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For children, adolescents, and adults with autism, AAC can have a tremendous positive impact on communication, social skills, and behavior. Now there's a comprehensive, up-to-date research volume that shows professionals what today's most effective AAC methods are—and why they're a perfect fit with a variety of learning approaches that work for people with autism.

Pat Mirenda—a leading authority on AAC and autism—and Teresa Iacono partner with more than 30 other experts to give readers the most current, in-depth information on a wide range of AAC methods and technologies. Through clear and compelling examinations of the latest research studies, professionals supporting people with autism will discover how these evidence-based AAC interventions can be used to

• promote children's natural speech and language development
• expand literacy skills
• modify challenging behavior
• build young children's social interaction skills
• encourage students' full membership and participation in inclusive classrooms
• give children socially appropriate ways to express needs and preferences
• replace unconventional communicative acts with more conventional ones
• help adolescents and adults develop strong social networks within their community

Readers will also get clarification of the common characteristics of effective AAC interventions and insight into the future research required to make AAC technologies more meaningful and motivating.

Essential for educators, SLPs, OTs, PTs, and other direct service providers, this new addition to the renowned Augmentative and Alternative Communication series will give readers a complete understanding of today's diverse AAC options—knowledge they'll use to help people with autism develop the communication and social skills they need to succeed.

Help people with autism benefit from

• speech generating devices
• visual schedules and other types of visual supports
• peer-mediated interventions
• manual signing and gestures
• graphic symbols
• written supports
• and more!

Practically Speaking is part of the Augmentative and Alternative Communication Series.

Series Preface
Series Editors, Editorial Advisor, and Editorial Advisory Board
Volume Preface
About the Editors
Contributors
Acknowledgments

I: Overview and Assessment

1. Introduction to AAC for Individuals with Autism Spectrum Disorders
Pat Mirenda

2: Assessment Issues
Teresa Iacono and Teena Caithness

II: Communication Modalities

3: Presymbolic Communicators with Autism Spectrum Disorders
Charity M. Rowland

4: Research on the Use of Manual Signs and Graphic Symbols in Autism Spectrum Disorders: A Systematic Review
Oliver Wendt

Appendix A: Overview and Appraisal of Studies Involving Manual Signs and Gestures

Appendix B: Overview and Appraisal of Studies Involving Graphic Symbols

5: Speech Output and Speech-Generating Devices in Autism Spectrum Disorders
Ralf W. Schlosser, Jeff Sigafoos, & Rajinder K. Koul

6: Effects of AAC on the Natural Speech Development of Individuals with Autism Spectrum Disorders
Diane C. Millar

III: AAC Interventions

7: AAC and the SCERTS® Model: Incorporating AAC within a Comprehensive, Multidisciplinary Educational Program
Emily Rubin, Amy C. Laurent, Barry M. Prizant, & Amy M. Wetherby

8: The System for Augmenting Language: Implications for Young Children with Autism Spectrum Disorders
MaryAnn Romski, Rose A. Sevcik, Ashlyn Smith, R. Micheal Barker, Stephanie Folan, & Andrea Barton-Hulsey

9: Using AAC Technologies to Build Social Interaction with Young Children with Autism Spectrum Disorders
Kathryn D.R. Drager, Janice C. Light, & Erinn H. Finke

10: The Picture Exchange Communication System: Clinical and Research Applications
Andy Bondy & Lori Frost

11: A Picture Is Worth a Thousand Words: Using Visual Supports for Augmented Input with Individuals with Autism Spectrum Disorders
Pat Mirenda & Kenneth E. Brown

12: Functional Communication Training and Choice-Making Interventions for the Treatment of Problem Behavior in Individuals with Autism Spectrum Disorders
Jeff Sigafoos, Mark F. O'Reilly, & Giulio E. Lancioni

13: The Role of Aided AAC in Replacing Unconventional Communicative Acts with More Conventional Ones
Krista M. Wilkinson & Joe Reichle

IV: AAC-Related Issues

14: Literacy in Individuals with Autism Spectrum Disorders Who Use AAC
David A. Koppenhaver & Karen A. Erickson

15: Membership, Participation, and Learning in General Education Classrooms for Students with Autism Spectrum Disorders Who Use AAC
Michael McSheehan, Rae M. Sonnenmeier, & Cheryl M. Jorgensen

Appendix: Beyond Access Model Best Practices

16: Supporting the Participation of Adolescents and Adults with Complex Communication Needs
Teresa Iacono, Hilary Johnson, & Sheridan Forster

Index

Excerpted from Autism Spectrum Disorders and AAC
Edited by Pat Mirenda, Ph.D., & Teresa Iacono, Ph.D.
©2009. Brookes Publishing. All rights reserved.

EVIDENCE-BASED PRACTICE

A relatively recent development in the field of AAC is an increased emphasis on evidence-based practice (EBP) for assessment, intervention planning, and implementation. EBP is “the integration of best and current research evidence with clinical/educational expertise and relevant stakeholder perspectives to facilitate decisions for assessment and intervention that are deemed effective and efficient for a given stakeholder” (Schlosser & Raghavendra, 2003, p. 263). EBP does not mean that either clinical reasoning or the perspectives of individuals who use AAC and their families are discounted during the AAC assessment or decisionmaking processes. Rather, in addition to these important elements, a third component—current research evidence—is added to the mix.

The EBP process, described by Schlosser and Raghavendra (2003), can be used to make decisions about the intervention components that are most likely to lead to positive outcomes for a given individual. The six steps of this process are

1. Ask a well-built question, such as “Should we use manual signing or should we use graphic symbols to teach requesting to this adolescent with autism?” or “Should we use an SGD to teach social interaction skills to this child with Rett syndrome?”
2. Select evidence sources (e.g., textbooks, research databases, journals).
3. Search the literature.
4. Examine the evidence systematically.
5. Apply the evidence to make decisions on behalf of the specific individual who requires AAC.
6. Evaluate the outcome of the decision over time.

One of the practical outcomes of the emphasis on EBP has been the generation of a number of integrative reviews of AAC research. In such reviews, authors examine research related to a specific type of AAC intervention (e.g., SGDs) with a specific population (e.g., children with ASDs), using either statistical or narrative techniques. They also provide summary statements regarding, for example, the benefits that have been shown to result from the use of a specific intervention or the optimum conditions for generating positive outcomes. Many authors in this book have used this process or a variation thereof to integrate existing research on specific aspects of AAC. In addition, integrative reviews on AAC for individuals with ASDs have addressed topics such as manual signing (Goldstein, 2002; Mirenda, 2001, 2003b; Wendt, Schlosser, & Lloyd, 2005), graphic symbols (Mirenda, 2001, 2003b; Wendt et al., 2005), SGDs and computers with speech output (Schlosser & Blischak, 2001; Wendt et al., 2005), functional communication training (Bopp, Brown, & Mirenda, 2004; Wendt et al., 2005), and visual schedules that use graphic symbols (Bopp et al., 2004).

Decision making that incorporates research evidence is important when designing AAC interventions for individuals with ASDs for a number of reasons. First, these individuals constitute an extremely heterogeneous group with regard to the social, cognitive, motivational, and motor abilities that underlie successful communication. Thus, AAC decisions must be made on the basis of individual skill and preference profiles, rather than on the basis of an ASD diagnosis alone. Researchers have therefore examined strategies for incorporating the modality preferences of individuals with ASDs into the decisionmaking process (Sigafoos, O’Reilly, Ganz, Lancioni, & Schlosser, 2005; Son, Sigafoos, O’Reilly, & Lancioni, 2006).

Second, the field of ASDs in general is “littered with the debris of dead ends, crushed hopes, ineffective treatments, and false starts” (Schreibman, 2005, p. 7). With regard to AAC, this was highlighted in 1970s by the wholesale adoption of total communication as “the answer” for all individuals with ASDs who were unable to speak; in the 1990s, a similar furor focused on facilitated communication. The tendency of many professionals and families to adopt the latest fad intervention, regardless of the quantity or quality of research evidence to support it, can be counteracted by the adoption of an EBP approach to decision making.

Third, for professionals in the field, EBPs are guaranteed to keep us humble by making us aware of just how much we still have to learn. The fact is that we do not know even more than we do know about AAC for individuals with ASD. We do not know how to select the combination of AAC modalities that will result in optimal communication for each individual; how to design comprehensive AAC instructional interventions that truly build on each person’s abilities and strengths; or how to maximally support social, language, and literacy development through AAC. If it is indeed true that with humility comes wisdom, the systematic examination of research evidence for decision making is essential for the field to move forward.

CONUNDRUMS AND CONTROVERSIES

The Merriam-Webster Online Dictionary (2007) defines a conundrum as “an intricate and difficult problem.” In the field of AAC, as in all other fields of scientific endeavor, a number of conundrums have come and gone over the years, while several have lingered and are still active today. Many of the currently controversial issues as they pertain to individuals with ASDs are examined in individual chapters of this book, including the use of SGDs for individuals with ASDs (Chapter 5) and how various AAC modalities affect the likelihood of speech production (Chapter 6). Additional chapters examine the use and effectiveness of both behavioral and social/developmental instructional approaches, including the Picture Exchange Communication System (Chapter 10; see also Frost & Bondy, 2002); the Social Communication, Emotional Regulation, and Transactional Support (SCERTS®) Model (Chapter 8; see also Prizant, Wetherby, Rubin, Laurent, & Rydell, 2005a, 2005b); and various aided language models (Chapters 7 and 9). Chapters on the use of AAC techniques for problem behavior (Chapters 12 and 13), literacy development (Chapter 14), and inclusive education (Chapter 15) also address conundrums that confront and challenge many families and AAC professionals who support individuals with ASDs. This chapter explores three additional controversial issues: 1) integrating AAC with other early intervention approaches for young children with ASDs, 2) deciding whether or not AAC is appropriate and choosing individualized AAC techniques, and 3) critically reexamining conventional assumptions about ASDs as they apply to AAC.

Early Intervention and AAC

The importance of early intervention for young children with ASDs is not a matter for debate. In a comprehensive, evidence-based report, the U.S. National Research Council (NRC) Committee on Educational Interventions for Children with Autism (2001) strongly recommended that entry into intervention programs should begin as soon as an ASD diagnosis is seriously considered, rather than waiting until it is confirmed. The NRC Committee also concurred that “active engagement in intensive instructional programming” (p. 219) should be provided to children at least up to age 8 years for a minimum of 25 hours per week on a year-round basis, and should consist of “repeated, planned teaching opportunities” (p. 219) conducted in both one-to-one and very small group sessions. They also recommended that emphasis be placed on the use of evidence-based instructional techniques in six main instructional areas: 1) functional, spontaneous communication using speech and/or AAC; 2) developmentally appropriate social skills with parents and peers; 3) play skills with peers; 4) various goals for cognitive development, with emphasis on generalization; 5) positive behavior supports for problem behaviors; and 6) functional academic skills, as appropriate.

The NRC Committee (2001) acknowledged that a wide range of instructional approaches may be used to accomplish these goals. These approaches include structured teaching based on the principles of applied behavior analysis such as discrete trial teaching (Smith, 2001), incidental teaching (McGee, Morrier, & Daly, 1999), applied verbal behavior (Sundberg & Partington, 1998), and pivotal response training (Koegel & Koegel, 2006). They also include social/developmental approaches such as the Developmental, Individual-Difference, Relationship-Based (DIR) model (Greenspan & Weider, 1999) and the SCERTS Model (Prizant et al., 2005a, 2005b). Although the NRC Committee did not recommend a specific curriculum or approach, they stressed the importance of goal-directed, evidence-based, individualized programs that meet the needs of both children with ASDs and their families.

Because of these recommendations, immediately after receiving a diagnosis for their child, families are faced with the daunting task of deciding what to do for their child with ASD and how best to do it. Some of their decisions may affect the extent to which AAC techniques of various types will be accepted and used (e.g., in an applied verbal behavior approach, manual signing may be accepted but graphic symbols may not be; see Mirenda, 2003b; Sundberg, 1993). Even when there is agreement about the techniques to implement, AAC practitioners will almost always need to work with other professionals whose views may be quite divergent from (and perhaps even incompatible with) their own. The potential for controversy is considerable and the potential for conflict is high; therefore, the ability to negotiate and collaborate is required of all involved.

To AAC or Not to AAC?

If the goal of an AAC system is to “enable individuals to efficiently and effectively engage in a variety of interactions and participate in activities of their choice” (Beukelman & Mirenda, 2005, p. 8), it is critical that AAC interventions be maximally individualized. This principle raises a number of contentious issues, the first and foremost of which is that many parents of young children (and some practitioners as well) are reluctant to implement AAC interventions out of concern that they will prevent speech production (Cress & Marvin, 2003). Despite credible research evidence to the contrary (Chapter 6; see also Millar, Light, & Schlosser, 2006), this reluctance continues to limit the extent to which individuals who can benefit from AAC have access to it. In addition, AAC is no less immune to “one-size-fits-all” thinking than is any other type of educational intervention. Some practitioners who ascribe to this way of thinking institute one or more AAC techniques with everyone whose social-communication interactions are lacking, regardless of whether AAC is actually required. Other practitioners espouse the superiority of a particular instructional technique over all others, regardless of the abilities and preferences of individuals with ASDs or their families. Still others may always prescribe the specific AAC modality with which they have experience, rather than considering the entire range of available options. For example, some practitioners claim that manual signing is the best AAC technique for all individuals with ASDs, based largely on theoretical arguments rather than on empirical evidence (Mirenda, 2003b). Regardless, this one-size-fits-all thinking invariably limits the communication options that are available to individuals with ASDs and can be avoided by adopting the general EBP approach that was described in a previous section of this chapter.

(Mis)conceptions About ASDs and AAC

Research has called into question at least two of the assumptions that most people accept about ASDs in general: 1) motor impairments are not part of the disorder and 2) in most cases, intellectual disability is. Mirenda (2008) noted that these two assumptions directly affect both the design and the goals of AAC interventions for many individuals with ASDs. Alternative access or instructional supports are rarely provided to compensate for the types of motor planning or coordination problems that appear to be more common than previously thought (e.g., Dziuk et al., 2007; Hardan, Kilpatrick, Keshavan, & Minshew, 2003; Ming, Brimacombe, & Wagner, 2007; Minshew, Sung, Jones, & Furman, 2004). AAC goals are often focused solely on basic requesting skills, under the assumption that most individuals with ASDs will be unable to acquire a broad range of communicative functions because of limited cognitive capacity. Edelson (2006) and others (e.g., Dawson, Soulières, Gernsbacher, & Mottron, 2007), however, have provided empirical evidence to challenge the conventional presumption that intellectual disability usually co-occurs with ASDs. In addition, some researchers have started to demonstrate that individuals with ASDs can become much more communicatively competent through the use of AAC than might be expected in the presence of intellectual disability (e.g., Light et al., 2005). Given all of this, Mirenda (2008) urged AAC clinicians and researchers to “question what we think we know about people with ASD in general and how we support those individuals whose speech does not develop to communicate through AAC in particular.” It remains to be seen whether the AAC community will take up this challenge both to reconceptualize ASDs in general and to design innovative AAC interventions that push traditional boundaries and presume the potential for competence.

CONCLUSION

Decision making related to AAC interventions for individuals with ASDs is a complex and challenging endeavor. Because of the wide heterogeneity of this population, decisions about appropriate AAC techniques cannot and should not be made in the abstract; rather, they must be made for specific learners, in specific contexts, to meet specific needs (Beukelman & Mirenda, 2005). It is clear that that the success or failure of any AAC intervention is not simply a matter of choosing symbols or devices; instructional variables are also critically important. Indeed, when AAC fails to result in spontaneous, functional communication, this failure usually reflects limitations in the procedures and methods used for instruction rather than an inherent problem with AAC itself. In the end, the combination of research-based modality selection, excellent instruction, and goodness-of-fit (Bailey et al., 1990) with regard to environments, communication partners, and communication needs are all needed to maximize the possibility of successful communication for individuals with ASDs.