558254

research-article2014
CDQXXX10.1177/1525740114558254Communication Disorders QuarterlyShire and Jones

Systematic Review
Communication Disorders Quarterly

Communication Partners Supporting

2015, Vol. 37(1) 3­–15
© Hammill Institute on Disabilities 2014
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DOI: 10.1177/1525740114558254

Communication Needs Who Use AAC: cdq.sagepub.com

A Systematic Review

Stephanie Y. Shire, PhD1 and Nancy Jones, PhD2

Abstract
Communication partners who efficiently use augmentative and alternative communication (AAC) are essential interaction
partners for children learning to communicate using AAC. This systematic review examines studies targeting interventions
designed to help communication partners support children with complex communication needs who use AAC. Overall,
the 13 studies of moderate methodological quality rated using published rating scales reported positive findings for
partners’ skills and children’s communication. Author-reported effect sizes and calculation of improvement rate difference
indicated that multiple studies demonstrated large effects that were maintained 1 to 2 months post intervention. Delivery
considerations for partner training including device training, enhancing partners’ understanding of communication targets,
and the timing of partner training are discussed. The importance of supporting successful interactions across learning
contexts and domains of communication as well as over time is highlighted. Furthermore, implications for dyads with
unique characteristics including limited experience with AAC and children who are developmentally young are examined.

Keywords
augmentative and alternative communication (AAC), communication, intervention, strategies, development, exceptionalities

The purpose of augmentative and alternative communica-
tion (AAC) is to “enable individuals to efficiently and
effectively engage in a variety of interactions and partici-
pate in activities of their choice” (Beukelman & Mirenda,
2005, p. 8). Interventions for people using AAC often
solely focus on an individual’s ability to navigate the AAC
system, only one component of the bidirectional, co-con-
structed process of communication. To ensure that chil-
dren with complex communication needs who use AAC
have access to engage in the social world, it is essential to
secure opportunities for children to engage with compe-
tent communication partners (Light & Drager, 2007). A
communication partner could include a child’s interven-
tionist, caregiver, or school personnel. Considering the
viewpoint that language learning occurs within the context
of social interactions between novice communicators and
a partner (Tomasello, 2001), just like novice communica-
tors who speak, children using AAC can also benefit from
an environment that is infused with language models and
symbols that are relevant to the child’s focus of attention
by a partner (Brady, Herynk, & Fleming, 2010). Yet, the
AAC system adds an extra dimension that complicates
these social interactions creating a quadratic interaction
between two people, a shared focus of attention, and the
AAC system (Benigno & McCarthy, 2012). It is necessary
to support communication partners’ ability to provide fre-
quent and high-quality social interactions critical for chil-
dren’s language development in this complex interaction.
This systematic review will examine intervention studies
designed to help partners learn to support children with
complex communication needs who use AAC, focusing on
the adult partners’ fidelity of intervention strategy
implementation.
Interactions Including AAC
Both aided AAC systems (e.g., picture exchange communi-
cation system [PECS], speech-generating devices [SGDs])
and unaided AAC systems (e.g., gestures, manual sign,
facial expressions) vary in their ease of use for a novice
1
University of California Los Angeles, USA
2
Neuren Pharmaceuticals, Ltd., Camberwell Australia
Corresponding Author:
Stephanie Y. Shire, University of California Los Angeles, 67-448
Neuropsychiatric Institute, 760 Westwood Plaza, Los Angeles, CA
90024, USA.
Email: sypatterson@ucla.edu
4 Communication Disorders Quarterly 37(1)
partner (Light & Drager, 2007). It may be challenging for
partners who are not efficient AAC users to integrate AAC
and provide the same frequency and quality of learning
opportunities as partners using only spoken language
(Brady et al., 2010). Broadly, communication partners
require two types of skills. First, the partner must be able to
understand the way the child is communicating, including
spoken communication (SC), nonverbal communication as
well as any mode of AAC used by the child. Second, the
partner must also appropriately model augmented commu-
nication and respond to the child via this same array of
types or modes of communication. Research to date sug-
gests that the behavior of communication partners in these
dyads may differ from spoken language dyads in important
ways. For example, communication partners of children
using AAC tend to dominate and interrupt interactions with
question asking and otherwise redirection of the child’s
attention leaving few communicative turns for the child
(Kent-Walsh & McNaughton, 2005). This style of interac-
tion restricts development to a limited range of communica-
tion functions and places the child who uses AAC in the
passive role of a responder rather than an initiator of com-
munication (Kent-Walsh & McNaughton, 2005). As such,
partners may require strategies to interact with children
using AAC in a style that facilitates both responding and
initiating.
Training Communication Partners:
Verbal and AAC Modalities
Research examining spoken language interventions demon-
strates that communication partners can learn to facilitate
children’s language development. Roberts and Kaiser’s
(2011) meta-analysis showed that parents can successfully
deliver interventions leading to gains in communication
skills for children with speech and language delays.
Moreover, clinicians in research settings have been shown
to use strategies such as keeping the AAC system within
reach, prompting communication, and using multiple stim-
uli to encourage AAC usage (Snell, Chen, & Hoover, 2006).
Overall, many of these interventions follow principles of
behavior focusing on antecedent, behavior, and conse-
quence frameworks for teaching (Snell et al., 2006) and
focus on participants with language delays as well as devel-
opmental disabilities.
Specific Aims of the Current Review
For the purpose of the review, the term communication
partner will be used to refer to any individual engaged in
communicative interactions with an individual communi-
cating via an AAC system. In intervention studies, commu-
nication partners are those receiving support to enhance
interactions with the child using AAC. Valuable narrative
reviews have explored communication partner supports by
focusing on theoretical instructional frameworks (Granlund,
Bjorck-Akesson, Wilder, & Ylven, 2008) or by highlighting
trends (Kent-Walsh & McNaughton, 2005); however, these
reviews have not provided an extensive review of partners’
strategy implementation to facilitate children’s AAC use.
Therefore, this systematic review will explore the efficacy
of teaching practices designed to help communication part-
ners learn to engage with children with complex communi-
cation needs who communicate using AAC systems. Due to
the focus on partner training, only studies where partners’
strategy implementation is included as a dependent variable
with numerical data have been included. Specifically, the
review will:
1. identify experimental studies that have examined
practices to help communication partners interact
with children using AAC systems;
2. evaluate the methodological quality of the evidence
using published rating scales; and
3. highlight considerations regarding the development
and delivery of communication partner training
programs.
Method
Search Strategy
A comprehensive search of 10 electronic databases span-
ning biomedical, educational, and medical content areas
was completed in October 2012 and updated October 2013.
Online First releases from relevant journals (e.g.,
Augmentative and Alternative Communication,; Autism;
Journal of Speech, Language, and Hearing Research;
Journal of Autism and Developmental Disorders) were
scanned to pick up articles that may not yet be indexed by
electronic databases. A detailed description of the search
string, and the full set of searches can be obtained from the
first author.
Study Selection
Gray literature including theses and dissertations was
included, and no restrictions were placed on the date of pub-
lication. Only studies published in English were included.
The inclusion criteria were designed to select experimental
quantitative studies that provided empirical data for both
partners and for children with complex communication
needs who are using AAC. Studies included in this review
met the following inclusion criteria: (a) Utilized a quantita-
tive experimental design including group or single-subject
experimental research designs (SSRDs). Studies providing
quantitative data utilizing preexperimental designs (e.g.,
pre–post with no control group, case study designs) were
Shire and Jones
not included due to the methodologically low level of evi-
dence provided (Logan, Hickman, Harris, & Heriza, 2008);
(b) Included children using an AAC system and who have
complex communication needs. No restrictions were placed
on the children’s diagnosis or the type of AAC system; (c)
Included an intervention delivered to adult communication
partners of children using AAC. Studies examining AAC
interventions with no explicit teaching of partners were
excluded. Peers were excluded in the definition of commu-
nication partners due to the differing nature of programming
required for child peers versus adult partners; (d) Included
communication partner fidelity or other partner behavior as
a primary outcome (dependent variable) where numerical
data for both partners’ and children’s outcomes were pro-
vided. Studies including outcomes only for the children who
use AAC were excluded (e.g., Howlin, Gordon, Pasco,
Wade, & Charman, 2007); (e) Included a primary outcome
(dependent variable) in communication or language for chil-
dren using AAC; (f) Studies using SSRDs must include
graphical data to allow for calculation of improvement rate
difference (IRD: Parker, Vannest, & Brown, 2009) for at
least one primary outcome. Notably, three studies examining
a reading-based intervention for children with Rett syn-
drome were excluded due to a lack of graphical data appro-
priate for IRD (e.g., Koppenhaver, Erickson, & Skotko,
2010); (g) Articles detailing a subset of a participant sample
already included in another article were excluded (e.g.,
Romski, Sevcik, Adamson, Cheslock, & Smith, 2006
included 30 of 68 participants from Romski et al., 2010).
Assessment of Methodological Quality
Published methodological rating scales for randomized
control trials (RCTs) and SSRDs were used to assess the
quality of the studies. Based on recommendations made by
the Cochrane Collaboration (Higgins & Green, 2011), the
Jadad et al. (1996) scale was used to evaluate the RCT. The
seven-item Jadad scale focuses on the processes and docu-
mentation of randomization and blind assessment and pro-
vides a quality rating score of “low” (0–2 points) or “high”
(3–5 points). A limitation of the scale is that it demands
double blind assessment for a high rating, which is not
always appropriate for intervention trials where caregivers
or educational personnel are receiving training. Given this
limitation, an additional seven-item scale covering items
related to participant inclusion criteria, adherence to inter-
vention assignment, validity of measures, blind assessment,
appropriate statistical analyses, attrition, and control for
confounds was included (American Academy for Cerebral
Palsy and Developmental Medicine [AACPDM], 2008).
This scale provides an overall quality rating of “weak” (0–3
points), “moderate” (4–5), or “strong” (6–7).
Studies using SSRDs were assessed using a 14-item
scale by Logan et al. (2008) and a supplementary 7-item
scale (Smith et al., 2007), which captured important
5
methodological items that are not found in the AACPDM
scale (e.g., maintenance/generalization and intervention
fidelity). The Logan et al. (2008) scale provides an overall
quality score of “strong” (11–14 points), “moderate,” (7–
10), or “weak” (0–6). No summary ratings are available for
the Smith et al. (2007) scale; therefore, the total number of
points achieved out of a total of 7 possible items was
reported for each study (see Table 2). These scales have
been used in prior published work with high reliability (e.g.,
Patterson, Smith, & Mirenda, 2012).
All studies were assessed by two independent raters.
Intra-class correlations (ICCs) were calculated for each
scale, indicating high reliability for the single-subject scales
(Logan et al., 2008: α = .821; Smith et al., 2007: α = .954).
Due to the small number of items, ICCs could not be calcu-
lated for the group study (Romski et al., 2010), so inter-rater
agreement was calculated by dividing agreements by dis-
agreements for each item. Agreement was 100% for the
Jadad et al. (1996) scale and 83.3% for the AACPDM
(2008) scale. Following Cochrane Collaboration standards,
discrepancies were resolved through discussion with a third
independent rater (Higgins & Green, 2011).
Data Extraction and Analysis
Data encompassing participant characteristics, research
design, intervention, context, outcomes, statistical and/or
visual analysis, and study conclusions were extracted by
one reviewer using a pretested data extraction form adapted
from Ospina et al. (2008). A second reviewer verified the
accuracy and completeness of the extracted data.
Author-reported effect sizes for group designs are
described, while IRD (Parker et al., 2009) was calculated
for studies using SSRDs. IRD has a strong history in medi-
cine and allows for the calculation of the magnitude of the
intervention effect in SSRDs (Parker et al., 2009). IRD has
the advantages of the ability to obtain confidence intervals,
no data assumption required for use, hand calculation, and
ease of interpretation (Parker et al., 2009). As such, IRD
was selected for estimation of overlapping data.
Results
A systematic search of the literature targeting training pro-
grams for partners working with children with complex
communication needs who use an AAC system led to 3,994
citations. Citation titles and abstracts were examined for
any indication that the study systematically addressed part-
ner training. Five hundred sixty-seven of those articles were
identified as relevant and thus retrieved and examined
against the inclusion criteria. Eleven papers were included.
An updated search produced an additional 1,009 citations
where 27 manuscripts were retrieved and examined leading
to the inclusion of two papers for a total of 13 that met all
seven inclusion criteria.
6 Communication Disorders Quarterly 37(1)
Participant Characteristics
Communication partners. Parents (87 mothers, 8 fathers)
were included as partners in 10 studies (see Table 1). Par-
ents’ ethnicity included African American (n = 19), Asian
(n = 5), Caucasian (n = 39), and Hispanic (n = 5) as reported
for 68 parents (Binger, Kent-Walsh, Berens, Del Campo, &
Rivera, 2008; Nunes & Hanline, 2007; Romski et al., 2010;
Rosa-Lugo & Kent-Walsh, 2008). Parents’ level of educa-
tion as reported for 72 parents included high school degree
(n = 9), completion of some college (n = 11) or a college
degree (n = 30), an associate’s degree (n = 1), enrollment or
completion of a post-graduate degree (n = 21; Binger et al.,
2008; Cafiero, 1995; Kent-Walsh, Binger, & Hasham,
2010; Nunes & Hanline, 2007; Romski et al., 2010; Rosa-
Lugo & Kent-Walsh, 2008).
Educational assistants were included in three studies
(see Table 1). They were primarily female (8 of 9); had
completed high school (n = 3), some college (n =2) or a col-
lege degree (n = 4); and were of a range of ethnicities
(African American = 1; Hispanic = 2; unknown: 6). All
assistants had 3 to 5 years of classroom experience except
two who had less than 4 months.
Children using AAC. Studies enrolled a total of 105 partici-
pants (see Table 2 for characteristics). The majority of par-
ticipants were male (n = 72). Ethnicity as reported for 76
participants across six studies was Caucasian (n = 40), Afri-
can American (n = 23), Asian (n = 7), and Hispanic (n = 6).
Studies included 87 toddlers or preschoolers, 17 school-age
children, and 1 adolescent. The children received a range of
diagnoses, including autism or autism spectrum disorder
(n = 16), pervasive developmental disorder not otherwise
specified (n = 2), bilateral schizencephaly (n = 1), cerebral
palsy (n = 3), cleft palate (n = 1), cystic hygroma (n = 1),
DiGeorge syndrome (n = 1), Down syndrome (n = 7), dys-
arthria (n = 1), phonological processing disorder (n = 1),
and unspecified developmental delays (n = 9). One study
(Romski et al., 2010) including 62 of the 105 total partici-
pants provided only a general description of diagnoses
received by participants, including genetic syndromes, sei-
zure disorders, and cerebral palsy.
Language skills. Table 2 outlines the language assess-
ments (clinician delivered and standardized parent report
measures) used in the nine studies reporting entry language.
Across measures, the majority of participants had very lim-
ited language skills for their chronological age. Age equiva-
lent receptive and/or expressive language scores from four
studies (see Table 2) indicated language scores below 24
months (range = 1–24 months). In addition, in two studies
(Iacono, Chan, & Waring, 1998; Romski et al., 2010) 73 of
75 participants entered with 20 or fewer expressive words
(range: 8–20) based on raw MacArthur-Bates Communica-
tion Development Inventory (MCDI; Fenson et al., 1993)
scores. Finally, four studies (Binger, Kent-Walsh, Ewing,
& Taylor, 2010; Kent-Walsh et al., 2010; Rosa-Lugo &
Kent-Walsh, 2008) indicated significant delays in receptive
language, including eight participants at or below the 3rd
percentile and three participants between the 16th and 61st
percentiles (Test of Auditory Comprehension–3; Carrow-
Woolfolk, 1999). Altogether, these nine studies included
children with significant language delays.
AAC systems and exposure. Eleven studies examined
aided AAC systems, whereas three included unaided AAC
(e.g., manual sign and gesture) for at least one child (see
Table 2). Aided AAC included communication boards or
picture cards (eight studies) and/or SGDs (nine studies).
Four studies failed to report children’s prior AAC exposure
(Iacono et al., 1998; Nunes & Hanline, 2007; Romski et al.,
2010; Stiebel, 1999). Seven children in two studies (Binger
et al., 2008; Chang, 2009) had no AAC history. All other
studies required AAC exposure based on duration (e.g., at
least 6 months; Cafiero, 1995), number of symbols (e.g., at
least 10; Rosa-Lugo & Kent-Walsh, 2008), or PECS mas-
tery (Ganz et al., 2013).
Intervention: Protocol Types
Studies used a variety of strategies and contexts to teach
partners to support children’s use of AAC (see Table 1).
Intervention fidelity was measured in five studies, whereas
individual strategies were examined in seven studies.
Strategies included a range of support levels from minimal
direct support such as modeling and environmental arrange-
ment (e.g., Nunes & Hanline, 2007) to direct approaches
such as verbal and physical prompting (e.g., Bingham,
Spooner, & Browder, 2007). The majority of studies (8 of
13) took place in family homes. Communication skills were
targeted in the context of academic or play settings (eight
studies), home (two studies), and recreational routines (one
study). Only three studies examined two or more contexts
(see Table 1).
Book reading. In four studies (Binger et al., 2008; Binger
et al., 2010; Kent-Walsh et al., 2010; Rosa-Lugo & Kent-
Walsh, 2008), varied adaptations of a book reading inter-
vention were examined as the context for increasing
communication via AAC. The protocol varied by study but
primarily included brief practice and feedback (e.g., 4–6 hr;
Rosa-Lugo & Kent-Walsh, 2008) using either minimal sup-
ports (e.g., modeling, contingent responding, waiting, and
open-ended questions) or a heavily prompted question-ask-
ing protocol focused on responding (e.g., Binger et al.,
2010).
Other protocols. Novel protocols referred to as “naturalis-
tic” (Cafiero, 1995; Nunes & Hanline, 2007) consisted of
modeling communication behaviors as well as prompting
 Table 1. Communication Partner Information and Outcomes.

Reported effect size (group designs)

Study Communication partner Intervention Primary outcome IRD and 85% confidence interval (SSRDs)

Binger, Kent-Walsh, Berens,
Del Campo, and Rivera
(2008)
Binger, Kent-Walsh, Ewing,
and Taylor (2010)
Bingham, Spooner, and
Browder (2007)
Cafiero (1995)
Chang (2009)
Douglas, Light, and
McNaughton (2012)
Ganz et al. (2013)
Kent-Walsh, Binger, and
Hasham (2010)
Iacono, Chan, and Waring
(1998)
Nunes and Hanline (2007)
Romski et al. (2010) RCT
Rosa-Lugo and Kent-Walsh
(2008)
Stiebel (1999)
Parent: Female (2), male (1); some college/ Book reading activity Percentage of steps correctly Intervention—1 large; Generalization—1 large;
degree (3); Hispanic (3) implemented Maintenance—1 large
Educational assistants (3): females; some Book reading Percentage of steps correctly 1 large
college/degree (3); African American (AA: 1), implemented
Hispanic (2)
Educational assistants (3): female; high school Classroom AAC use Number of prompts and Prompting child: 1 large
(3); experience: 2.5–65 months responses to child Responses to child: 1 large
Parent: HS (1), college degree (1), education Natural aided language Intervals with: PCS; parent– PCS (n = 4): 0.73 [0.62, 0.84] moderate; Parent
NR (1); lower middle class (2), upper class stimulation child talk communication (n = 4): 0.14 [0.12, 0.16] small;
(2), NR (1) Stress: No graphical data for IRD
Parent: No other information provided Mass trials Average implementation After 1 week training: 0.23 [0.20, 0.26] small
score After 6 week training: 0.28 [0.24, 0.32] small
Paraprofessionals (3): female (2), male (1), IPLAN and MORE Communication opportunities Intervention—1 large
college degree (2), nurse (1) provided Maintenance—0.93 large
Preschool therapists (3): Female (2), male (1), PECS Frequency of PECS Intervention—1 large
master’s degree (3); experience: 3–4 opportunities provided Generalization—0.17 small
years (2), 4 months (1)
Parents: Female (6), high school (1), some Book reading Level and rate of parent No graphical data provided
college/degree (4), associate’s degree (1); acquisition of skills
AA (3), Caucasian (3)
Parent; females; middle-upper class (5) Milieu Parent utterance type No graphical data provided
Parent: Female; high school (1); low Four naturalistic teaching Environmental arrangement, Environmental arrangement: PR: 0.88 large; Gen:
socioeconomic status (1) strategies Mands, Mands with AAC, −0.66 none; CR: 0.47 small; Gen: 0 none
and Models across PR and Mands: PR: 0.25 small; Gen: 0.33 small CR: −0.22
CR none; Gen: 1 large
Mands with AAC: PR: 0.58 moderate; Gen: −0.33
none; CR: −0.11 none; Gen: −0.33 none
Models: PR: 0.25 small; Gen: 0 none; CR: −0.11
none; Gen: 0 none
Parent: High school (6), some college or degree Augmented and spoken Parents: Mean length Group by session (three conditions) effect size:
(33), post-grad (21), no report (2); AA (18), strategies utterance, mean length of MLU: η2p = .02 NS; mean length turn: η2p = .17
Asian (5), Caucasian (39) turn, total turns NS; parent total turns: η2p = .27 small
Parent: Female (2), high school (2); Hispanic (2) Book reading Accuracy of implementation Intervention—1 large; Generalization—1 large;
Maintenance—1 large
Parent: No other information provided Problem solve Chances to communicate 0.96 (0.82–1.10) large

Note. IRD = improvement rate difference; SSRDs = single-subject experimental designs; AAC = augmentative and alternative communication; HS = high school; NR = not reported; PCS = picture communication symbols;
IPLAN = Identify activities for communication, Provide means for communication, Locate and provide vocabulary, Arrange environment, use iNteraction strategies; MORE = Model AAC, Offer opportunities for communication,
Respond to communication, Extend communication; PECS = picture exchange communication system; PR = play routines; CR = caregiver routines; RCT = randomized control trial; MLU = mean length of utterance; NS = not
significant.

7
8
Table 2. Child Participant Information, Study Outcomes, and Methodological Quality.

Type of AAC, prior AAC

N, Age, Gender, experience and language level, Primary outcomes: Methodological
Study and design Ethnicity Diagnosis Intervention and primary outcome Range (median) reported effect size and IRD quality

SSRDs
Binger, Kent-Walsh, N=3 Phonological processing Book reading activity (NR) and Communication board (1) Intervention—1 large Logan et al. (9);
Berens, Del Campo, Preschool (3) disorder (1), frequency of spontaneous and SGD (2) Generalization—1 large Smith et al. (5)
and Rivera (2008) Male (1), female (2) DiGeorge syndrome imitated messages Yes (1) Maintenance—1 large Moderate
Multiple probe Hispanic (3) (1), cleft palate (1) TACL-3 SS
106–109 (106)
Binger, Kent-Walsh, N=3 Developmental delay Book reading (3–5 × 10-min SGD (3) Intervention—1 large Logan et al. (11);
Ewing, and Taylor Preschool (1), school (2), dysarthria (1) sessions) and frequency of Not reported Generalization—1 large Smith et al. (5)
(2010) age (2) multi-symbol messages TACL-3 SS/AE Maintenance—1 large Strong
Multiple probe Male (2), female (1) 61–98 (85)/3;6–5;7 (3;6)
African American (2),
Hispanic (1)
Bingham, Spooner, and N=3 Developmental delay (3) Classroom AAC use (1–2 hr Picture symbols (3) Responding with AAC: Logan et al. (3);
Browder (2007) School age (2), intro, 6 hr role playing, 2 hr on Big Macs (1) Intervention—0.78 moderate Smith et al. (3)
Multiple probe adolescent (1) self-evaluation) and frequency Must use an AAC system to be Follow-up—1 large Weak
Male (1), female (2) of responding with AAC; included Occurrences of problem behavior:
frequency of problem behavior Baseline AAC frequency Intervention—0.59 moderate
0–1 (0) Follow-up—1 large
Cafiero (1995) N=5 Autism (4), PDD (1) Natural aided language stimulation Picture symbols (3) Child communication (n = 4): Logan et al. (2);
Multiple probe Preschool (5) (2 × group training, 7–10 hr Used AAC for at least 6 months 0.31 small Smith et al. (3)
Male (4), female (1) in home) and child responses, No assessments reported Parent–child communication (n = 4): Weak
initiations with picture Parents reported: babbling 0.44 small
communication symbols through 1 to 3 word
utterances
Chang (2009) N=6 Autism (6) Mass trials and parent training Picture cards (6) Across 3 routines: Logan et al. (6);
Multiple baseline Preschool (1), school targeting responses across three No past AAC exposure Phase 1: 0.66–0.78 moderate, Phase 2: Smith et al. (3)
age (5) routines (e.g., play, snack) for VABS communication AE 0.58–0.98 moderate-large Weak
Male (6) each participant 0;1–0;8 (0;5) Parent training: 0.58–1 moderate-large
Douglas, Light, and N=3 Down syndrome IPLAN and MORE intervention Voice output (1); sign and Child communication turns: Logan et al. (8);
McNaughton (2012) Preschool (3) (1), developmental strategies in 15-min play gesture (2) Intervention—1 large, Smith et al. (3)
Multiple baseline probe Male (1), female (2) delay and hard of sessions Some anecdotal exposure to sign Maintenance—0.80 large Moderate
hearing (1), bilateral, (children using 1–3 single signs)
schizencephaly (1)
Ganz et al. (2013) N=3 Autism (1), ASD (1), PECS Children have mastered at Independent PECS exchanges: Logan et al. (12);
Multiple probe Preschool (3) PDD-NOS (1) least one phase of the PECS Intervention—0.76 moderate Smith et al. (4)
Male (2), female (1) protocol Generalization—0.25 small Strong
Kent-Walsh, Binger, N=6 Cerebral palsy (3), Book reading (2–2.5 hr) and Communication board (1) Communication turns: Logan et al. (11);
and Hasham (2010) Preschool (1), school Down syndrome (3) number of communication turns Manual sign (1) Intervention—1 large, Generalization—1 Smith et al. (5)
Multiple probe age (5) (comments and questions) via SGD (4) large, Maintenance—1 large Strong
Male (4), female (2) any modality; different concepts At least 10 AAC symbols Different concepts:
African American (3), Peabody Picture Vocabulary Test–III Intervention—1 large, Generalization—1
Caucasian (3) SS/AE large, Maintenance—1 large
40–110 (62)/2;1-6;0 (2;5)
TACL-3 SS/AE
49–104 (62)/3;0–5;2 (3;7)
Iacono, Chan, and N=5 Developmental delay Problem-solving using milieu Manual sign (5) Linguistic unit production (n = 5): Logan et al. (5);
Waring (1998) Preschool (5) (2), Down syndrome teaching (28 sessions at 2.5 hr History not reported 0.35 small Smith et al. (1)
Multiple baseline Male (3), female (2) (3) each) and number of linguistic Reynell AE Frequency of vocalizations (n = 2): Weak
units; frequency of vocalizations 1;8–2;0 (1;9) 0.96 large
and gestures; modality of MCDI receptive total Frequency of gestures (n = 2):
linguistic unit 206–279 (215) 0.42 small
MCDI expressive total Modalities (no graphical data)
14–72 (20)
(continued)
 Table 2. (continued)

Type of AAC, prior AAC

N, Age, Gender, experience and language level, Primary outcomes: Methodological
Study and design Ethnicity Diagnosis Intervention and primary outcome Range (median) reported effect size and IRD quality

Nunes and Hanline N=1 Autism (1) Four naturalistic teaching Communication board (1) Communication turns Logan et al. (8);
(2007) Preschool (1) strategies (2 hr per play and History not reported PR: 1 large, generalization (Gen): 1 large; Smith et al. (3)
Multiple baseline Male (1) caregiver routine) and AAC LAP AE CR: 0.09 small; Gen: 1 large Moderate
use; gesture and manual sign; 21 months Imitative response
vocalizations and verbalizations PR: 0.11 small; Gen: 0 None
(all variables in both PR and CR) CR: 0 none; Gen: 0 none
Child response AAC use
PR 0.88 large; Gen: 0 none
CR: 0.4 small; Gen: 0 none
Verbal response—PR: 0.5 moderate; Gen: 0
none; CR: −0.11 none; Gen: 0 none
Gesture and sign response: PR: 0.63
moderate; Gen: 1 large; CR: 0.2 small;
Gen: 1 large
Rosa-Lugo and Kent- N=2 Cystichygroma (1), Book reading (1 hr intro, SGD (2) Intervention—1 large Logan et al. (6);
Walsh (2008) School age (2) developmental delay 2–5 hr practice) and number of At least 10 AAC symbols Generalization—1 large Smith et al. (4)
Multiple baseline Male (1), female (1) (1) communicative turns Receptive One Word Picture Maintenance—1 large Weak
Vocabulary Test—SS: 55
TACL-3 SS
64–66 (65)
Stiebel (1999) N=3 Autism (3) Problem-solving home routines Picture cards (3) Intervention—0.63 moderate Logan et al. (8);
Multiple baseline Preschool (2), school (1–2 × 1–1.5 hr) and frequency History not reported Maintenance—0.81 large Smith et al. (3)
age (1) of spontaneous card use Vineland Adaptive Behavior Scale: Moderate
Male (3) Communication-SS: 34–45 (38)
Hispanic (2)
Randomized control trials
Romski et al. (2010) N = 62 Unspecified genetic Naturalistic strategies in three SGDs (62) Group by session Jadad et al. (1);
Preschool and developmental conditions: ACI, ACO, and SC; History not reported Augmented words AACPDM (5)
2
Males (43), females (19) disorders (autism 18 × 30 min) and number of Scores reported for Intervention: ACO > ACI ηG = .11 NS Low/moderate
2
excluded) augmented words and spoken AC-I/ AC-O /SC groups Spoken words ηG = .04 NS
words; number of different MSEL receptive SS Vocabulary size η2 = .47
spoken words and vocabulary 28/29/27; expressive SS ACO > ACI > SC—Significant post hoc
size; MLU; mean turn length; 22/22/21 test
2
type/token ratio; utterance SICD receptive AE MLU ηp = .15, mean turn length
intelligibility; utterance rate; 18/20/19; expressive AE η2p = .14
2
total turns 12/13/13 Type/token ratio ηp = .26
MCDI receptive total score Intelligibility η2 = .59, utterance rate
p
114/144/155; expressive total η2p = .26
2
score 11/14/8 Total turns ηp = .26

Note. AAC = augmentative and alternative communication; IRD = improvement rate difference; SSRDs = single-subject experimental designs; SGD = speech-generating device; TACL = Test for Auditory Comprehension of
Language; SS/AE = Standard Score/Age Equivalent; PDD = pervasive developmental disorder; VABS = Vineland Adaptive Behaviour Scale; IPLAN = Identify activities for communication, Provide means for communication, Locate
and provide vocabulary, Arrange environment, use iNteraction strategies; MORE = Model AAC, Offer opportunities for communication, Respond to communication, Extend communication; ASD = autism spectrum disorder;
PDD-NOS = pervasive developmental disorder not otherwise specified; PECS = picture exchange communication system; MCDI = MacArthur-Bates Communication Development Inventory; PR = play routines; CR = caregiver
routines; LAP = Learning Accomplishment Profile; ACI = Augmentative Communication Input; ACO = Augmentative Communication Output; SC = spoken communication; MLU = mean length of utterance; MSEL = Mullen
Scales of Early Learning; SCID = Sequenced Inventory of Communication Development; AACPDM = American Academy for Cerebral Palsy and Developmental Medicine.

9
10
and environmental supports. Both Douglas, Light, and
McNaughton (2012) and Ganz et al. (2013) used play rou-
tines as the context to elicit communication opportunities.
In addition, Chang (2009) used a mass trial learning
approach (repeated sets of teaching trials), whereas Stiebel
(1999) applied a home routine problem-solving
intervention.
Comparison of conditions. Only one study compared multi-
ple teaching conditions (Romski et al., 2010). Parent–child
dyads were randomized to one of three conditions, which
differed in two ways: (a) target output (AAC or SC) and (b)
presence or absence of demand for output (AC output
[ACO] or AC input [ACI]). Treatment consisted of 18 clinic
sessions and 6 home sessions to teach parents prompting
and environmental strategies.
Measures and Primary Target Outcomes
Communication partners. Fidelity of intervention implemen-
tation and strategy use were the most common partner out-
comes (seven studies; see Table 1) as well as provision of
opportunities for child communication (two studies). In
addition, three studies examined partners’ mean length of
utterance (MLU) as well as mean length and number of
turns (Romski et al., 2010), the function and type of part-
ners’ utterances (Iacono et al., 1998) as well as their style of
interaction (e.g., prompting vs. contingent responding;
Bingham et al., 2007). Cafiero (1995) explored parent stress
using the Parent Stress Index (PSI; Abidin, 1995).
Children using AAC. Language outcomes obtained through
live coding or coding of videotape included MLU, AAC
use, gestures, vocalizations, and picture exchange. These
outcomes were presented as one variable that collapses both
responses and initiations. In addition, six studies examined
transcribed interactions to explore expressive communica-
tion (e.g., spoken and augmented words, MLU, number and
length of turns, communication rate). In addition, one study
included frequency of problem behavior (Bingham et al.,
2007).
Research Design
Studies included one RCT (Romski et al., 2010) using a
three-group comparison design, and 12 SSRDs including
multiple baseline and multiple probe designs.
Quality of Conduct
Quality of conduct scores for each study is described in
Table 2. Itemized scores for SSRD quality are found in
Table 3 and scores for the one RCT are described in the text
to follow. The bulk of the included studies used SSRDs.
Communication Disorders Quarterly 37(1)
These 12 studies varied in quality (3–12 points, median = 8)
on the Logan et al. (2008) scale, including studies rated as
“weak” (five studies), “moderate” (four studies), and
“strong” (three studies). Corresponding scores on the Smith
et al. (2007) scale ranged from 1 to 5 out of 7 (median = 3).
Overall, interventions and outcomes were well described,
research designs were accurately reported, and graphical
data were accurately represented. Approximately half of the
studies established stable baseline measures, demonstrated
intervention effects across at least three participants, and
reported generalization measures for all participants.
However, the majority of studies failed to require blind
assessment or measure treatment fidelity. Furthermore, the
studies failed to adequately report participant characteris-
tics or describe level, trend, or variability within the data.
Finally, the RCT (Romski et al., 2010) was of low–moder-
ate quality, scoring 2 points (low) on the Jadad et al. (1996)
scale due to a lack of description of the randomization pro-
cess and lack of double blind procedures. The study earned
5 points (moderate) on the AACPDM (2008) scale, due to
well-described inclusion criteria, use of reliable measures,
inclusion of power calculations, and controls for potential
confounds.
Outcomes
Author-reported effect sizes are shown in Tables 2 and 3
and interpreted within Cohen’s (1992) framework of small
(.20–.49), medium (.50–.79), and large effects (.80–1.0).
For studies using SSRDs, IRD analysis was conducted. IRD
benchmarks (Parker et al., 2009) include small (0–.50),
moderate (.51–.70), and large effects (.71–1.0).
Communication partner outcomes. From those studies that
measured intervention fidelity and provided graphical data,
it was observed that several partners began intervention
with scores below 25% (e.g., Rosa-Lugo & Kent-Walsh,
2008), many near zero (e.g., Binger et al., 2008). Large
effects of intervention were found on partner’s strategy use
in three of four reading studies (see Table 1) and at follow-
up, while small effects on fidelity of mass trial teaching
were reported (Chang, 2009). Furthermore, when fidelity of
a specific strategy was examined (e.g., prompting, respond-
ing, providing opportunities, modeling, and environmental
supports), partners also entered intervention with near zero
scores (e.g., Bingham et al., 2007; Ganz et al., 2013). Large
effects were found for both partner prompting and provision
of communication opportunities in two studies (Bingham
et al., 2007; Douglas et al., 2012), while Nunes and Hanline
(2007) reported mixed effects.
In addition, five studies examined partners’ discrete
communication behaviors (e.g., partner’s MLU; Romski
et al., 2010). Three studies found large increases in child
communication opportunities provided by the partner
Shire and Jones 11

Table 3. Methodological Characteristics of Single-Subject Studies.

Number of studies
American Academy for Cerebral Palsy and Developmental Medicine (2008) quality components (%) N = 12
1. The participant(s) are well described to allow comparison with other studies or with the reader’s 5 (42%)
own patient population
2. Independent variables were operationally defined to allow replication 8 (67%)
3. Intervention conditions operationally defined to allow replication 10 (83%)
4. Dependent variables were operationally defined 8 (67%)
5. Inter-rater/intra-rater reliability of dependent measures was assessed before and during each phase 10 (83%)
of the study
6. Outcomes assessors were blind 0
7. Baseline data were stable 6 (50%)
8. Type of SSRD was clearly and correctly stated 12 (100%)
9. Adequate number of data points in each phase (min 5) 2 (17%)
10. Intervention was replicated across three or more subjects 6 (50%)
11. Authors conducted and reported visual analysis 4 (33%)
12. Graphs used for visual analysis follow standard conventions 8 (67%)
13. Authors report tests of statistical analysis 5 (42%)
14. All criteria met for statistical analysis 5 (42%)

Smith et al. (2007) quality components

1. Use of single-case experimental design 12 (100%)
2. Specific inclusion and exclusion criteria for enrollment in study along with dropouts and intervention 6 (50%)
failures
3. Participant samples were well-defined (i.e., standardized diagnostic tests, standardized intelligence 0
tests, adaptive behavior)
4. Intervention effects were replicated across three or more participants 6 (50%)
5. Assessment of generalization of intervention effects was conducted in at least one other setting or 10 (83%)
the study measured maintenance of treatment effects over time
6. Measurement of outcomes was conducted by assessors who were blind to purpose of the study 0
7. Fidelity of intervention implementation was monitored through direct observation 8 (67%)

Note. SSRD = single-subject experimental design.

(Douglas et al., 2012; Ganz et al., 2013; Stiebel, 1999),
while Cafiero (1995) found moderate effects for partner
communication frequency. Finally, Romski et al. (2010)
found small effects for communication turn frequency and
no effects for parent MLU or mean turn length.
Children’s outcomes. Overall, children made gains in AAC
use, turns, and receptive vocabulary although some mixed
effects were found. Effects were found across multiple stud-
ies for low-rate communicators, including children with
zero functional symbols at entry who exited intervention
with 2 to 15 symbols per 10- to 30-min session (e.g., Binger
et al., 2008, Romski et al., 2010, Rosa-Lugo & Kent-Walsh,
2008). Examination of the intervention effects indicates
large effects for children’s use of AAC in eight studies (see
Table 1).
Spoken language. Spoken language and/or vocalizations
were targeted in three studies. Large (Iacono et al., 1998) to
moderate effects (Nunes & Hanline, 2007) on vocalizations
were found. In the RCT (Romski et al., 2010), although
some children showed increases, effects on spoken lan-
guage were not significant. Romski et al. (2010) examined
additional aspects of the interactions, finding a number of
small and moderate effects for vocabulary and intelligi-
bility where children using AAC experienced the greatest
increases.
Follow-up and generalization. Large effects were also
found for follow-up measures in six studies (see Table 2) for
child communication outcomes, including messages during
book reading and children’s communication turns. How-
ever, Nunes and Hanline (2007) found mixed generalization
effects with large effects in play for gesture, sign, and turns,
but no effects for AAC or spoken responding, and imitation.
Discussion
The importance of partner training has been highlighted in
the extant literature, yet few empirical examinations of
12
training programs for partners have been published. The 13
studies included in this review provide preliminary evidence
of moderate methodological quality, demonstrating that both
parents and educational assistants are adopting interaction
strategies through brief and targeted instructional programs
that positively influenced children’s AAC use.
Partners’ adoption and accurate implementation of com-
municative strategies and their impact on children’s out-
comes may be influenced by a number of factors that need
to be addressed for a full understanding of the efficacy of
partner training programs. The studies reviewed here reflect
some key limitations of the current literature and highlight
critical methodological considerations for further research
in this area. In particular, we will discuss the relevance of
device training, timing of partner training, selection of
developmentally appropriate communication targets for the
child, and the maintenance and generalization of partners’
strategy implementation.
Device Training
What is missing from these training programs is explicit
reporting of protocols used to help partners navigate the
AAC systems including specific information about the base-
line level of AAC proficiency of participants as well as
methods to familiarize participants with the selected mode
of AAC. All but two studies included children who had some
experience with AAC, but no study reported on partners’
previous AAC history. Particularly for dyads that lack this
experience, both parties may require training in how to use
the AAC system prior to interaction training. Multiple stud-
ies included SGDs which require that partners be able to
program new symbols and navigate the device features to
effectively engage the child. Therefore, consideration of the
type of AAC system and the breadth and depth of training
needed is critical to make a fair comparison of the effective-
ness of a training program across different AAC systems.
Furthermore, partner training dosage and intervention effects
varied across studies with similar intervention protocols but
varied populations (e.g., Binger et al., 2008, Bingham et al.,
2007). Without knowing the baseline-level AAC experience
of the partners, it is difficult to draw conclusions about opti-
mal intervention dosage from these studies. Further research
should include in their designs an identification of the level
of expertise of both the children and the partner relative to
the type of AAC system to be used.
Timing the Introduction of Partner Training
The timing of the introduction of partner training also must
be considered along with the level of experience with AAC
systems. Two studies staggered the start of clinician–child
intervention and partner training, starting with clinician
only intervention before adding partner sessions (Chang,
2009; Romski et al., 2010). These studies included children
Communication Disorders Quarterly 37(1)
with minimal or no AAC experience prior to intervention.
Beginning with direct clinician–child intervention may
have served to jump start the child’s use of the AAC.
Pushing back the entry of partners into the interaction may
allow both parties time to absorb basic strategies. Further
examination of the timing of this merger with examination
of partner fidelity and subsequent effects on children’s com-
munication is required.
Teaching Targets
In addition, explicitly teaching partners the difference
between children’s initiations of communication and
responding to adult bids is crucial. Much like interventions
targeting spoken language, spontaneous communication is
an important AAC outcome (Mirenda, 2003). Children who
rely on prompting to communicate (responding) would not
meet this benchmark. Only four included studies targeted
nonimitated and nonprompted spontaneous communicative
initiations and collected these data separate from elicited
(prompted) language. Together, these studies provide pre-
liminary evidence for interventions targeting spontaneous
communication in play and book-based interactions with
parents (Binger et al., 2008; Kent-Walsh et al., 2010;
Romski et al., 2010; Stiebel, 1999). The limited focus on
spontaneous initiations and emphasis on responding in the
literature has implications for how and what we teach part-
ners to do to support children using AAC. Natural social
interactions include both responses and initiations and as
such, it is crucial to present a range of strategies to support
both sets of skills.
Another consideration for target communication out-
comes is the function of the bid. For example, social com-
munication includes two broad categories, including
requesting (e.g., asking for an object) and commenting
(e.g., to share social interest in an activity). Although
requesting is a frequent target in both communication
interventions targeting spoken and augmented language,
other social functions including commenting are very lim-
ited (Kasari et al., 2014). In addition to supporting chil-
dren’s communicative initiations, fostering social
initiations will enhance the child’s ability to engage in
more flexible social interactions. It is notable that no study
included in this review clearly or systematically docu-
mented the functions of the children’s spoken and aug-
mented utterances. However, several studies did state
within the text that comments were likely included in
counts such as number of different words and number of
utterances. For example, sample interactions provided by
Romski et al. (2010) indicate that both prompted requests
and prompted comments were included in the outcome
variables. Therefore, it is critical that future studies not
only explicitly differentiate and record spontaneous and
prompted communication but also the function of those
communicative bids.
Shire and Jones
Across Contexts and Over Time
Helping partners support children using AAC across multi-
ple contexts and communication domains is also essential
to securing high-quality opportunities for children’s lan-
guage learning. The inclusion of multiple environments
(e.g., home, community, school) and multiple contexts (e.g.,
play, homework, and home routines) within partner training
protocols may increase partners’ ability and confidence to
consistently use interaction strategies throughout the child’s
day. Only 2 studies included more than one context with 11
studies focusing on one specific context such as book read-
ing or play. Large effects were found for partners’ strategy
use as well as children’s communication for book reading in
four studies; but outside this context, the magnitude of
effects varied widely. This lack of generalization across
contexts was captured and led to a lower score on the Smith
et al. (2007) scale. Future research targeting multiple con-
texts in both intervention and generalization programming
is necessary to understand the degree to which children
using AAC and their partners can flexibly engage in com-
municative interactions across the child’s day.
In addition, it is also important that partners are able to
implement the strategies over time once consultation and
support from the trainer has faded. Maintenance of interven-
tion gains was measured in 8 of the 11 studies (see Table 3).
Follow-up periods were brief (1–2 months), demonstrating
varied continuation of treatment gains for both partners and
children using AAC. Maintenance measures were taken in a
context very similar to the intervention context with little
variation in the materials used (e.g., different books; Kent-
Walsh et al., 2010). Overall, mixed maintenance of treat-
ment gains was demonstrated 1 to 2 months post exit.
Variability in Dyads: Children’s Developmental
Level and Receptive Language
As communicative interactions are bidirectional, child
characteristics such as developmental level and receptive
language may also influence these interactions. Sixty-one
children entered their respective interventions developmen-
tally 24 months of age or below (Iacono et al., 1998; Nunes
& Hanline, 2007; Romski et al., 2010). Overall, these par-
ticipants increased from zero instances of AAC use or
vocalizations at study entry to 5 to 14 spoken words or
words produced using AAC during treatment. These studies
indicate that preschool children with complex communica-
tion needs who are minimally verbal and developmentally 2
years of age or younger can make gains in communication
through brief targeted interventions. Children who are mini-
mally verbal (i.e., less than 20 functional spontaneous
expressive symbols; Tager-Flusberg & Kasari, 2013) are a
unique population of children who are underrepresented in
the literature. Little is known about the development of
13
language for school-age children who remain minimally
verbal. Notably, preschool children who had some spoken
language were the majority of participants. For these chil-
dren, AAC can be viewed as a way to jump start communi-
cative development. Missing from these studies are older
individuals using AAC who continue to have minimal com-
municative skills and who are often viewed as lifetime users
of AAC. It is possible that these dyads may require a differ-
ent dosage or type of intervention to facilitate gains.
Furthermore, the development of receptive language
skills may be essential for this specific population.
Increasing receptive language may help children navigate
the demands of their daily world, even if language produc-
tion remains limited. Therefore, receptive language out-
comes may be particularly important targets for children
who are minimally verbal and using AAC. Yet, it is notable
that no study measured children’s receptive language post
intervention. Therefore, we have yet to understand how cur-
rent partner training programs are influencing children’s
receptive language. The inclusion of receptive language
measures in future studies will help demonstrate the effi-
cacy of current practices on children’s understanding of
language.
Strengths and Limitations
Although a variety of adult partners were included, a limita-
tion of this review is the exclusion of studies including
peers as communication partners. Due to the unique proto-
cols required to train peers in comparison with adult part-
ners, these studies were excluded. A strength of this review
is the inclusion of gray literature. Due to the preliminary
state of the literature, this literature was included to provide
a comprehensive review. Another strength of the review is
the evaluation of methodological quality. Although all pub-
lished rating scales have limitations, the chosen scales were
selected because they included items that represent critical
issues in the design and execution of quantitative research.
The scales are limited in that they provide equal weight to
all items although some items may be considered of greater
importance to methodological quality (e.g., experimental
control). Yet, this evaluation of quality helps provide con-
text for the interpretation of study findings. The method-
ological limitations of all studies receiving “weak” quality
ratings are important to consider when interpreting
findings.
Future Directions
The studies included in this review demonstrate concurrent
increases in communication partners’ skills and children’s
communication skills. Demonstration of a directional asso-
ciation between the increasing skills of the partner and the
children’s increasing communication skills is an important
14
next step. In addition, it will also be important to clearly
delineate the instructional strategies provided to partners as
well as differential children’s communicative initiations
versus responses. Both sets of skills are necessary for suc-
cessful social interactions; however, it is not clear within
the included studies whether children developed both func-
tions. Finally, the strength of the evidence is currently lim-
ited by the small number of group design studies, including
RCTs. RCTs are a viable design for large-scale trials of
existing interventions as well as comparative trials and are
necessary to increase the strength of the evidence provided
for partner training.
Conclusion
Overall, the effectiveness of interventions focusing on AAC
usage will be measured by the interactions of children using
AAC with their communication partners in their everyday
environment. The current review demonstrates that inter-
vention research designed to support communication part-
ners provides positive preliminary evidence for partners’
adoption of strategies to support children using AAC.
Further investigation of partner training programs within
larger-scale studies of high methodological quality will help
inform and refine intervention protocols. Additional exami-
nation of partner training strategies and focus on the context
and functions of communication targeted may help guide
the merger of these strategies into existing interventions tar-
geting spoken language. Future research may examine how
this body of literature and intervention practices may be
modified to include children using AAC systems and sup-
port their communicative development.
Authors’ Note
Nancy Jones is now at Neuren Pharmaceuticals. The work pre-
sented here was completed while at the University of California
Los Angeles Department of Applied Linguistics.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: The
first author received fellowship funds from the Canadian Institutes
of Health Research (Doctoral Foreign Study Award) and Autism
Speaks (Weatherstone Pre-Doctoral Fellowship) throughout the
preparation of this manuscript.
References
*Indicates studies included in the review.
Abidin, R. R. (1995). Parenting Stress Index. Odessa, FL:
Psychological Assessment Resources.
Communication Disorders Quarterly 37(1)
American Academy for Cerebral Palsy and Developmental
Medicine. (2008). Methodology to develop systematic reviews:
Treatment interventions. Retrieved from http://www.aacpdm.
org/UserFiles/file/systematic-review-methodology.pdf
Benigno, J. P., & McCarthy, J. W. (2012). Aided symbol-infused
joint engagement. Child Development Perspectives, 6, 181–
186.
Beukelman, D., & Mirenda, P. (2005). Augmentative and alter-
native communication: Supporting children and adults with
complex communication needs (3rd ed.). Baltimore, MD:
Brookes.
*Binger, C., Kent-Walsh, J., Berens, J., Del Campo, S., & Rivera,
D. (2008). Teaching Latino parents to support the multi-sym-
bol message productions of their children who require AAC.
Augmentative & Alternative Communication, 24, 323–338.
*Binger, C., Kent-Walsh, J., Ewing, C., & Taylor, S. (2010).
Teaching educational assistants to facilitate the multisymbol
message productions of young students who require augmen-
tative and alternative communication. American Journal of
Speech-Language Pathology, 19, 108–120.
*Bingham, M. A., Spooner, F., & Browder, D. (2007). Training
paraeducators to promote the use of augmentative and alterna-
tive communication by students with significant disabilities.
Education and Training in Developmental Disabilities, 42,
339–352.
Brady, N. C., Herynk, J. W., & Fleming, K. (2010). Communication
input matters: Lessons from prelinguistic children learning
to use AAC in preschool environments. Early Childhood
Services, 4, 141–154.
*Cafiero, J. M. (1995). Teaching parents of children with autism
picture communication symbols as a natural language to
decrease levels of family stress (Unpublished doctoral disser-
tation). The University of Toledo, OH.
Carrow-Woolfolk, E. (1999). Test for auditory comprehension of
language (3rd ed.). Austin, TX: Pro-Ed.
*Chang, G. T. M. (2009). A visually based naturalistic com-
munication intervention for nonverbal persons with autism
(Unpublished doctoral dissertation). Claremont Graduate
University, CA.
Cohen, J. (1992). A power primer. Psychological Bulletin, 112,
155–159.
*Douglas, S. N., Light, J., & McNaughton, D. B. (2012). Teaching
paraeducators to support the communication of young chil-
dren with complex communication needs. Topics in Early
Childhood Special Education, 33, 91–101.
Fenson, L., Dale, P. S., Reznick, J. S., Thal, D., Bates, E., Hartung,
J. P., & Reilly, J. S. (1993). MacArthur Communicative
Development Inventories: User’s guide and technical man-
ual. Baltimore, MD: Brookes.
*Ganz, J. B., Goodwyn, F. D., Boles, M. M., Hong, E. R.,
Rispoli, M. J., Lund, E. M., & Kite, E. (2013). Impacts of
a PECS instructional coaching intervention on practitio-
ners and children with autism. Augmentative & Alternative
Communication, 29, 210–221.
Granlund, M., Bjorck-Akesson, E., Wilder, J., & Ylven, R.
(2008). AAC interventions for children in a family environ-
ment: Implementing evidence in practice. Augmentative &
Alternative Communication, 24, 207–219.
Higgins, J. P. T., & Green, S. (2011). Cochrane handbook for
systematic reviews of interventions (Version 5.1.0). The
Shire and Jones
Cochrane Collaboration. Available from www.cochrane-
handbook.org
Howlin, P., Gordon, R. K., Pasco, G., Wade, A., & Charman, T.
(2007). The effectiveness of Picture Exchange Communication
System (PECS) training for teachers of children with autism:
A pragmatic group randomized controlled trial. Journal of
Child Psychology and Psychiatry, 48, 472–481.
*Iacono, T. A., Chan, J. B., & Waring, R. E. (1998). Efficacy of
a parent-implemented early language intervention based on
collaborative consultation. International Journal of Language
& Communication Disorders, 33, 281–303.
Jadad, A. R., Moore, A., Carroll, D., Jenkinson, C., Reynolds, J.
M., Gavaghan, D. J., & McQuay, H. J. (1996). Assessing the
quality of reports of randomized clinical trials: Is blinding
necessary? Controlled Clinical Trials, 17, 1–12.
Kasari, C., Kaiser, A., Goods, K., Nietfeld, J., Mathy, P., Landa,
R., . . .Almirall, D. (2014). Communication interventions
for minimally verbal children with autism: Sequential mul-
tiple assignment randomized trial. Journal of the American
Academy of Child and Adolescent Psychiatry, 53, 635–646.
*Kent-Walsh, J., Binger, C., & Hasham, Z. (2010). Effects of par-
ent instruction on the symbolic communication of children
using augmentative and alternative communication during
storybook reading. American Journal of Speech-Language
Pathology, 19, 97–107.
Kent-Walsh, J., & McNaughton, D. (2005). Communication part-
ner instruction in AAC: Present practices and future directions.
Augmentative & Alternative Communication, 21, 195–204.
Koppenhaver, D. A., Erickson, K. A., & Skotko, B. G. (2010).
Supporting communication of girls with Rett syndrome and
their mothers in storybook reading. International Journal of
Disability, Development and Education, 48, 395–410.
Light, J., & Drager, K. (2007). AAC technologies for young chil-
dren with complex communication needs: State of the science
and future research directions. Augmentative & Alternative
Communication, 23, 204–216.
Logan, L. R., Hickman, R. R., Harris, S. R., & Heriza, C. B. (2008).
Single-subject research design: Recommendations for levels
of evidence and quality rating. Developmental Medicine &
Child Neurology, 50, 99–103.
Mirenda, P. (2003). Toward functional augmentative and alterna-
tive communication for students with autism: Manual signs,
graphic symbols, and voice output communication aids.
Language, Speech, and Hearing Services in Schools, 34,
203–216.
*Nunes, D., & Hanline, M. F. (2007). Enhancing alterna-
tive and augmentative communication use of a child with
autism through a parent-implemented naturalistic interven-
tion. International Journal of Disability, Development and
Education, 54, 177–197.
15
Ospina, M. B., Seida, J. K., Clark, B., Karkhaneh, M., Hartling, L.,
Tjosvold, L., . . .Smith, V. (2008). Behavioural and develop-
mental interventions for autism spectrum disorder: A system-
atic review. PLoS ONE, 3, 1–32.
Parker, R. I., Vannest, K. J., & Brown, L. (2009). The improve-
ment rate difference for single-case research. Exceptional
Children, 75, 135–150.
Patterson, S. Y., Smith, V., & Mirenda, P. (2012). Parent training
programs for families of children with autism: A systematic
review of single case contributions. Autism: International
Journal of Research and Practice, 16, 498–522.
Roberts, M. Y., & Kaiser, A. P. (2011). The effectiveness of par-
ent-implemented language interventions: A meta-analysis.
American Journal of Speech-Language Pathology, 20, 180–
199.
Romski, M., Sevcik, R. A., Adamson, L. B., Cheslock, M., &
Smith, A. (2006). Parents can implement AAC interventions:
Ratings of treatment implementation across early language
intervention. Early Childhood Services, 1, 249–259.
*Romski, M., Sevcik, R. A., Adamson, L. B., Cheslock, M.,
Smith, A., Barker, R. M., & Bakeman, R. (2010). Randomized
comparison of augmented and nonaugmented language inter-
ventions for toddlers with developmental delays and their par-
ents. Journal of Speech, Language, and Hearing Research,
53, 350–364.
*Rosa-Lugo, L. I., & Kent-Walsh, J. (2008). Effects of parent
instruction on communicative turns of Latino children using
augmentative and alternative communication during sto-
rybook reading. Communication Disorders Quarterly, 30,
49–61.
Smith, T., Scahill, L., Dawson, G., Guthrie, D., Lord, C., Odom,
S., . . .Wagner, A. (2007). Designing research studies on
psychosocial intervention in autism. Journal of Autism and
Developmental Disorders, 37, 354–366.
Snell, M. E., Chen, L., & Hoover, K. (2006). Teaching augmenta-
tive and alternative communication to students with severe
disabilities: A review of intervention research 1997-2003.
Research and Practice for Persons with Severe Disabilities,
31, 203–214.
*Stiebel, D. (1999). Promoting augmentative communication dur-
ing daily routines: A parent problem-solving intervention.
Journal of Positive Behavior Intervention, 1, 159–169.
Tager-Flusberg, H., & Kasari, C. (2013). Minimally verbal school-
age children with autism: The neglected end of the spectrum.
Autism Research, 6, 468–478.
Tomasello, M. (2001). Perceiving intention and learning words
in the second year of life. In M. Bowerman & S. Levinson
(Eds.), Language acquisition and conceptual development
(pp. 133–158). New York, NY: Cambridge University
Press.