

Measure Number of cases Tau-U Level of effect SD

Participant characteristics
Age
Toddler 6 .90 Very large 0.13
Preschool 47 .83 Very large 0.21
Elementary 58 .87 Very large 0.20
Adolescent 4 .86 Very large 0.15
Adult 7 .37 Moderate 0.28
Diagnosis
Autism 34 .74 Large 0.27
Down syndrome 19 .90 Very large 0.12
Cerebral palsy 21 .86 Very large 0.12
Intellectual/developmental disability 20 .75 Large 0.37
Developmental delay 10 .94 Very large 0.11
Childhood apraxia of speech 6 .97 Very large 0.06
Other 11 .88 Very large 0.23
Receptive language skills
Within normal limits 19 .91 Very large 0.15
Delayed or deviant 85 .86 Very large 0.19
Receptive language age
6–24 months 10 .68 Large 0.21
24–36 months 22 .92 Very large 0.14
36–48 months 23 .87 Very large 0.21
> 48 months 10 .89 Very large 0.11
Intervention characteristics
Partner
Researcher 47 .84 Very large 0.17
Parent 19 .97 Very large 0.10
Peer 9 .89 Very large 0.14
Paraprofessional 22 .94 Very large 0.22
SLP 3 .90 Very large 0.18
Multiple partners 19 .52 Moderate 0.30
Aided AAC system
SGD 56 .88 Very large 0.23
Non-SGD 66 .79 Large 0.24
Nature of input
Key word 88 .84 Very large 0.24
Full phrase, multiple symbols 9 .91 Very large 0.15
Full phrase, single symbol 13 .72 Large 0.15
Timing of input
Simultaneous 57 .77 Large 0.26
Asynchronous 51 .93 Very large 0.17
Intervention components
Multicomponent 102 .84 Very large 0.26
Isolated 20 .77 Large 0.13
Partner instruction
Yes 60 .88 Very large 0.22
No 62 .78 Large 0.24
Time spent in intervention
1 hr or less 32 .91 Very large 0.20
1–2 hr 37 .88 Very large 0.19
2–5 hr 19 .87 Very large 0.10
> 5 hr 15 .54 Moderate 0.31
Outcome characteristics
Nature of outcome measure
Expression 96 .84 Very large 0.25
Comprehension 12 .76 Large 0.10
Language domain
Pragmatic 57 .76 Large 0.31
Semantic 35 .85 Very large 0.15
Morphosyntactic 30 .93 Very large 0.11

Note. The number of cases does not always equal the number of participants included because of the variability across studies in the number
of dependent variables reported. AAC = augmentative and alternative communication; non-SGD = non–speech-generating device; SLP =
speech-language pathologist.

1758 Journal of Speech, Language, and Hearing Research • Vol. 61 • 1743–1765 • July 2018
in the augmented communication input group producing
more spoken words than those in the group receiving only
spoken communication input. Outcomes comparing the
overall number of symbols (spoken and graphic) produced
could not be calculated based on the data included in the
published study.
Quality of Evidence
The quality of each study was also evaluated to deter-
mine the level of certainty that the intervention implemented
in the study resulted in a change in the dependent variable
(see Tables 3 and 4). Of the 28 included studies, 15 studies
met the highest standards and were rated conclusive. An
additional five studies presented preponderant evidence, in-
dicating that there were minor methodological issues, but
outcomes were more likely to have occurred because of the
AAC intervention than not. The remaining eight studies
had significant limitations in the methods that precluded
determination of the effectiveness of the intervention. These
limitations typically related to flaws in design (e.g., failure
to establish stable baseline, lack of systematic replication
of the independent variable) or missing or inadequate pro-
cedural integrity or reliability.
Discussion
The results of this systematic review provide evidence
that individuals with developmental disabilities and com-
plex communication needs associated with various diagnoses,
ages, and language skills can derive benefits in communica-
tion as a result of interventions that include aided AAC
input. The average Tau-U score of .83 for single-case stud-
ies and the medium effects resulting from group studies
indicate that these interventions had generally positive and
large effects on the communicative outcomes measured.
The remainder of the discussion will be organized by the
aims of the study outlined in the introduction.
Effects of Aided AAC Input on
Comprehension and Expression
The findings of this review suggest that aided AAC
input may serve as a mechanism to support comprehen-
sion (e.g., Drager et al., 2006; Harris & Reichle, 2004) and
model expressive output (e.g., Binger et al., 2010; Kent-
Walsh et al., 2010) for individuals who require AAC, much
like spoken language models serve as a mechanism for lan-
guage acquisition in children developing typically (Hoff,
2006). Partners in the included studies provided linguistic
input using both speech and aided AAC. Pairing the spoken
word with the aided symbol may have served to rebalance
input–output asymmetries and improve comprehension
of the partner’s message (Romski & Sevcik, 1993; Smith
& Grove, 2003). The spoken input provided by partners
was often simplified and likely delivered at a slow rate be-
cause of the effort required to locate symbols on the aided
displays, which may have promoted comprehension and
allowed learners more time to process the input (Smith,
2015). Positive gains noted in expressive outcomes (e.g.,
communicative turns, multisymbol messages) suggest that
aided AAC input was also effective to model expressive
output. Partners provided a model of how the system could
be used and for what purposes (Sevcik et al., 1995).
Despite the positive gains noted in interventions that
targeted both comprehension and expression, very few
studies examined outcomes related to comprehension, and
these studies were limited to receptive vocabulary without
considering comprehension of morphosyntax (Dada &
Alant, 2009; Drager et al., 2006; Harris & Reichle, 2004;
Ho, 2000). There are several possible reasons for the cur-
rent lack of investigations in this area. First, the focus
of intervention for individuals who require AAC typically
centers on language expression rather than comprehension
(Light, 1997; Romski & Sevcik, 1993). This places out-
comes related to expression in the forefront to the neglect
of outcomes related to comprehension. Second, standardized
measures of early comprehension development are often
unsuitable for individuals with complex communication
needs (Light, 1997). Informal assessment procedures may
be required making it more difficult to measure compre-
hension gains. Third, comprehension is difficult to assess
because it “takes place in the mind of the listener” (Miller
& Paul, 1995, p. 7). Unlike expression that results in an
observable behavior (e.g., spoken word, activating graphic
symbol on an SGD), comprehension must be inferred from
a behavioral response. However, this review demonstrates
that comprehension can be reliably assessed within AAC
interventions, (e.g., Dada & Alant, 2009; Drager et al., 2006;
Harris & Reichle, 2004), and it is a critical area that deserves
attention.
Effects by Participant, Intervention,
and Outcome Characteristics
Effects by Participant Characteristics
It is encouraging that the effects of interventions
involving aided AAC input were strong across a range of
ages, diagnoses, and language levels. However, the effects
were not as strong for adults (i.e., individuals over the age
of 22 years) or for those at the earliest stages of lan-
guage development (i.e., receptive language age of less than
24 months). There may be a number of hypotheses related
to the interventions and/or the participants to explain these
results. For instance, the interventions were very short,
and the aided AAC input was diffuse. Adults with complex
communication needs may have a history of failure or
learned helplessness that may require longer interventions
to learn new skills. Children who are early language learners
may also require longer interventions that provide more
time to acquire new language skills. In addition, it is possi-
ble that interventions using aided graphic symbols may
not be developmentally appropriate for individuals at the
earliest stages of communication development (e.g., indi-
viduals who are preintentional). Caution should be used in
interpreting these results given the small number of adults
O’Neill et al.: Effects of Aided AAC Input 1759
(n = 7) and individuals in the 0- to 24-month language age
(n = 8).
It is also important to note that the effects were strong
for individuals with ASD, with a Tau-U of .74 indicating a
large overall effect. Despite previous research that indi-
cates that individuals with ASD may only attend to input
from one sensory modality (i.e., auditory or visual; e.g.,
Carr et al., 1978) or may have difficulty with imitation (e.g.,
Toth et al., 2006), it appears that the participants with ASD
included within this review derived benefits from aided
AAC input that included simultaneous auditory and visual
input.
Effects by Intervention Characteristics
Interventions that included SGDs resulted in a slightly
higher effect size than interventions that included non-SGDs.
Aided AAC input provided with a non-SGD generally in-
cludes two sources of input: (a) the spoken input from the
partner and (b) the indicated AAC symbols. When aided
input is provided with an SGD, the voice output serves as a
third source of auditory input. Previous work has suggested
that the auditory input from an SGD may be an integral
part of AAC interventions because it may support compre-
hension and help to reconfigure the input–output asymmetry
in interactions involving individuals who use AAC and
their partners who use natural speech (Sevcik & Romski,
2002; Smith & Grove, 2003). The findings of this review
may lend some support to this assertion. However, interven-
tions with both SGDs and non-SGDs resulted in very
large or large effect sizes, suggesting that aided AAC in-
put with or without the inclusion of voice output can sup-
port improved communicative outcomes. Regardless of the
type of AAC, partners generally provided both spoken and
graphic (i.e., symbol) inputs for the individual who used
AAC. Therefore, the individual using AAC continued to
receive speech input in conjunction with aided symbols,
which may be a critical component of interventions that
include aided AAC input.
Full-phrase multisymbol input, in which each sym-
bol corresponded with one spoken word or morpheme, ap-
peared to result in the most positive outcomes. However,
caution should be used in interpreting these results because
a limited number of participants (n = 9) received this type
of input. It could be that grammatical input provided in
well-formed sentences is more facilitative of communica-
tion outcomes compared with telegraphic aided input (i.e.,
key word input) or full-phrase single-symbol input. Fey,
Long, and Finestack (2003) identified the use of grammati-
cal models as an important practice for children with spe-
cific language impairment. The same may apply in regard
to aided input for individuals who use AAC.
Also interesting to note was that interventions that
included asynchronous aided input (i.e., aided input pro-
vided before or after spoken input) yielded a higher effect
size than interventions that included simultaneous spoken
and aided input. It is possible that simultaneous spoken
and aided input may cause partners to change their spoken
input to accommodate the aided AAC system, resulting
1760 Journal of Speech, Language, and Hearing Research • Vol. 61 • 1743–1765 • July 2018
in a telegraphic spoken model, whereas asynchronous
input may be more facilitative of a grammatical spoken
model. In addition, simultaneous input may require di-
vided attention by the individual using AAC to attend
to both the partner and the AAC system simultaneously,
which could increase cognitive load compared with asyn-
chronous input.
Aided AAC input seems to be effective when used
in isolation or in combination with other intervention com-
ponents. A post hoc analysis of effect sizes by intervention
component revealed that, when outcomes were aggregated
across studies including each particular component (e.g.,
expectant delay, contingent responding), the resulting effect
sizes were similar (range = .81–.84). For example, the
aggregated effect size for all studies that included an ex-
pectant delay was .84, and the aggregated effect size for
studies that included contingent responding was .83. One
exception was that the effect size for studies that included
expansion was slightly larger (Tau-U = .91). However,
only six studies involving 16 participants (18%) included
this component. Use of expansions and recasts may be
a critical element within interventions that include aided
AAC input. Evidence shows that recasts and expansions
facilitate language expression for children learning spoken
language by allowing children to compare their utterance
with the adult standard. Because recasts and expansions
share words with the child’s original utterance, cognitive
and working memory demands are decreased, allowing chil-
dren to focus on linguistic content (e.g., Proctor-Williams,
Fey, & Loeb, 2001). This may be especially important for
individuals with disabilities who require AAC as they may
experience vulnerabilities in working memory (Thistle &
Wilkinson, 2013).
Interventions including partner instruction for natu-
ral communication partners to provide aided AAC input
yielded a very large effect size. This coincides with find-
ings from the recent meta-analysis by Kent-Walsh, Murza,
Malani, and Binger (2015), which found that partner in-
struction interventions have positive effects on communica-
tion performance of individuals using AAC.
Finally, there are a few considerations regarding the
intensity of intervention. The effects were very large for
interventions less than 5 hr in total time (range = .84–.91).
Therefore, interventions that include aided AAC input have
the potential to result in positive outcomes over a short
period, at least for some participants. It should be noted
that, within the single-case intervention studies evaluated,
intervention was typically terminated once participants
attained criterion. Therefore, intervention times are neces-
sarily shorter for those participants who benefited the most,
which could inflate the effect size for shorter intervention
periods. One area of concern is that the effect for partici-
pants who spent the most time in intervention (> 5 hr) was
only moderate. There are several possible reasons for this
finding. First, it included only a limited number of partici-
pants (n = 15), of whom nine were from studies that presented
inconclusive evidence (i.e., Beck et al., 2009; Hall, 2014),
lending caution to this interpretation. Second, it included
participants with the lowest receptive language age (e.g.,
Drager et al., 2006).
Very few studies included information regarding the
frequency of intervention sessions and the rate of aided
AAC input during intervention sessions. Rate of aided
AAC input (i.e., number of aided inputs divided by length
of session in minutes) could only be calculated for six
single-case studies involving 19 participants (21%). A
post hoc analysis of these studies indicated a larger effect
size for studies that included aided input at a rate of one
or more per minute (Tau-U = .87) compared with studies
that included aided input at a rate of less than one per minute
(Tau-U = .71). This suggests that a higher rate of aided
input will result in more positive results; however, this
interpretation is based on a limited number of studies/
participants for whom these data were available. When
reported, rates of aided input were generally low (i.e.,
about two per minute). The low rates observed could be
related to the increased motor, cognitive, linguistic, and
visual demands placed on partners who provide aided
input.
Effects by Outcome Characteristics
Interventions including aided AAC input had positive
effects across the domains of pragmatics, semantics, and
morphosyntax. Studies examining semantics evaluated both
expressive vocabulary (e.g., number of different concepts
expressed; Kent-Walsh et al., 2010) and receptive vocabu-
lary (e.g., number of symbols understood; Drager et al.,
2006). Studies examining outcomes related to morphosyn-
tax evaluated only expressive morphosyntax (e.g., frequency
of multisymbol messages; Binger et al., 2010), whereas
no studies evaluated receptive morphosyntax.
Limitations of the Evidence
Several limitations of the existing evidence warrant
consideration. A primary limitation is the amount of varia-
tion overall in the goals and delivery of aided AAC input
across studies (e.g., rate, timing, relation to spoken input,
inclusion of other intervention components) and the resulting
difficulty specifying best practices for specific participants/
circumstances (Allen et al., 2017). Given the consistent and
strong effects across participants, partners, and contexts
noted within interventions that included aided AAC input
(alone or in isolation), it seems likely that this intervention
strategy does have a positive effect on communicative
outcomes for individuals who use AAC; however, the evi-
dence cannot be considered conclusive until specific imple-
mentation factors associated with aided AAC input (e.g.,
language and cognitive skills of participants, intensity of
intervention, inclusion of other intervention components)
are consistently and thoroughly described and analyzed.
For example, it is possible that other strategies used in com-
bination with aided AAC input such as expectant delay,
contingent responding, and/or expansions and recasts resulted
in positive effects or that these additional intervention com-
ponents amplified the effects of aided AAC input.
A second limitation is that all of the studies included
were short term (e.g., 3–28 weeks) and targeted specific
communication skills that often fell into one language
domain and focused on either comprehension or expres-
sion. Very little is known about the effects of aided AAC
input on language development more generally. In addi-
tion, aided AAC input typically occurred in specific activi-
ties or times of the day, rather than throughout the day
as in typical language development. Little is known about
uptake of the strategy by natural communication partners
as well as long-term use in the natural environment.
Another important consideration is the actual behav-
iors of partners who are using aided AAC. The partners
in the studies generally selected key AAC symbols in tele-
graphic form (i.e., key word aided input), rather than pro-
viding full models of AAC use. These telegraphic models
may guide the production of specific target behaviors but
may potentially limit development of comprehension and
advanced expressive skills for individuals who use AAC
(Fey, 2008). Fey (2008) recommended that spoken models
should include complete syntax, but he noted that aided
models “cannot correspond one-to-one with target gram-
mar” (Fey, 2008, p. 48). Overall, it seems that grammar fa-
cilitation for individuals with complex communication
needs is a complex process that may not be fully supported
using only aided AAC input. This may be related to vari-
ous reasons such as the system missing necessary function
words and morphemes as well as the time and effort re-
quired to model full syntax using aided AAC systems (Sut-
ton, Soto, & Blockberger, 2002).
In addition, it is plausible that partners will only pro-
vide aided input using symbols that the partner has already
acquired or only those symbols already available on the
display. This could result in impoverished language input
and may limit the individual who uses AAC from learn-
ing new concepts that would enhance the form and content
of his or her language. Existing investigations have pro-
vided little guidance regarding the symbols that should
be modeled and how they relate to the learner’s existing
repertoire.
Two final limitations of the existing evidence warrant
consideration. One is that there were only two comparison
studies. These two group studies provided preliminary
evidence of the relative effectiveness of interventions that
included aided AAC input compared with those that do
not include this strategy; however, a definitive conclusion
cannot be reached. Second, the success of interventions that
included aided AAC input relies largely on visual attention
to the aided AAC system by the individual with complex
communication needs (Rose, Trembath, & Bloomberg,
2016). None of the studies in the current review evaluated
this important learner variable that could impact the out-
comes of the interventions.
Clinical Implications
There are several broad clinical implications that emerge
from this systematic review. First, the findings suggest that
O’Neill et al.: Effects of Aided AAC Input 1761
there is evidence to support the use of partner aided AAC
input to enhance a wide range of communication out-
comes for individuals who use AAC of various ages, diag-
noses, and language abilities. Second, these interventions
can be effective when implemented by everyday commu-
nication partners in naturally occurring environments over
relatively short periods. Instruction for parents, school
employees, and other communication partners should
result in improved outcomes for individuals who use AAC.
Finally, the review demonstrated that aided AAC input
can be effective by itself or in combination with other key
intervention components. Therefore, clinicians can cus-
tomize interventions to best meet the needs of individuals
who require AAC within the demands of busy real-world
environments.
Given the variation in the implementation of aided
AAC input across studies and the limited research to date,
it is difficult to provide specific recommendations regard-
ing the provision of aided AAC input (Allen et al., 2017).
Although future research is necessary to provide conclusive
recommendations regarding how partners should provide
aided AAC input, this review lends support to a few spe-
cific behaviors that may be effective. First, partners should
provide aided AAC input by selecting AAC symbol(s) in
conjunction with grammatically correct spoken phrases/
sentences. The aided input may include either one or two
key words, or full phrases. It may be beneficial to provide
aided AAC input at a rate of more than one time per min-
ute. It may also be beneficial for partners to utilize other
interaction strategies in combination with aided input (e.g.,
expectant delay, expansions, or recasts).
Limitations of This Systematic Review
One limitation of this review is that, for single-case
studies, this review only compared baseline phase mea-
surements with intervention phase measurements, which
limits an evaluation of the effects of the interventions in
the context of generalization or maintenance phases. Sec-
ond, it was not possible to aggregate results across the
single-case and group-design studies, limiting the synthesis
of results and conclusions. Third, this review considered
only AAC interventions that included aided AAC input,
whereas studies related to unaided AAC input were ex-
cluded. Finally, although an attempt was made to identify
all studies that used aided AAC input, it is possible that
some have been left out. This review only included studies
that were published or approved as dissertations or theses;
therefore, the data set may have been influenced by pub-
lication bias (Rothstein et al., 2005).
Future Research
This systematic review suggests the potential posi-
tive benefits of interventions that include aided AAC input;
however, future research is required to advance under-
standing and improve outcomes for individuals who use AAC.
There are several areas in which the existing evidence is
1762 Journal of Speech, Language, and Hearing Research • Vol. 61 • 1743–1765 • July 2018
limited, and additional research is needed to confirm or
refute the results of the current review. These areas include
(a) investigation of the effects of aided AAC input on adults
and individuals with the lowest receptive language age; (b)
investigation of the effects of aided AAC input as the sole
independent variable, rather than as part of a multicompo-
nent intervention; and (c) investigation of the effects of
aided AAC input on comprehension, particularly compre-
hension of morphosyntax. In addition, there are several
areas in which there is virtually no existing evidence, mak-
ing them high priorities for future research, including (a) in-
vestigation of strategies to reduce the demands on partners
implementing aided AAC input, (b) investigation of the
mechanisms by which aided AAC input impacts compre-
hension and expression to advance theory, and (c) investi-
gation of the effects of partner use of AAC (aided and
unaided) on long-term language development (i.e., compre-
hension and expression across all domains including prag-
matics, semantics, and syntax). To begin to investigate
these areas, it is critical that future studies include a thor-
ough description of implementation factors associated
with aided AAC input (e.g., relationship between spoken
and aided input, timing of input, type of AAC). Specifi-
cally, future studies should include specific information re-
garding intervention intensity (number and frequency of
sessions), as well as frequency of aided AAC input (num-
ber of aided inputs per session), to allow for replicability
and to provide guidance for clinical practice (Allen et al.,
2017). Studies should also include a thorough description of
the cognitive–linguistic skills of participants and make ef-
forts to evaluate the effects of aided AAC input on the gen-
eralization and maintenance of communication outcomes.
Conclusion
Since Goossens (1989) first recommended the use of
aided language stimulation nearly two decades ago, aided
AAC input has become a widely recommended component
of AAC interventions, both clinically and in research
studies. This review provides empirical support for the
use of this intervention strategy by a variety of partners
to improve communicative outcomes for a wide range of
individuals with developmental disabilities who use AAC.
Ultimately, aided AAC input may reduce input–output
asymmetry and improve expressive and receptive language
for individuals who use AAC, thus enhancing their com-
munication skills and their overall quality of life.
Acknowledgment
This project was conducted in partial fulfillment of the first
author’s doctoral training. It was supported, in part, by funding
from the (a) Penn State AAC Leadership Project, a doctoral training
grant funded by U.S. Department of Education Grant H325D110008
(awarded to Tara O’Neill, principal investigator: Janice Light), and
(b) Rehabilitation Engineering Research Center on Augmentative
and Alternative Communication, funded by Grant 90RE5017
from the National Institute on Disability, Independent Living, and
Rehabilitation within the Administration for Community Living of
the U.S. Department of Health and Human Services (principal in-
vestigators: David Beukelman, Susan Fager, Melanie Fried-Oken,
Tom Jakobs, Janice Light, and David McNaughton).
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