AUGMENTATIVE AND ALTERNATIVE COMMUNICATION

2018, VOL. 34, NO. 3, 206–218

https://doi.org/10.1080/07434618.2018.1470668

RESEARCH ARTICLE

The effects of literacy interventions on single-word reading for individuals who

use aided AAC: a systematic review
Kelsey Mandak, Janice Light and Susannah Boyle
The Pennsylvania State University, University Park, PA, USA

ABSTRACT ARTICLE HISTORY

The purpose of this systematic review was to investigate the effects of instruction on single-word read- Received 2 October 2017
ing of individuals who use aided augmentative and alternative communication (AAC). A systematic Revised 21 March 2018
search identified nine single-case experimental design studies that involved 24 individuals who used Accepted 25 April 2018
aided AAC. Overall, the evidence indicated that instruction had positive effects on reading at the sin-
KEYWORDS
gle-word level for individuals across ages and diagnostic categories (i.e., autism spectrum disorder Systematic review; single-
(ASD), cerebral palsy (CP), Down syndrome, and intellectual disability). The studies revealed that these word reading; augmentative
effects were consistent across a range of participant, intervention, and outcome measure characteris- and alternative
tics. Phonological approaches, sight-word approaches, and a combination of these two approaches communication (AAC)
yielded very large effects. Despite the large effects, the findings must be viewed with caution due to
limitations in the number of studies and participants and limitations in the reporting of detailed partici-
pant and intervention characteristics across the studies. In order to determine which interventions are
most effective for which individuals, future research directions are discussed, including the need for
greater specificity in describing participant and intervention characteristics, investigations into how to
best measure intervention outcomes without requiring spoken responses, and investigations into lon-
ger-term interventions targeting a wider range of reading skills.

Introduction (Adams, 1990). One critical component of skilled reading is

In today’s world, the acquisition of literacy skills is necessary
to participate successfully in education, employment settings,
and society. The ability to read and write allows individuals
to build relationships, make choices, and access the technol-
ogy and tools of the 21st century (Light & McNaughton,
2013). Although it is well agreed that the acquisition of liter-
acy skills is a highly desired skill for all, the acquisition of
these skills is especially important for individuals with com-
plex communication needs who use augmentative and alter-
native communication (AAC) (Foley & Wolter, 2010; Light &
McNaughton, 2013). Not only do literacy skills promote par-
ticipation in society, but they also support generative lan-
guage, communicative competence, and independence for
individuals who use AAC (Light & McNaughton, 2013).
Despite this clear importance, it has been estimated that up
to 90% of individuals with complex communication needs
enter adulthood without functional literacy (Foley & Wolter,
2010). Without the acquisition of literacy, individuals who use
AAC are bound to be restricted in their participation in edu-
cation, employment, relationships, and society. Thus, there is
an urgent need to find effective ways to promote literacy
among individuals who use AAC, and so prevent such nega-
tive outcomes.
Skilled reading relies on the acquisition and integration of
knowledge and skills across a number of domains
the ability to read individual words. Adams asserts that,
unless the processes involved in word recognition are work-
ing properly, nothing else in the complex reading system can
run properly. Although word recognition skills are insufficient
to become a skilled reader, they are essential. Readers who
fail to accurately read more than a few individual words will
not comprehend the written text. It is well supported that
poorly developed word recognition skills are the most perva-
sive source of reading problems, are more prevalent in indi-
viduals with disabilities, and increase an individual’s risk for
reading failure (Adams, 1990; Perfetti, 1985; Share &
Stanovich, 1995; Spector, 2011).
When approaching a written word, an individual may
either decode the word or recognize the word by sight. If
decoding, the individual looks at the letters, retrieves the
sound of each letter, blends the sounds, and thus deter-
mines the word (Adams, 1990). Alternatively, an individual
may focus primarily on the orthography of the word and
associate it with its referent by sight (Browder & Xin, 1998).
Single-word reading is vital as, once an individual with com-
plex communication needs can decode or recognize words
by sight, this opens the door to meaningful reading experi-
ences (Light, McNaughton, Weyer, & Karg, 2008).
Unfortunately, many individuals who require aided AAC
never acquire the skills to read single words (Foley &
Wolter, 2010).

CONTACT Kelsey Mandak kch5029@psu.edu Department of Communication Sciences and Disorders, The Pennsylvania State University, Ford Building,
University Park, PA 16802, USA
ß 2018 International Society for Augmentative and Alternative Communication

Although there has been some research investigating
interventions to teach single-word reading skills, there has
been no comprehensive review of the evidence to date. In
order to provide effective word reading instruction for indi-
viduals who use AAC, interventions must be critically
reviewed to ensure the utilization of evidence-based instruc-
tion. Systematic reviews are essential because they provide
access to pre-filtered evidence, which reduces the time and
expertise required to locate and review individual studies
(Schlosser, Wendt, & Sigafoos, 2007). They also inform future
research by highlighting gaps in the current evidence base.
Two previous reviews (i.e., Barker, Saunders, & Brady,
2012; Machalicek et al., 2010) have investigated the research
on literacy interventions for students who use AAC; however,
each had its own limitations. Machalicek et al. evaluated
research on literacy interventions for individuals with physical
and developmental disabilities who used aided AAC, with a
wide range of intervention outcomes. They concluded that
students with physical and developmental disabilities who
used aided AAC seemed to benefit from receiving literacy
instruction in typical contexts (i.e., contexts including direct
instruction, scaffolding, and storybook reading interactions).
Although the authors reported positive findings, the results
should be interpreted with caution, because they included
non-experimental designs, a broad range of participants, and
a wide range of intervention outcomes including emergent
literacy skills, phonological awareness, decoding, and sym-
bolic communication. With so few studies, involving only a
small number of participants, it is difficult to draw any con-
clusions regarding the effectiveness of literacy instruction.
Barker et al. (2012) narrowed their search and specifically
looked at the component skills of decoding and the acquisi-
tion of phonological awareness skills for students with severe
speech impairments who used unaided or aided AAC. Rather
than reviewing the outcomes of literacy instruction on indi-
vidual participants, the review focused on the reporting of
participant heterogeneity, assessment, and instruction modifi-
cations, and the strength of the research designs. No conclu-
sions could be made regarding the effectiveness of the
literacy interventions.
No review exists that evaluates experimental designs
investigating instruction on single-word reading of individu-
als who use aided AAC. The present review synthesized high-
quality studies in order to provide clinicians and teachers
with the evidence to deliver evidence-based instruction. Its
purpose was to answer the following research questions:
What are the effects of intervention on the single-word read-
ing of individuals who use aided AAC? and Do effects differ
across participant and intervention characteristics? The cur-
rent review differs from prior reports by (a) including only
experimental designs, (b) focusing on one intervention out-
come—single-word reading, (c) including both phonological
and sight-word approaches to intervention, and (d) focusing
on individuals who use aided AAC.
Method
The review protocol used was developed with reference to the
Cochrane Collaboration Handbook (Higgins & Greene, 2011)
AUGMENTATIVE AND ALTERNATIVE COMMUNICATION 207
and the Preferred Reporting Items for Systematic reviews
and Meta-Analyses (PRISMA; Moher, Liberati, Tetzlaff,
Altman, & The Prisma Group, 2009). The protocol comprised
(a) the purpose and research questions, (b) the search strat-
egy, (c) the inclusion criteria, and (d) the data coding and
analysis procedures.
Inclusion criteria
In order to be included, each study had to (a) have at least
one participant who used aided AAC (single-case studies) or
an entire treatment group that used aided AAC (group stud-
ies); (b) be a peer-reviewed publication or dissertation pub-
lished before or during 2017; (c) employ an experimental
design (i.e., randomized controlled trials, quasi-experimental
designs, or single-case experimental designs); (d) investigate
the effects of instruction with at least one dependent vari-
able related to single-word reading; and (e) be published
in English.
Search procedures
Potential studies were identified through a multi-faceted pro-
cess illustrated in Figure 1. The first step of the search proce-
dures was an electronic database search in order to identify
studies for this review, with studies through 2017 eligible for
inclusion. The following databases were searched: ERIC,
Linguistics & Language Behavior Abstracts (LLBA), PubMed,
PsycInfo, and ProQuest Dissertation and Theses. The disserta-
tions and theses database was considered essential to review
in order to obtain data that were potentially more current
than published literature. It should be noted that including
only published studies might have resulted in a dataset influ-
enced by publication bias.
The following three search term categories were used: (a)
Intervention (including ‘instruct’
, ‘teach’
, ‘interven’
, or
‘educat’
), (b) AAC (including ‘AAC’, ‘augmentative
communication’, or ‘alternative communication’), and (c)
Word Identification (including ‘decod’
, ‘word identification’
or ‘word recognition’, ‘word reading’, or ‘sight words’). One
search term from each of the categories was always used, for
a total of three search terms. Every combination of search
terms was used to identify appropriate articles (e.g.,
‘“instruct”
“AAC” “decod”
’ and ‘“teach”
“augmentative
communication” “word recognition”’ and so on). When exam-
ining ERIC, LLBA, PubMed, and PsycInfo, the search terms
could be found anywhere in the article. When searching
ProQuest Dissertation and Theses, the search was narrowed
to the abstract or key words of the dissertations. This first
step of the search procedures yielded 736 articles. After elim-
inating duplicate articles, 79 articles remained and were
assessed at the title and abstract level to determine eligibility
for full-text review. Of these, 70 were excluded based on lack
of relevance to the review’s aims. The remaining nine articles
were reviewed at the full-text level because of their potential
to meet the inclusion criteria; five met the criteria
for inclusion.
208 K. MANDAK ET AL.

inclusion decisions were in 100% agreement with the first

736 studies identified 657 duplicate author (i.e., inclusion of 11 studies).
through database search studies removed

Data extraction and coding procedures

79 studies screened for
relevance at title/abstract 70 studies
level excluded
9 studies reviewed at full- 4 studies excluded
text level based on inclusion
criteria
5 studies identified that met
inclusion criteria
6 additional studies
identified through ancestry
search
0 studies identified through
author search
11 total studies included in
review
Figure 1. Search strategy.
The second step was an ancestry search of the 79 studies
identified from the database search. The reference lists were
searched for potential studies that would additionally meet
the inclusion criteria. Any articles related to literacy instruc-
tion and individuals who used AAC were screened at the
abstract level, and then the full-text level, if appropriate. This
step resulted in the inclusion of six additional studies. An
ancestry search was then conducted on these six studies, but
it did not result in the inclusion of additional unique studies.
Following the ancestry searches, the first and last names of
first authors of included studies (n ¼ 11) were searched,
which did not result in additional studies.
To ensure reliability of the inclusion and exclusion deci-
sions, a doctoral student in Communication Sciences and
Disorders reviewed articles at two points during the search
procedures. First, she reviewed all 79 title and abstracts to
determine relevance to the review. The student and first
author’s decisions were in 100% agreement with each other.
She then reviewed the nine identified articles assessed at the
full-text level and the six additional articles identified through
the ancestry search (i.e., a total of 14 articles). The student’s
The coding form and manual that were developed were
adapted from the work of Kent-Walsh, Murza, Malani, and
Binger (2015) and Schlosser and Wendt (2008). The coding
forms included the following sections: (a) Study Identification
(i.e., author names and year of publication); (b) Study Design
(i.e., single case or group design); (c) Participant
Characteristics; (d) Intervention and Independent Variables;
(e) Dependent Variables; (f) Outcome Measures; and (g)
Quality of Evidence. A coding manual was also developed,
and included the operational definitions associated with each
of the sections on the coding form.
Data were extracted only for participants who used aided
AAC. The participants were coded for age, gender, and
diagnosis. The interventions were coded for the type of
single-word reading skills taught to the participants and
were differentiated by approach: phonological or sight–word.
Phonological approaches were instruction in letter–sound
correspondence, blending sounds, decoding, phoneme seg-
mentation, and reading connected text. Sight word
approaches were instruction in reading sight words in isola-
tion or in connected text. Each intervention was also coded
based on the type of instructional strategies used by the
interventionists. The strategies were divided into pre-
response (i.e., strategies employed before the individual’s
response) and post-response, depending on when the inter-
ventionist used the strategy. Pre-response strategies were (a)
stimulus adaptations (i.e., changing the field size, stimulus
fading, and stimulus shaping), and (b) response prompts (i.e.,
physical guidance, modelling, and time delay). Post-response
strategies were (a) reinforcement, (b) error correction, and (c)
error analysis. Interventions were additionally coded for the
interventionist, the context of intervention (i.e., one-on-one
or group), and the number and length of intervention ses-
sions. Each study was also coded for measurement of the
dependent variable (i.e., percentage or number of words
read correctly) and tasks used to assess the effectiveness of
instruction (e.g., presenting a written word and prompting
the learner to choose a picture from a field of choices).
The following effect sizes were calculated in order to com-
pare the intervention outcomes across studies: gain scores,
percentage of non-overlapping data (PND; Scruggs,
Mastropieri, & Casto, 1987), and Tau-U (Parker, Vannest,
Davis, & Sauber, 2011). All effect sizes were calculated from
data at the participant level. Gain scores and PND were cal-
culated due to their frequency of use in the field. Gain scores
provide a measure of the magnitude of intervention out-
comes by subtracting the mean performance during baseline
from the mean performance during intervention. PND is con-
ceptualized as the percentage of intervention data points
that exceed the highest baseline data point (Scruggs et al.,
1987). Based on guidelines set by Scruggs et al., a PND score
of 90% or higher indicates very effective interventions;
between 70% and 90% indicates effective interventions;

between 50% and 70% indicates interventions with question-
able effect; and 50% or lower indicates ineffective
interventions.
In addition to gain scores and PND, Tau-U was calculated
by measuring data non-overlap between two phases (i.e.,
baseline and intervention), with the option of controlling for
baseline trend. The advantage of using Tau-U is that it is a
complete measure of all data obtained from single-case
designs, because it accounts for both the level change across
phases and positive baseline trend. A Tau-U score ranges
from 0–1 and can be interpreted using the following criteria:
0.20 or lower is a small effect; between 0.20 and 0.60 is a
moderate effect; between 0.60 and 0.80 is a large effect; and
between 0.80 and 1 is a very large effect (Vannest &
Ninci, 2015).
Finally, the certainty of evidence was evaluated using
quality markers offered by Horner et al. (2005) for single-case
designs. Based on the quality markers, the evidence from
each study was rated as inconclusive, suggestive, preponder-
ant, or conclusive, as defined by Schlosser and Wendt (2008).
Reliability of coding
In order to ensure inter-rater reliability, the third author was
trained in the coding procedures. Using the coding form, the
first and third authors independently coded each study. Once
independent coding was complete, all codes were compared.
Inter-rater reliability was calculated by taking the number of
agreements divided by the number of agreements plus dis-
agreements, and multiplying by 100. Overall agreement was
95% across categories, and ranged from 91–100%. Any dis-
agreements were resolved through discussion.
Reliability was also calculated for effect size scores for all
dependent variables. Calculations yielded 100% agreement
for gain scores, 98% agreement for PND scores, and 96%
agreement for Tau-U scores. All discrepancies were resolved
through discussion.
Systematic review procedures
In order to evaluate the intervention effectiveness across
studies by participant, intervention, and outcome measure
characteristics, effect sizes (i.e., Tau-U scores) were aggre-
gated by taking the average effect sizes for specific coded
variables (e.g., participant age, type of instructional approach,
type of interventionist, etc.). The average effect size was used
as an indicator of the effectiveness of instruction, based on
criteria set by Vannest and Ninci (2015).
Results
Table 1 provides a summary of participant, intervention, and
outcome characteristics for all studies that met inclusion cri-
teria. A total of 11 single-case studies, including 34 partici-
pants, met the criteria for inclusion. In order to measure the
certainty of whether the interventions caused changes in the
participants’ single-word reading, the quality of evidence for
each of the 11 studies was assessed. The authors of this
AUGMENTATIVE AND ALTERNATIVE COMMUNICATION 209
review took a ‘best evidence’ approach (Millar, Light, &
Schlosser, 2006), including only studies that established
experimental control (i.e., provide greater certainty of evi-
dence). Any study rated as inconclusive per the guidelines
set by Schlosser and Wendt (2008) was excluded. This
resulted in the exclusion of two studies and 10 participants
(i.e., Ainsworth, 2013; Truxler & O’Keefe, 2007). These two
studies did not establish experimental control with respect to
the relationship between instruction and single-word reading,
which made it difficult to draw reliable conclusions.
Therefore, their participant, intervention, and outcome meas-
ure characteristics are not included in the results reported in
this review.
The remaining nine studies, including 24 participants, met
an adequate level of methodological rigour for inclusion. Of
the nine studies, two studies were rated as conclusive, mean-
ing that the reported outcomes were undoubtedly the result
of intervention (Schlosser & Wendt, 2008). These studies (i.e.,
Caron, 2016; Heller, Fredrick, Tumlin, & Brineman, 2002) were
experimentally sound and included strong reliability and pro-
cedural integrity. Four studies were rated as preponderant,
meaning that outcomes were likely due to the interventions,
but minor flaws were apparent in either the design, reliability
of the dependent variable, or procedural integrity. Four stud-
ies were rated as suggestive, meaning that outcomes were
plausibly due to the interventions. These studies may have
included minor flaws in design, in addition to inadequate
reliability or procedural integrity (Schlosser & Wendt, 2008).
Participant characteristics
The nine single-case studies included 24 participants who
ranged from 6–22 years-old (M ¼ 11;6 [years;months],
SD ¼ 3.8). Of the 24 participants, 11 (46%) were female and
13 (54%) were male. Although various diagnoses were repre-
sented, two were prevalent: ASD (n ¼ 11, 46%) and CP (n ¼ 7,
29%). Other disabilities included Down syndrome, intellectual
disability, and Holt-Oram Syndrome; and one participant was
diagnosed with a traumatic brain injury. Types of aided AAC
used by the participants included speech-generating devices
(n ¼ 16), low-technology AAC such as line drawings or real
objects (n ¼ 7), and a combination of the two (n ¼ 1).
Seven of the studies reported some literacy skills among
the participants. Of these, some reported specific literacy
skills demonstrated by participants (e.g., knowledge of letter-
correspondences), while others reported standardized meas-
ures of literacy (e.g., scores from the Woodcock Reading
Mastery Test). One study reported that the participants did
not previously participate in a reading curriculum, but did
not include information regarding the literacy skills of the
participants (Hetzroni & Shalem, 2005). Another study did not
report previous literacy instruction or the participant’s literacy
skills at the start of the study (i.e., van der Meer et al., 2015).
Only three studies provided a language measure to
describe participants: One provided measures of receptive
vocabulary and emerging language abilities (i.e., Peabody
Picture Vocabulary Test—Third Edition [PPVT-III] and Test of
Early Communication and Emerging Language; Caron, 2016),
Table 1. Summary of coded variables for included single-case studies.
210

Outcomes
Participants Type of Number of Number of
Study authors and design (ID/age/gender/disability) aided AAC IV DV (measurement task) sessions words targeted Gain scores PND (%) Tau-U Quality of evidence
Ahlgrim-Delzell et al. Royce: 10, M, DS LT PA, SWA % of words read correctly 19 NR þ34% 84 1 Suggestive; researcher-
(2014): Multiple base- (spoken word–text developed measures
line/multiple probe choices) with limited detail
% of words read correctly 19 NR þ36% 84 0.96
(text–picture choices)
Ainsworth (2013): Multiple Jo: 13, F, CP SGD SWA, PA # of words read correctly 10 5 þ1.7 words 50 0.65 Inconclusive; unstable
K. MANDAK ET AL.

baseline/multiple probe Anna: 14, F, RS LT (spoken word–text 10 5 þ2.1 words 70 0.72 baselines and lack of
Sam: 13, M, MD SGD choices) 8 5 þ2.7 words 38 0.89 experimental control
Dean: 15, M, ASD SGD 8 5 þ2.6 words 100 1
Bobby: 11, M, ASD LT 13 5 þ1.7 words 69 0.79
Ash: 12, M, ASD LT 15 5 þ1.7 words 47 0.71
Chuck: 15, M, ASD SGD 15 5 þ2.1 words 33 0.83
Caron (2016): Multiple Chad: 10;10, M, ASD LT SWA % of words read correctly 16 12 þ57% 100 1 Conclusive
baseline/multiple probe Nate: 18;7, M, ASD LT (text–picture choices) 15 12 þ60% 100 0.85
Coleman-Martin et al. Alice: 11, F, CP SGD PA % of words read correctly 6 5 þ39% T: 83 0.89 Suggestive; potential
(2005): (text–spoken choices) 4 5 þ83% TCAI: 100 1 influence of the
Alternating treatments 4 5 þ60% CAI: 100 1 sequencing
Beth: 12, F, ASD SGD 4 5 þ68% T: 100 1 of conditions
6 5 þ60% TCAI: 100 1
3 5 þ73% CAI: 100 1
Carrie: 16, F, TBI SGD 14 5 þ30% T: 57 0.64
8 5 þ70% TCAI: 100 1
12 5 þ62% CAI: 100 1
Crowley et al. (2013): Participant 2: 7, M, ASD SGD SWA # of words read correctly 19 18 þ87% þ2.7 words 96 0.97 Suggestive; < 5 base-
Multiple baseline/ (text–spoken choices) line points and lack
multiple probe of treatment fidelity
Fallon et al. (2004): Dale: 11;9, M, MR SGD PA # of words read correctly 5 10 þ36% þ3.6 words 100 1 Preponderant; < 5 base-
Multiple baseline/ Sam: 14;0, M, MR SGD (text–picture choices) 5 10 þ31% þ3.1 words 100 1 line points
multiple probe Nate: 9;5, M, DS SGD 17 10 þ34% þ3.4 words 88 0.89
Heller et al. (2002): Al: 9;3, M, Holt-Oram syndrome SGD PA % of words read correctly 3 10 þ72% 100 1 Conclusive
Multiple baseline/ Betsy: 16;1, F, CP SGD (spoken word–text 10 10 þ57% 100 1
multiple probe Cathy: 22;11, F, CP SGD choices) 6 10 þ61% 100 1
Hetzroni and Shalem Max: 11, M, ASD LT SWA # of words read correctly 9 8 þ36% 67 0.56 Preponderant; lack of
(2005): Multiple Bob: 11, M, ASD SGD (picture-text choices) 10 8 þ40% 60 0.89 treatment fidelity
baseline/multiple probe Gina: 13, F, ASD LT 8 8 þ53% 88 0.96
Lara: 10, F, ASD LT/ SGD 10 8 þ29% 60 0.58
Sara: 10, F, ASD LT 11 8 þ31% 82 0.90
Al: 10, F, ASD LT 8 8 þ33% 50 0.82
Swinehart-Jones and Alice: 8, F, CP SGD PA # of words read correctly 24 10 þ96% 100 1 Preponderant; weak
Heller (2009): Changing- Beth: 7, F, CP SGD (spoken word–text 24 10 þ98% 100 0.96 external validity,
criterion design Carl: 6, M, CP SGD choices) 24 10 þ100% 100 1 shown effects with
Dave: 12, M, CP SGD 24 10 þ100% 100 1 one participant
Truxler and O’Keefe Child 1: 8;0, M, CP LT PA % of words read correctly 3 14 9% 0 1 Inconclusive; unstable
(2007): Multiple base- Child 2: 9;6, F, CP LT (spoken word–text 12 14 þ29% 92 0.89 baselines and lack of
line/multiple probe Child 4: 9;6, M CP LT choices) 4 14 13% 0 1 experimental control
van der Meer et al. (2015): Harley: 10;2, M, ASD SGD SWA % of words matched cor- 36 12 þ66% 100 1 Preponderant; < 5 base-
Multiple baseline/ rectly to picture (text- line points
multiple probe picture choices)
IV: independent variable; DV: dependent variable; ASD: autism spectrum disorder; CP: cerebral palsy; DS: Down syndrome; MD: multiple disabilities; MR: mental retardation; RS: Rett syndrome; TBI: traumatic brain injury;
LT: low-technology AAC (line drawings or real objects); SGD: speech-generating device; PA: phonological approach; SWA: sight-word approach; T: teacher implemented instruction; TCAI: teacher and computer-assisted
instruction; CAI: computer-assisted instruction; NR: not reported.
 AUGMENTATIVE AND ALTERNATIVE COMMUNICATION 211

one provided measures of receptive vocabulary and auditory
comprehension (i.e., PPVT-III and Test for Auditory
Comprehension of Language—Third Edition; Fallon, Light,
McNaughton, Drager, & Hammer, 2004), and one provided a
measure of expressive language (i.e., The Rossetti Infant-
Toddler Language Scale; van der Meer et al., 2015). Of the
other studies that provided some description of participants’
language, the descriptions were very general and included
statements such as, ‘delays in communication’,
‘comprehension difficulties’, and ‘non-functional speech’.
Only two studies provided information regarding the cog-
nitive level of participants: One provided an estimated IQ for
its participant (i.e., Ahlgrim-Delzell, Browder, & Wood, 2014),
while the other provided a formal cognitive measure (i.e.,
TONI-2; Heller et al., 2002).
Intervention characteristics
Interventionist and context
All of the single-case studies (n ¼ 9) provided instruction in a
one-on-one setting and none of the included studies investi-
gated the effects of instruction in small or large groups.
Educators provided the intervention in four of the studies,
and researchers (i.e., authors of the studies) served as the
interventionists in the remaining five studies.
Instructional approach and strategies
The interventions were coded with respect to both the
instructional approach (i.e., what skills the interventionist
was teaching; e.g., letter-sound correspondence) and the
instructional strategies (i.e., what instructional strategies the
interventionist employed during intervention; e.g., modelling).
Most interventions (n ¼ 8) took a single approach to interven-
tion. A phonological approach was reported in four studies
(i.e., Coleman-Martin, Heller, Cihak, & Irvine, 2005; Fallon et al.,
2004; Heller et al., 2002; Swinehart-Jones & Heller, 2009), and
four studies took a sight–word approach (i.e., Caron, 2016;
Crowley, McLaughlin, & Kahn, 2013; Hetzroni & Shalem, 2005;
van der Meer et al., 2015). One study (i.e., Ahlgrim-Delzell
et al., 2014) used a combination intervention with both
phonological and sight-word approaches (see Table 2).
Various instructional strategies were used to support par-
ticipants to acquire the target single-word reading skills, with
studies ranging in the number of strategies employed. The
strategies were separated into pre-response and post-
response strategies, and then further differentiated within
these two categories. All interventionists used one or more
pre-response strategies during instruction. Two studies
included stimulus adaptations, specifically changing the field
size (i.e., Caron, 2016) and stimulus fading (i.e., Hetzroni &
Shalem, 2005). Response prompts were used across all stud-
ies, with three of the studies employing time delay (i.e.,
Ahlgrim-Delzell et al., 2014; Caron, 2016; van der Meer et al.,
2015) and one using physical guidance during instruction
(i.e., van der Meer et al., 2015). All but two of the studies
(i.e., Hetzroni & Shalem, 2005; van der Meer et al., 2015) used
modelling during instruction. One or more post-response
strategies were also used by the majority of the intervention-
ists. As shown in Table 3, all studies used reinforcement dur-
ing instruction, and most used error correction and
error analysis.

Table 2. Specific instructional approaches and target skills of included studies.

Phonological approach Sight word approach
Letter–sound Blending Phoneme Reading Isolated sight–word Sight words in
Study correspondence sounds Decoding segmentation connected text recognition connected text
Ahlgrim-Delzell et al. (2014) X X X X X X X
Ainsworth (2013) X X
Caron (2016) X
Coleman-Martin et al. (2005) X X
Crowley et al. (2013) X
Fallon et al. (2004) X X X
Heller et al. (2002) X X
Hetzroni and Shalem (2005) X
Swinehart-Jones and Heller (2009) X X
Truxler and O’Keefe (2007) X X X
van der Meer et al. (2015) X

Table 3. Specific post-response instructional strategies.

Error correction
Study Reinforcement No opportunity to retry Opportunity to retry Error analysis
Ahlgrim-Delzell et al. (2014) X
Ainsworth (2013) X
Caron (2016) X X X
Coleman-Martin et al. (2005) X X X
Crowley et al. (2013) X X X
Fallon et al. (2004) X X X
Heller et al. (2002) X X X
Hetzroni and Shalem (2005) X
Swinehart-Jones and Heller (2009) X X X
Truxler and O’Keefe (2007) X
van der Meer et al. (2015) X X
212 K. MANDAK ET AL.

Length of intervention Table 4. Findings by intervention, participant, and intervention outcome

measure characteristics.
All studies reported the number of intervention sessions,
Number Level of
ranging from 3–36 sessions per participant, with an average Measure of cases
Tau-U effect SD
of 12 sessions per participant (SD ¼ 8.15; see Table 1). Participant characteristics
Participants instructed in a phonological approach required Age
an average of 11 sessions (SD ¼ 8.00; range ¼ 3–24) to Elementary school (60–144 months) 19 0.92 Very large 0.13
Adolescent (12–17 years) 10 0.96 Very large 0.11
acquire an average of 7.6 target words (SD ¼ 2.56; Adult (18 years) 2 0.93 Very large 0.11
range ¼ 5–10). Those instructed in a sight–word approach Diagnosis
required an average of 14 sessions (SD ¼ 8.58; range ¼ 8–36) Autism spectrum disorder 15 0.88 Very large 0.16
Cerebral palsy 7 0.97 Very large 0.06
to acquire an average of 10.2 words (SD ¼ 3.33; Down syndrome 3 0.96 Very large 0.07
range ¼ 8–18). The one participant instructed in a combin- Intellectual disability 2 1.00 Very large 0
ation approach took 19 sessions to complete instruction; the Other 4 1.00 Very large 0
Intervention characteristics
number of target words acquired was not reported. Although Interventionist
all studies reported the number of sessions per participant, Educator 19 0.97 Very large 0.08
only four reported session length. Of these, three studies Researcher 12 0.87 Very large 0.15
Instructional approach
reported sessions ranging from 15–20 min (Ahlgrim-Delzell Phonological approach 19 0.97 Very large 0.09
et al., 2014; Caron, 2016; Crowley et al., 2013). Caron (2016) Sight–word approach 10 0.85 Very large 0.16
and Crowley et al. (2013) both devoted this time targeting a Combination approach 2 0.98 Very large 0.03
Outcome measure characteristics
single skill (i.e., sight word recognition). It appeared that Measurement task
Ahlgrim-Delzell et al. (2014) targeted multiple skills during Text ! spoken choices 17 0.97 Very large 0.09
Text ! picture choices 7 0.96 Very large 0.06
the 15–20-min session. One study reported session lengths of Spoken word ! text choices 1 1.00 Very large 0
60 min (van der Meer et al., 2015). Picture ! text choices 6 0.79 Large 0.17

The number of cases does not necessarily equal the number of participants
in each category, due to the variability in the number of dependent variables
Target skills/dependent variables across studies.

All of the studies shared the same dependent variable, that

overall. Seven of the studies had PND scores in the highly
is, accuracy reading single words. Five studies measured the
effective range, one had PND scores in the effective range
percentage of words read correctly, and four measured the
(Ahlgrim-Delzell et al., 2014), and one had scores in the ques-
number of words read correctly. All but one (Ahlgrim-Delzell
tionable effect range (Hetzroni & Shalem, 2005; i.e., 50–70%).
et al., 2014) reported the number of words targeted. The
The mean effect size (Tau-U value), aggregated across the
remaining eight studies (i.e., 23 participants) varied in the
included studies, was 0.93 (SD ¼ 0.12; range ¼ 0.56–1), which
number of words targeted, ranging from 8–18 words per par-
is considered a very large effect. Tau-U values indicated very
ticipant, with an average of 10.7 words per participant. The
large effects for eight of the studies and a large effect for
studies varied in the specific task used to measure the num-
one of the studies. Table 4 provides the mean Tau-U values
ber or percentage of words read correctly. The following
and standard deviations by participant, intervention, and out-
measurement tasks were used: (a) Text-Spoken Choices (n ¼ 4
come measure characteristics. It should be noted that the
studies, 11 participants) (i.e., interventionist shows learner a
number of cases in Table 4 does not necessarily equal the
written word, learner chooses correct spoken word from four
number of participants in each category, due to the variabil-
choices spoken aloud by interventionist); (b) Text-Picture
ity in the number of dependent variables across studies (e.g.,
Choices (n ¼ 3 studies, 6 participants) (e.g., interventionist
there were two relevant dependent variables for one partici-
shows learner a written word, learner chooses picture from a
pant in Ahlgrim-Delzell et al., 2014). As displayed in Table 4,
field of four); (c) Picture-Text Choices (n ¼ 1 study, 6 partici-
when the Tau-U scores were aggregated across studies and
pants) (e.g., interventionist shows learner a picture, learner
participants, all intervention and participant characteristics
chooses written word from a field of four); and (d) a combin-
were found to have either large or very large effects.
ation of measurement tasks within a single study (n ¼ 1
Although some studies reported maintenance and generaliza-
study, 1 participant) (i.e., Spoken Word-Text Choices and
tion data, aggregate effect sizes comparing baseline to these
Text-Picture Choices).
additional phases were not possible because most studies
did not report these data.
Effects of intervention on accuracy of reading
single words
Participant characteristics
Table 1 provides the Gain scores, PND values, and Tau-U val- Effect sizes, including age and diagnosis, were also calculated
ues for the measured outcomes of all participants. All of the across participant characteristics; these were very large for
included studies reported positive gains in single-word read- elementary school-aged participants (n ¼ 16; Tau-U ¼ 0.92),
ing as a result of intervention. The gains for the dependent adolescents (n ¼ 6; Tau-U ¼ 0.96), and adults (n ¼ 2; Tau-
variable across studies ranged from 29–100%, with an aver- U ¼ 0.93), as shown in Table 4. Interventions yielded a very
age gain score of 58%. The mean PND was 90 (SD ¼ 15.43; large effect for all diagnostic categories, including ASD, cere-
range ¼ 50–100), which indicates very effective interventions bral palsy, Down syndrome, and intellectual disability.

Intervention characteristics
The phonological approach (Tau-U ¼ 0.97), sight word
approach (Tau-U ¼ 0.85), and combination approach (Tau-
U ¼ 0.98) to intervention all resulted in very large interven-
tion effects. Tau-U data were also aggregated based on who
provided instruction. Interventions implemented by both
educators (n ¼ 4; Tau-U ¼ 0.97) and researchers (n ¼ 5; Tau-
U ¼ 0.87) yielded very large effects.
Outcome measure characteristics
As shown in Table 4, the effect size varied depending on the
type of measurement task used, with very large effects for
Text–Spoken Choices (Tau-U ¼ 0.97), Text–Picture Choices
(Tau-U ¼ 0.96), and Spoken Word–Text Choices (Tau-U ¼ 1);
and a large effect for the Picture–Text Choices task
(Tau-U ¼ 0.79).
Discussion
Overall, the evidence indicates that instruction for individuals
who use aided AAC has positive effects on their accuracy in
reading single-words. Individuals who used aided AAC in the
included studies acquired skills to read single words. As evi-
denced by the overall Tau-U score (0.93), instruction can be
very effective for this group of individuals, across diagnoses
and ages. These results add support to earlier reviews indi-
cating that individuals with complex communication needs
can acquire early literacy skills with instruction (e.g., Barker
et al., 2012; Browder, Wakeman, Spooner, Ahlgrim-Delzell, &
Algozzinexya, 2006; Machalicek et al., 2010).
Participants
Across the studies, the participants were highly heteroge-
neous, which is typical of studies with individuals who use
AAC. Use of single-case designs allows for evaluation of the
efficacy of interventions that include heterogeneous partici-
pants, because each serves as his or her own control
(Richards, Taylor, & Ramasamy, 2014); however, given the lim-
ited number of participants in each diagnostic and age cat-
egory, it is difficult to draw generalizations about the
effectiveness of intervention. Although the findings indicate
that instruction can be very effective across a wide range of
participants, replications are necessary in order to strengthen
generalization to other individuals and boost exter-
nal validity.
Despite the inclusion of the best-available evidence within
this review, participant characteristics were significantly
under-reported in the included studies. Given the challenges
related to conducting research with heterogeneous individu-
als, it is incumbent upon researchers to ensure detailed
descriptions of all participants. In intervention studies, it is
necessary to not only determine whether instruction is effect-
ive but also with which participants. As emphasized by
Barker et al. (2012), research reports must include explicit
descriptions of several aspects of participants’ functioning,
including natural speech abilities (e.g., speech intelligibility),
AUGMENTATIVE AND ALTERNATIVE COMMUNICATION 213
reading skills (e.g., phonological awareness skills, word recog-
nition, word comprehension, etc.), and past literacy experien-
ces. If researchers increase specificity of participant
descriptions, future interventions can be better tailored and
modified for individuals with heterogeneous skill sets. In pur-
suit of this goal, one approach for researchers to consider is
Precision Medicine Research (Beukelman, 2016), which
accounts for the influence of participant variability when
investigating the factors that impact intervention effective-
ness. Many factors may influence the effectiveness of literacy
interventions and it is up to researchers to identify those fac-
tors associated with success.
Intervention characteristics
All of the approaches to intervention (phonological, sight–
word, and a combination of these two approaches) yielded
very large effects (Tau-U ¼ 0.97, 0.85, 0.98). Half of the studies
employed a sight–word approach (i.e., Caron, 2016; Crowley
et al., 2013; Hetzroni & Shalem, 2005; van der Meer et al.,
2015), which has a long tradition in educational programs for
students with disabilities (Browder & Xin, 1998; Browder,
Courtade-Little, Wakeman, & Rickelman, 2006). The tendency
for educators to provide sight–word instruction is not ill
advised, as there are many benefits to the approach. The
mastery of sight words can provide a sense of accomplish-
ment for students, increase one’s motivation to read, teach
the communicative intent of print, and improve access to
functional tasks such as reading environmental signs
(Browder & Xin, 1998; Spector, 2011). Once a corpus of sight
words is learned, this can serve as a foundation upon which
more abstract literary concepts can build. Sight–word instruc-
tion may be more appropriate for some students, for
example, those with ASD, who have difficulty with auditory-
based abstract concepts (Spector, 2011).
Despite the benefits of sight–word instruction, reading
with fluency and comprehension depends on having deep
knowledge of letter–sound correspondences, as well as a
sight–word vocabulary (Adams, 1990). If students are only
taught to recognize words, they will only be able to identify
those words that are explicitly taught. Adams (1990)
asserts that
Perhaps the most well-respected value of letter-sound instruction
is that it provides children with a means of deciphering written
words that are not familiar as wholes. Applying their knowledge
of letter-to-sound correspondences, they can sound the word out
discovering or confirming its identity by themselves (p. 216).
Four of the studies took a phonological approach (i.e.,
Coleman-Martin et al., 2005; Fallon et al., 2004; Heller et al.,
2002; Swinehart-Jones & Heller, 2009), and included founda-
tional skills such as letter-correspondences, phoneme seg-
mentation, and blending sounds. When instructed in a
phonological approach, learners are taught how to process
letter sequences both orthographically (e.g., recognizing the
letter “t”) and phonologically (e.g., corresponding the letter
“t” with the sound t). When approaching an unknown word,
learners instructed in a phonological approach will have
more information to attach to the word (e.g., orthographic
214 K. MANDAK ET AL.
and phonologic knowledge) than if instructed in a sight–-
word approach alone. The more information they can attach
to words, the more likely it is that learners will recognize and
comprehend words efficiently (Adams, 1990). Even if learners
are unable to decode a word fully, they can use the founda-
tional skills of letter–sound correspondences and phono-
logical awareness to make an educated guess, such as
choosing a word with the same initial letter (i.e., partial
alphabetic phase; Vandervelden & Siegel, 1995).
Although the intervention approaches were reviewed and
analysed as separate entities, it should be noted that both
phonological and sight–word skills are necessary in order to
become a skilled reader, suggesting that the ideal for begin-
ning readers is a combination approach, as employed by one
of the included studies. As Browder, Courtade-Little, et al.
(2006) emphasized, literacy intervention is most effective if
sight–word identification is paired with decoding instruction.
Sight–word instruction should be embedded as a strand
within a comprehensive literacy programme that includes
instruction in phonological skills and comprehension
(Browder, Courtade-Little, et al., 2006).
Across the various intervention approaches, all studies
used both pre-response and post-response strategies. More
specifically, all provided response prompts (e.g., physical
guidance, modelling, and time delay), which were defined as
interventionists’ actions before a participant’s response that
may increase the chances of an accurate response. Although
modelling of target word reading was used across most of
the studies, time delay was present in only half. Time delay is
a form of systematic prompting that evolved from behaviour
analysis and the concept of transferring stimulus control
(Browder, Ahlgrim-Delzell, Spooner, Mims, & Baker, 2009).
When using this strategy, the interventionist starts by provid-
ing a delay between presentation of a stimulus and prompt
to clearly mark the opportunity for a learner to respond and
to encourage independent performance; the length of the
delay is gradually reduced until the learner is able to inde-
pendently provide a correct response upon presentation of
the stimulus. Time delay has been proven as an effective evi-
dence-based practice in teaching students with developmen-
tal disabilities symbol recognition (Browder et al., 2009).
Specifically, the evidence is strongest for teaching sight–word
and picture recognition to students with moderate and
severe disabilities. Considering the evidence, interventionists
should feel confident in their use of time delay and strongly
consider its use in future instruction.
All of the studies provided some form of feedback to the
participant. Most provided error correction and analysis,
which have been linked to increased reading accuracy
(Browder & Xin, 1998). Although most of the studies provided
error correction, only one provided an opportunity to re-try
the trial after the correction (Coleman-Martin et al., 2005).
Compared to providing only a model of the correct response
as error correction, allowing students to make an active
response after the correction has been shown to be more
effective in terms of acquiring and maintaining sight words
(Barbetta, Heron, & Heward, 1993). Error analyses provide
additional benefits because they allow interventionists to
identify areas of strength (e.g., learner performs well on initial
sound identification) or difficulty (e.g., learner performs
poorly on initial sound identification), and can provide valu-
able information on how to adapt instruction (Light &
McNaughton, 2013). Overall, many of the studies in the cur-
rent analysis included effective instructional strategies,
including the use of models, time delay, error correction with
opportunities for learners to re-try, and error analyses.
In addition to evaluating the effectiveness of instruction, it
is important to consider the efficiency as well. Although all
of the included studies reported the number of intervention
sessions (i.e., ranging from 3–36 sessions), many did not
report the length of time spent teaching single-word reading,
nor did they target similar numbers of words. As a result,
although it is possible to evaluate the effectiveness of
instruction, it is difficult to determine the efficiency. These
limitations highlight the need for future researchers to
improve the specificity and reporting of intervention charac-
teristics, including the number and the length of
each session.
Finally, findings indicated that instruction can be success-
fully implemented by both researchers and educators.
Interventions implemented by educators yielded a very large
effect, which is encouraging because, ideally, literacy instruc-
tion is implemented within students’ typical educational cur-
riculum. Although the interventionists varied, all instruction
was conducted one-on-one. None of the studies investigated
the effects of group instruction, which is associated with
many social and educational benefits for learners
(Koppenhaver & Erickson, 2003).
Outcome measure characteristics
It is necessary to discuss the various adaptations that
researchers made in measuring intervention outcomes. In lit-
eracy curricula, learners typically use spoken responses to
participate in instruction. Learners with complex communica-
tion needs are unable to participate via spoken responses
and, thus, instructors must use adaptations to measure inter-
vention outcomes and progress. As shown in Table 4, there
were four distinct tasks used to measure single-word reading
in the studies, each placing varying demands on the learners.
One adaptation used to measure the single-word reading
of the participants was the use of closed response sets,
which were used in all measurement tasks. Although the use
of closed response sets was consistent across the studies, the
type of stimuli within the response sets varied (e.g., pictures
vs written words). With varying stimuli come varying
demands on learners. For example, the Text-Spoken Choices
and Spoken Word-Text Choices tasks did not require learners
to translate written language into oral language (i.e., phono-
logical recoding). In the measurement task completed by
most participants (i.e., Text-Spoken Choices), learners were
presented with a written word (e.g., dog), and then offered
spoken choices to choose from. In this task, the intervention-
ist removed significant demands from the learner by com-
pleting the phonological recoding process; the learner had
only to recognize the correct spoken choice.

In contrast, two of the tasks required learners to complete
phonological recoding of the written word (i.e., Picture–Text
Choices, Text–Picture Choices), and thus may have been clos-
est to actual reading demands. For example, in the
Picture–Text Choices task, the learner was presented with a
picture of a dog (the target word) and was then offered a
field of four written words as choices. This task required the
learner to re-code not only the correct word choice, but also,
potentially, to re-code the three incorrect word choices and,
in so doing, placed increased demands on the learner, who
had to differentiate among choices in a ‘higher’ order symbol
array (i.e., words) vs ‘lower’ order symbols (i.e., pictures)
(Franklin, Mirenda, & Phillips, 1996). The picture–text and
text–picture tasks also varied from the other tasks in that
they required learners to access the meaning of the picture
representations. For example, in the Text–Picture Choices
task, the learner not only had to re-code the target word
(e.g., dog), but also had to retrieve the meaning of the four
picture options (e.g., pictures of mop, dog, doll, and frog),
which added additional demands.
Considering the varying demands across the tasks, it is
apparent that these assessment adaptations result in tasks
that cannot mirror the typical task of decoding print to
sound. Thus, the adaptations used across the studies con-
found conclusions regarding the effectiveness of single-word
reading instruction. Despite the inherent and potentially
unknown demands of these tasks, however, the use of alter-
native response modes is valuable for individuals who use
aided AAC. Removing the requirement of a spoken response
and providing these adaptations to learners who use AAC
can increase participation in instruction and assist the learn-
ing of literacy skills (Fallon et al., 2004; Light & McNaughton,
2013). It is necessary for interventionists and researchers to
be cognizant of the demands of reading and carefully ana-
lyse the tasks to replicate these demands.
Limitations and future research
Although this review contributes to the evidence base on
instruction in single-word reading, there are limitations. First,
the review only investigated instruction in one aspect of
functional reading. Reading requires the integration and
interaction of various processes (Adams, 1990) and, thus,
instruction in single-word reading must be complemented by
other skills. Accordingly, future research must investigate
instruction that moves beyond reading a closed set of single
words that have been trained directly. The end goal of liter-
acy instruction should be to support individuals in learning
to extract meaning, learn from text, and read independently
(Carnine, Silbert, Kame’enui, & Tarver, 2010; Duke & Carlisle,
2011). As such, future research should include longer-term
intervention studies that investigate the effects of instruction
on advanced reading skills. Instruction must aim to
strengthen the connections between individual words and
their meanings, as it is essential that beginning readers read
meaningful words in meaningful contexts (Adams, 1990).
Most of the studies in this review did not address reading in
connected text or comprehension, which are critical skills for
AUGMENTATIVE AND ALTERNATIVE COMMUNICATION 215
functional literacy. Reading and comprehending connected
text requires the integration of a range of skills, and,
although learners across the studies made significant gains, it
is not known if they will eventually acquire functional liter-
acy. It is incumbent upon future researchers to move past
the current state of the evidence and consider the interplay
of multiple skills when investigating literacy interventions.
Second, many of the studies lacked adequate reporting of
participant and intervention characteristics. Only three stud-
ies provided a language measure to describe participants,
and only two studies described the cognition of participants.
Without specific participant descriptions, researchers and
educators do not know which interventions are most effect-
ive with which leaners under which conditions. Regarding
instructional characteristics, many of the studies did not
report the length of time spent providing instruction (i.e.,
minutes per session). Without this information, the efficiency
of instruction is unknown, which again limits the ability to
compare interventions. Consequently, despite the positive
outcomes across the studies, the interpretation, replication,
and generalization of results are limited. The need to develop
reporting guidelines for future research is crucial, and must
include how to report intrinsic participant characteristics that
may affect literacy learning (e.g., sensory-perceptual skills,
cognitive skills, speech intelligibility, phonological awareness
skills, etc.), as well as extrinsic characteristics (e.g., prior liter-
acy experiences) and the critical characteristics of instruction
(e.g., number of words targeted, number of sessions, length
of sessions, interventionist, instructional strategies, etc.).
Knowing that instructional experiences are quantitatively dif-
ferent for learners with complex communication needs (i.e.,
less time devoted to literacy instruction), future researchers
must report this information and employ greater specificity
in order to replicate positive outcomes in the real world
(Zascavage & Keefe, 2004).
Third, a key limitation is that all included studies reported
limited data regarding generalization to other tasks or novel
words and maintenance of acquired single-word reading
skills. Only a few of the studies reported on maintenance or
generalization data, so aggregated effect sizes could not be
calculated. In order to demonstrate the development of
skilled reading, future researchers must include measurement
tasks that go beyond the probe tasks described in this
review. In future studies, tasks should require participants to
demonstrate their acquired single-word reading skills across
contexts and with novel words not previously encountered.
Fourth, the majority of the participants were elementary
school-aged children or adolescents with ASD, highlighting
the need for research with young children and adults who
use AAC and with individuals with other diagnoses. With
appropriate instructional supports, children with complex
communication needs as young as 4-5 years old can begin
to learn early literacy skills, including letter–sound corre-
spondences and spelling CVC combinations (Johnston,
Davenport, & Kanarowski, 2009). Previous reports also dem-
onstrate that adults who use AAC who start instruction later
in life are able to acquire early literacy skills, including let-
ter–sound correspondences, sight words, and spelling (e.g.,
Caron, Holyfield, Light, & McNaughton, 2017; McNaughton &
216 K. MANDAK ET AL.
Tawney, 1993). In future studies, researchers must consider
diagnoses and age groups that are under-represented in the
AAC literature. High-quality research with these populations
is essential in order to make evidence-based decisions for
these learners.
Fifth, the studies varied in how they measured single-
word reading. Future research must investigate how to best
measure intervention outcomes without requiring spoken
responses and how to select appropriate measures based on
the dependent variable of interest and participant character-
istics. As this review and previous research have demon-
strated (Erickson et al., 2008; Iacono & Cupples, 2004), there
is not an agreed word recognition assessment task for indi-
viduals with complex communication needs. Future research-
ers must determine how to measure intervention outcomes
that move beyond single-word reading (e.g., how to assess
reading connected text or reading comprehension). As high-
lighted earlier, multiple skills are necessary to become a
skilled reader, which means that multiple measurement tasks
will be necessary to assess outcomes of intervention. Future
research must include comparisons of these tasks to identify
their potential impact on the measurement of intervention
outcomes and whether one or multiple tasks best assess an
individual’s skills.
Finally, with such a small number of studies in this review,
and the small number of participants contributing to some
of the analyses, readers should be cautioned against over-
generalizing or drawing definitive conclusions. Although the
effect sizes reported are large across the studies, attention
must be brought to future study design. The use of single-
case experimental designs is often invaluable, given the low
incidence and high heterogeneity of the AAC population;
however, working towards larger scale interventions may be
beneficial in order to compare the effectiveness and effi-
ciency of different interventions with larger groups of
participants.
When conducting future studies, it is crucial that research-
ers adhere to strict standards to ensure methodological rig-
our and, thus, ensure the certainty of the evidence provided
(see the EQUATOR network for reporting guidelines, 2017;
http://www.equator-network.org/). Once effective evidence-
based practices are defined through the use of high-quality
experimental designs, it must be a priority to investigate
techniques to ensure the effective translation of research to
everyday practice. In pursuit of this goal, the field of imple-
mentation science has evolved, which studies the translation
of interventions into real word practices (Durlak & Du Pre,
2008). Future researchers must prioritize this goal in order to
ensure the broad-based uptake of evidence-based literacy
instruction in the educational system.
Conclusion
Although the evidence base for teaching literacy skills to
individuals who use aided AAC is still limited, the reviewed
studies demonstrate strong intervention effects for this popu-
lation. The evidence shows that instruction can have positive
effects on the single-word reading skills of individuals of
various ages and diagnoses who use aided AAC. The studies
reveal that, across participant, intervention, and outcome
measure characteristics, individuals who used aided AAC suc-
cessfully acquired single-word reading skills with appropriate
instruction. In order to increase the robustness of the avail-
able research, there is an urgent need for future researchers
to (a) consider advanced reading skills in literacy instruction,
(b) increase the specificity of both participant and interven-
tion descriptions, (c) investigate how adapted measurement
tasks impact the measurement of single-word reading, and
(d) determine whether one or multiple tasks best assess the
reading skills of individuals who use aided AAC. Moving for-
ward, it is crucial for researchers to continue to strive to
enhance the rigour of AAC research and for educators to
continue to provide opportunities for individuals who rely on
AAC to acquire the essential skill of word reading. By doing
so, researchers and educators can maximize the potential to
enhance literacy outcomes for individuals who use AAC.
Disclosure statement
The authors report no conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
Funding
Portions of this article were submitted by the first author in partial fulfill-
ment of PhD requirements at The Pennsylvania State University
Department of Communication Sciences and Disorders. This project 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; and (b) Rehabilitation Engineering
Research Center on Augmentative and Alternative Communication (The
RERC on AAC), funded by grant #90RE5017 from the National Institute
on Disability, Independent Living, and Rehabilitation (NIDILRR) within the
Administration for Community Living (ACL) of the US Department of
Health and Human Services (HHS).
References

indicates studies included in the systematic review
Adams, M.J. (1990). Beginning to read: Thinking and learning about print.
Cambridge, MA: MIT Press.

Ahlgrim-Delzell, L., Browder, D., & Wood, L. (2014). Effects of systematic
instruction and an augmentative communication device on phonics
skills acquisition for students with moderate intellectual disability who
are nonverbal. Education and Training in Autism and Developmental
Disabilities, 49, 517–532. Retrieved from http://daddcec.org/
Publications/ETADDJournal.aspx

Ainsworth, M.K. (2013). Effectiveness of the ALL Curriculum to teach basic
literacy skills to groups of students with severe disabilities and complex
communication needs (Doctoral dissertation, George Mason
University).
Barbetta, P.M., Heron, T.E., & Heward, W.L. (1993). Effects of active stu-
dent response during error correction on the acquisition, mainten-
ance, and generalization of sight words by students with
developmental disabilities. Journal of Applied Behavior Analysis, 26,
111–119. doi:10.1901/jaba.1993.26-111
Barker, R.M., Saunders, K.J., & Brady, N.C. (2012). Reading instruction for
children who use AAC: Considerations in the pursuit of generalizable
results. Augmentative and Alternative Communication, 28, 160–170.
doi:10.3109/07434618.2012.704523
Beukelman, D.R. (2016). Precision intervention research for adults with
complex communication needs resulting from acquired medical

conditions. Augmentative and Alternative Communication, 32, 233–235.
doi:10.1080/07434618.2016.1252947
Browder, D., Ahlgrim-Delzell, L., Spooner, F., Mims, P.J., & Baker, J.N.
(2009). Using Time Delay to Teach Literacy to Students with Severe
Developmental Disabilities. Exceptional Children, 75, 343–364.
doi:10.1177/001440290907500305
Browder, D.M., Courtade-Little, G., Wakeman, S., & Rickelman, R.J. (2006).
From sight words to emergent literacy. In D. Browder & F. Spooner
(Eds.), Teaching language arts, math and science to students with sig-
nificant cognitive disabilities (pp. 63–91). Baltimore: Paul H. Brookes
Publishing.
Browder, D.M., Wakeman, S.Y., Spooner, F., Ahlgrim-Delzell, L., &
Algozzinexya, B. (2006). Research on reading instruction for individuals
with significant cognitive disabilities. Exceptional Children, 72,
392–408. doi:10.1177/001440290607200401
Browder, D., & Xin, Y. (1998). A meta-analysis and review of sight word
research and its implications for teaching functional reading to indi-
viduals with moderate and severe disabilities. Journal of Special
Education, 32, 130–153. doi:10.1177/002246699803200301
Carnine, D.W., Silbert, J., Kame’enui, E.J., & Tarver, S.G. (2010). Direct
instruction reading (5th ed.). Upper Saddle River, NJ: Prentice Hall.

Caron, J. (2016). Effects of adapted instruction on the acquisition of letter-
sound correspondences and sight words by pre-adolescent/adolescent
learners with complex communication needs and autism spectrum disor-
ders. (Doctoral dissertation, The Pennsylvania State University).
Caron, J., Holyfield, C., Light, J., & McNaughton, D. (2017). Reading and
writing intervention for adults with complex communication needs.
Presentation to ISAAC-Norway.

Coleman-Martin, M.B., Heller, K.W., Cihak, D.F., & Irvine, K.L. (2005).
Using computer-assisted instruction and the nonverbal reading
approach to teach word identification. Focus on Autism and Other
Developmental Disabilities, 20, 80–90. doi:10.1177/1088357605020
0020401

Crowley, K., McLaughlin, T., & Kahn, R. (2013). Using direct instruction
flashcards and reading racetracks to improve sight word recognition
of two elementary students with autism. Journal of Developmental
and Physical Disabilities, 25, 297–311. doi:10.1007/s10882-012-9307-z
Duke, N., & Carlisle, J. (2011). The development of comprehension. In M.
Kamil, P. Pearson, E. Moje, & P. Afflerbach (Eds.), Handbook of reading
research (Vol.4, pp. 199–228). New York, NY: Routledge.
Durlak, J.A., & Du Pre, E.P. (2008). Implementation matters: A review of
research on the influence of implementation on program outcomes
and the factors affecting implementation. American Journal of
Community Psychology, 41, 327–350. doi:10.1007/ s10464-008-9165-0
Erickson, K.A., Clendon, S.A., Cunningham, J.W., Spadorcia, S.,
Koppenhaver, D.A., Sturm, J., & Yoder, D.E. (2008). Automatic word
recognition: The validity of a universally accessible assessment task.
Augmentative and Alternative Communication, 24, 64–75. doi:10.1080/
07434610701437227
EQUATOR Network. (2017). Enhancing the quality and transparency of
health research. Retrieved from http://www.equator-network.org

Fallon, K.A., Light, J., McNaughton, D., Drager, K., & Hammer, C. (2004).
The effects of direct instruction on the single-word reading skills of
children who require augmentative and alternative communication.
Journal of Speech, Language, and Hearing Research, 47, 1424–1439.
doi:10.1044/1092-4388(2004/106)
Foley, B.E., & Wolter, J. (2010). Literacy intervention for transition-aged
youth: What is and what could be. In D. McNaughton & D. Beukelman
(Eds.), Transition strategies for adolescents and young adults who use
AAC (pp. 35–68). Baltimore, MD: Paul H. Brookes Publishing Co.
Franklin, K., Mirenda, P., & Phillips, G. (1996). Comparison of five symbol-
assessment protocols with non-disabled preschoolers and learners
with severe cognitive intellectual disabilities. Augmentative and
Alternative Communication, 12, 63–77. doi:10.1080/
07434619612331277518

Heller, K.W., Fredrick, L.D., Tumlin, J., & Brineman, D.G. (2002). Teaching
decoding for generalization using the nonverbal reading approach.
Journal of Developmental and Physical Disabilities, 14, 19–35.
doi:10.1023/A:1013559612238
AUGMENTATIVE AND ALTERNATIVE COMMUNICATION 217

Hetzroni, O.E., & Shalem, U. (2005). From logos to orthographic symbols:
A multilevel fading computer program for teaching nonverbal chil-
dren with autism. Focus on Autism and Other Developmental
Disabilities, 20, 201–212. doi:10.1177/10883576050200040201
Higgins, J.P., & Green, S. (Eds.). (2011). Cochrane handbook for systematic
reviews of interventions (Vol. 4). Chichester, UK: John Wiley & Sons.
Horner, R.H., Carr, E.G., Halle, J., McGee, G., Odom, S., & Wolery, M.
(2005). The use of single-subject research to identify evidence-based
practice in special education. Exceptional Children, 71, 165–179.
doi:10.1177/001440290507100203
Iacono, T., & Cupples, L. (2004). Assessment of phonemic awareness and
word reading skills of people with complex communication needs.
Journal of Speech Language and Hearing Research, 47, 437.
doi:10.1044/1092-4388(2004/035)
Johnston, S.S., Davenport, L., & Kanarowski, B. (2009). Teaching sound let-
ter correspondence and consonant- vowel-consonant combinations to
young children who use augmentative and alternative communica-
tion. Augmentative and Alternative Communication, 25, 123–125.
doi:10.1080/07434610902921409
Kent-Walsh, J., Murza, K.A., Malani, M.D., & Binger, C. (2015). Effects of
communication partner instruction on the communication of individu-
als using AAC: A meta-analysis. Augmentative and Alternative
Communication, 31, 271–284. doi:10.3109/07434618.2015.1052153
Koppenhaver, D.A., & Erickson, K.A. (2003). Natural emergent literacy sup-
ports for preschoolers with autism and severe communication impair-
ments. Topics in Language Disorders, 23, 283–292. doi:10.1097/
00011363-200310000-00004
Light, J., & McNaughton, D. (2013). Literacy intervention for individuals
with complex communication needs. In D.R. Beukelman & P. Mirenda
(Eds.), Augmentative and alternative communication: Supporting chil-
dren and adults with complex communication needs, (4th ed., pp.
309–351). Baltimore: Paul H. Brookes.
Light, J., McNaughton, D., Weyer, M., & Karg, L. (2008). Evidence-based lit-
eracy instruction for individuals who require augmentative and alter-
native communication: A case study of a student with multiple
disabilities. Seminars in Speech and Language, 29, 120–132.
doi:10.1055/s-2008-1079126
Machalicek, W., Sanford, A., Lang, R., Rispoli, M., Molfenter, N., &
Mbeseha, M.K. (2010). Literacy interventions for students with physical
and developmental disabilities who use aided AAC devices: A system-
atic review. Journal of Developmental and Physical Disabilities, 22,
219–240. doi:10.1007/s10882-009-9175-3
McNaughton, D., & Tawney, J. (1993). Comparison of two spelling instruc-
tion techniques for adults who use augmentative and alternative
communication. Augmentative and Alternative Communication, 9,
72–82. doi:10.1080/07434619312331276461
Millar, D.C., Light, J.C., & Schlosser, R.W. (2006). The impact of augmenta-
tive and alternative communication intervention on the speech pro-
duction of individuals with developmental disabilities: A research
review. Journal of Speech Language and Hearing Research, 49,
248–264. doi:10.1044/1092-4388(2006/021)
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D.G. & The Prisma Group
(2009). Preferred reporting items for systematic reviews and meta-
analyses: The PRISMA statement. PLoS Medicine, 6, 1–6. doi:10.1371/
journal.pmed.1000097
Parker, R.I., Vannest, K.J., Davis, J.L., & Sauber, S.B. (2011). Combining
nonoverlap and trend for single-case research: Tau-U. Behavior
Therapy, 42, 284–299. doi:10.1016/j.beth.2010.08.006
Perfetti, C. 1985. Reading ability. New York: Oxford University Press.
Richards, S., Taylor, R., & Ramasamy, R. (2014). Single subject research:
Applications in education and clinical settings. Belmont, CA:
Wadsworth, Cengage Learning.
Schlosser, R.W., Wendt, O., & Sigafoos, J. (2007). Not all systematic
reviews are created equal: Considerations for appraisal. Evidence-Based
Communication Assessment and Intervention, 1, 138–150. doi:10.1080/
17489530701560831
Schlosser, R.W., & Wendt, O. (2008). Effects of augmentative and alterna-
tive communication intervention on speech production in children
with autism: A systematic review. American Journal of Speech-
Language Pathology, 17, 212–230. doi:10.1044/1058-0360(2008/021)
218 K. MANDAK ET AL.
Scruggs, T.E., Mastropieri, M.A., & Casto, G. (1987). The quantitative syn-
thesis of single-subject research methodology. And Validation.
Remedial and Special Education, 8, 24–33. doi:10.1177/
074193258700800206
Share, D.L., & Stanovich, K.E. (1995). Cognitive processes in early reading
development: Accommodating individual differences into a model of
acquisition. Issues in Education: Contributions from Educational
Psychology, 1, 1–57.
Spector, J.E. (2011). Sight word instruction for students with autism: An
evaluation of the evidence base. Journal of Autism and Developmental
Disorders, 41, 1411–1422. doi:10.1007/s10803-010-1165-x

Swinehart-Jones, D., & Heller, K.W. (2009). Teaching students with
severe speech and physical impairments a decoding strategy using
internal speech and motoric indicators. The Journal of Special
Education, 43, 131–144. doi:10.1177/0022466908314945

Truxler, J., & O’Keefe, B. (2007). The effects of phonological awareness
instruction on beginning word recognition and spelling. Augmentative
and Alternative Communication, 23, 164–176. doi:10.1080/
07434610601151803

van der Meer, L., Achmadi, D., Cooijmans, M., Didden, R., Lancioni, G.E.,
O’Reilly, M.F., … Green, V.A. (2015). An iPad#-based intervention for
teaching picture and word matching to a student with ASD and
severe communication impairment. Journal of Developmental and
Physical Disabilities, 27, 67–78. doi:10.1007/s10882-014-9401-5
Vandervelden, M.C., & Siegel, L.S. (1995). Phonological recoding and
phoneme awareness in early literacy: A developmental approach.
Reading Research Quarterly, 30, 854. doi:10.2307/748201
Vannest, K.J., & Ninci, J. (2015). Evaluating intervention effects in single-
case research designs. Journal of Counseling & Development, 93,
403–411. doi:10.1002/jcad.12038
Zascavage, V.T., & Keefe, C.H. (2004). Students with severe speech and
physical impairments: Opportunity barriers to literacy. Focus on Autism
and Other Developmental Disabilities, 19, 223–234. doi:10.1177/
1088357604019004040
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