Effectiveness of Different Types of Augmentative and Alternative
Communication (AAC) in Improving Communication Skills
and in Enhancing the Vocabulary of Children with ASD: a Review
Christine K. Syriopoulou-Delli
Received: 22 July 2020 /Accepted: 14 May 2021
#The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021
Communication deficits are one of the core symptoms of autism spectrum disorder (ASD), and augmentative and alternative
communication (AAC) systems are utilized to facilitate the communication and language development of children with ASD.
This review examines the research literature on the use of aided and unaided AAC systems in interventions for children with
ASD, and investigates their effectiveness in enhancing language and communication skills in this population. Systematic review
methodology was used to limit bias in the search of electronic databases, and relevant studies were selected, 20 of which met the
inclusion criteria for the review. The findings of these studies indicate that AAC systems are able to facilitate and enhance
communication skills in children with ASD. It is apparent that this is a method that will be used increasingly in the future, and it is
imperative that meticulous research is conducted on the effects of the applications. Refinements in the study methodology are
recommended, and additional questions that might be addressed in future research are discussed.
Keywords Autism spectrum disorder .Augmentative and alternative communication .Communication .Assistive technologies .
Autism spectrum disorder (ASD) is characterized by a deficit
in communication, along with other symptoms. It is a
neurodevelopmental disorder that affects the development of
social interaction and communication skills, including both
verbal and non-verbal communication (Lal, 2010). The main
impairment is in the area of pragmatics, which is “employing
language as a social system to communicate”(Eigsti et al.,
2007), but children with ASD also exhibit other types of lan-
guage impairment, including semantic (Coderre et al., 2017)
and grammatical development (Wittke et al., 2017).
According to Coderre et al. (2017), semantic development
refers to “…the understanding of the meaning of a stimulus,
be it a word, picture, sentence, or sound.”
Kasari et al. (2013) estimated that approximately 30%
of people with ASD are non-verbal or have minimal ver-
bal abilities, and other authors report that between 25 and
50% of people with ASD never fully acquire functional
language, although early diagnosis and intervention may
reduce these rates (Brignell et al., 2016; Castelli, 2001;
Mazza et al., 2017; Ramdoss et al., 2010). In addition,
children with ASD display deficits in maintaining joint
attention (Ogletree, 2008), which is the ability to alternate
one’s gaze between objects and people, and is an indicator
of language development in children with ASD (Mundy
et al., 1990). Also, according to Bottema-Beutel’s, 2016
meta-analysis, joint attention deficits are directly linked to
poor language outcomes.
The use of augmentative and alternative communication
(AAC) is recommended to ensure that children with ASD do
not establish patterns of communication failure (Prizant et al.,
2003). AAC includes tools and strategies that an individual
with speech and/or language impairments can use to comple-
ment or even to replace speech or writing (Brignell et al.,
2016; ISAAC, 2018). Some examples of AAC are the
*Christine K. Syriopoulou-Delli
Department of Educational and Social Policy, University of
Macedonia, 156 EgnatiaSt., 54336 Thessaloniki, Greece
Review Journal of Autism and Developmental Disorders
Picture Exchange Communication System (PECS), Makaton
signing, and speech-generating devices (SGDs).
AAC systems have been categorized into aided and unaid-
ed systems. Unaided systems, such as sign language, require
no auxiliary equipment, and the individual’sbodyisusedas
the means of communication. Aided AAC systems require
auxiliary equipment for communication purposes. One low-
technology example of an aided AAC system is PECS, while
high-technology aided AACs include SGDs and other
Research on the effects of AAC on communication is de-
veloping rapidly. Millar et al. (2006), using AAC for 27 adults
and children with ASD or intellectual disability (ID), observed
better speech production in 89% of the participants. There is
as yet no consensus on which aided or unaided system is the
best for teaching children with ASD (Mirenda, 2003;
Schlosser & Sigafoos, 2006), and more recent studies
(Gevarter et al., 2013) showed that both PECS and SGDs were
almost equally successful in enhancing the communication
skills of children with ASD, after conducting a systematic
review and meta-analysis of 28 studies.
Many researchers have focused on the teaching of
requesting skills to children with ASD with the use of
AAC (Ganz, Earles-Vollrath, et al., 2012a). This comes
to no surprise, as the ability to make requests leads to
greater independence (LeBlanc et al., 2009), and children
with ASD have less flexibility in making requests than
their peers of typical development (TD) (Wahlberg &
Jordan, 2001). Requesting or demanding is defined by
Skinner as “a verbal operant in which the response is
reinforced by a characteristic consequence and is therefore
under the functional control of relevant conditions of dep-
rivation or aversive stimulation”(Skinner, 1957). In other
words, requesting allows individuals to express their
wants and needs, and is an essential way of developing
their communication skills (Still et al., 2015).
This review aimed to evaluate the most widely used methods
of enhancing the communication of children with ASD. The
main object was to assess the effectiveness of each type of
AAC in improving the communication skills of children with
ASD and to investigate the possible impact of ACC on their
vocabulary. We focused on requesting skills and vocabulary
development in particular, preference assessment for different
types of AACs, and alsoon generalization and maintenance of
acquired skills. In this context, we also tried to showcase the
different types of AAC employed by other researchers and
explore whether they represent the range of currently available
The review was based on the following research questions:
1. Were the forms of AAC used successful in teaching
requesting skills to children with ASD?
2. Were the forms of AAC used successful in enhancing the
vocabulary of children with ASD?
3. What types of AAC were employed, and do they ade-
quately represent the range of devices available?
4. Were AAC interventions effective in increasing the main-
tenance and generalization of communication in children
5. Did children with ASD demonstrate a preference for a
particular AAC method?
The methodology of this study was based on the 5 essential
methodological steps for conducting systematic reviews, as
indicated byKhan et al. (2003). The first step was to formulate
the research questions, which are presented above. The second
step was to search for articles in electronic databases, includ-
ing PubMed, Google Scholar, Scopus, and Science Direct, for
studies published between 2009 and 2019 that examined lan-
guage and communication development using some form of
AAC. The keywords used were “augmentative,”“alterna-
The third step was to formulate the eligibility criteria to
assess the applicability of the research papers for this re-
view. Specifically, only studies on preschool children and
children of school age with a diagnosis for ASD were
included, and each study should include an AAC instru-
with ASD. The review focuses on the effectiveness of
different types of AAC for children with autism that are
of preschool and school age. For reasons of space, studies
with groups of adolescent children with autism spectrum
disorders were not considered eligible. Each should be a
peer-reviewed primary study incorporating an interven-
tion, experiment, or case study; each should be empirical
and provide data that address the study hypotheses and
include a detailed description of the type of AAC used.
Only studies that met the methodological and content
criteria were included, and review articles, editorials,
and meta-analyses were excluded. In addition, studies that
included only specific age groups (e.g., only preschool
children or adolescents) were not included. Lastly, studies
providing no empirical data and those that did not incor-
porate the use of an AAC instrument as a variable were
The review was conducted by two researchers, and in
the case of disagreement regarding the inclusion or exclu-
sion of research papers, the final decision was made after
discussion. Figure 1shows the flowchart used in the
Rev J Autism Dev Disord
evidence-based minimum set of items for reporting in
systematic reviews and meta-analyses (Moher et al.,
The fourth step was a summarization of the evidence pro-
vided in the final selection of studies. The evidence was cat-
egorized according to the participants, setting, communication
modes, target communication skills, intervention outcome,
maintenance, and generalization. The analysis of the study
results includes the measurements of all the communicative
behaviors that the researchers reported. The fifth and final
review step was the interpretation of the findings, presented
in the “Discussion”section. The findings in each category are
discussed with reference to the initial research questions of the
The various types of AAC systems used with individuals with
ASD, and evaluated in the studies reviewed, are shown in Fig.
PECS was originally developed by Bondy and Frost in 1994.
It is a picture-based AAC system that uses basic behavioral
principles to teach children with ASD to use functional com-
munication in social contexts. The pictures are used to com-
municate, in exchange for items or tasks (Bondy & Frost,
1994,1998). It is of note that not all exchange-based
Fig. 1 PRISMA flow diagram
(after Moher et al., 2010)
Fig. 2 Categorization of augmentative and alternative communication
Rev J Autism Dev Disord
communication interventions are PECS, some are referred to
as picture exchange (PE).
PECS has been reported to be successful in interventions
with individuals with ASD (Ganz & Simpson, 2004;Ganz,
Davis, et al., 2012b), but the intervention was usually focused
on teaching the requesting of items, and not on enhancing
other aspects of communication (Ganz, Earles-Vollrath,
et al., 2012a). Although PECS is successful, its paper-based
nature has some disadvantages, such as preventing educators
from tracking the child’s progress, and adding social stigma
because the child has to carry a book or a folder constantly
(Miller et al., 2006).
SGDs are a high-technology form of aided AAC. They are
also referred to as voice-output communication aids (VOCAs)
(Lancioni et al., 2007). SGDs are used to facilitate both the
expressive and receptive communication of children with
ASD (Sigafoos et al., 2003), and are popular with teachers
and therapists because of the consistency that they provide
in terms of the messages produced (Koul, 2003;Schlosser&
Blischak, 2001). These systems implement the use of symbols
and pictures that represent words, and most children with
ASD process and respond to information better when it is in
visual form (Fleury et al., 2014).
SGDs include newer mobile tablets and other hand-held
devices that produce electronic digitized or synthesized
speech (Mirenda, 2003; Alamsaputra et al., 2006). They are
easily accessible due to the wide availability of “smart”de-
vices, and they are referred to as non-dedicated SGDs. In
recent years, non-dedicated SGDs based on iPads are becom-
ing increasingly popular, because iPads and other tablet de-
vices are used by large numbers of people, including children,
which makes them less “stigmatizing”for the user, unlike the
dedicated SGDs used in the past (Kagohara et al., 2013).
The Makaton Vocabulary is a language and communication
system for people with learning difficulties that was originally
designed by Margaret Walker in 1972 in the UK and is now
used in over 40 countries worldwide. The Makaton program is
used to teach communication and language skills, using man-
ual signs and/or graphic symbols, accompanied by speech. Its
vocabulary is based on a common core of functional concepts.
Once basic communication skills have been acquired, a stu-
dent may move towards more comprehensive language use
(Grove & Walker, 1990).
The Makaton Vocabulary consists of a Core Vocabulary,
with approximately 450 concepts, and a Resource Vocabulary
of over 7000 concepts, all of which are illustrated with signs
and graphic symbols (Walker & Armfield, 1981).
As shown in Fig. 1, the initial search yielded 254 relevant
publications for the years 2009–2019. Removal of duplicates
and application of the first phase of the study criteria left 230
articles, which on scrutiny led to a selection of 45, of which 20
articles met the requirements of the review, and are listed in
Participants and Settings
The 20 studies included a total of 242 children with ASD. For
studies that included participants both with and without ASD,
only data for the children with ASD were taken into consid-
eration. In addition, data on participants that were below 5
years of age were not coded. The sample size ranged between
1 and 84 children, with a mean number of 12.1. Only two case
studies concerned 1 participant. The age of the children in the
studies ranged from 5 to 13 years (mean 8.8 years). Some of
the studies provided only the age range of the participants and
not their exact ages. In this case, the mean of the sample was
used to calculate the overall mean age.
Most of the interventions were made in the participants’
schools (65%), but 3 of the studies were conducted in univer-
sity clinics (15%). One study (5%) was conducted in the par-
ticipant’s home, and two (10%) in both the school and the
Q1: Success of Different Forms of AAC in Teaching
Target Communication Skills
The dependent variables in this review were all target com-
munication skills, delineated in each study and classified into
broad categories. Specifically, the target communication skills
were as follows: (a) requesting skills (e.g., asking for preferred
items, food, snacks, activities, actions), (b) speech, conversa-
tion, and social communication skills, (c) preference assess-
ment for different types of AAC, (d) use of multi-symbol
messages, and (e) reading and spelling skills.
The communication skills assessed in the studies, among
others, were spontaneous communication, language and social
behavior, use of intelligible words, and frequency of commu-
Preference assessment is the process of enabling children to
express their preference for one communication option over
another (Van der Meer et al., 2011). Although clinicians and
educators can follow guidelines in the choice of the best com-
munication option for each child (Reichle, 1991), preference
assessment for AAC devices is considered to be an important
research variable (Van der Meer et al., 2011).
Rev J Autism Dev Disord
Table 1 Studies on the effectiveness of augmentative and alternative communication (AAC) in children with autism spectrum disorder (ASD) included in the review (n=20)
Authors Participant(s) Setting Type of AAC Target communication skills Target outcome(s) Summary of results Generalization Maintenance
1. Ganz et al.
to 6 years;
PECS Requesting skills/communication
Impact of PECS on communication
and effects on maladaptive
Participants learned how to exchange
pictures for requested items;
generalization was achieved for
Positive results Positive
2. Choi et al.
to 9 years;
PE and SGD Requesting skills Effectiveness of combining the
missing-item and wrong-item for-
mats to teach requesting and
Increase in correct rejecting
responses for all participant
Positive results Mixed results
3. Lal (2010) 8 children;
age 9 to 12
(Not specified) Makaton Communication skills Effectiveness of the Makaton
Vocabulary on development of
language and social behavior
Change in social behavior and
language, positive effect of AAC
on development of receptive and
age 4 to 10
PECS Communication skills/requesting
Form and function of spontaneous
communication in non-verbal chil-
dren with autism
Enhancement in children’s
- Mixed results
gs et al.
PECS Requesting skills Demonstration of experimental control
of each PECS training condition
over its respective target behavior
PECS protocols included
well-sequenced training phases
age 8 to 11
SGD and PECS Communication skills/requesting
Utility of the Apple iPad™as a
communication device compared
with a picture-based system
Some increase in communication
with the iPad. Preference for using
7. Van der
age 10 to
MS, PE and
Requesting skills/preference as-
Ability to learn requesting using 3
different AAC modes and
All participants learned how to make
requests using at least one of the 3
age 4 to 12
Requesting skills Efficacy of an SGD compared to
PECS; validation of the PECS
Increase in requesting skills with
both AAC modes; no significant
difference between PECS and the
9. Van der
age 10 to
MS, PE, and
Comparison of multistep requesting
and communication acquisition
using SL, PE, and an SGD.
Both participants acquired the skill
of multi-step requesting using
each AAC mode. One showed
preference for SGD
Positive results Mixed results
1 child; age
SGD Communication skills Efficacy of the SGD (training of
student, teacher, educational
Increase in communication skills - -
age 5 to 8
SGD Communication skills Efficacy of an SGD for improving
spontaneous speech in minimally
verbal children with ASD
Improvement in spontaneous
communicative utterances, novel
words and comments
ton et al.
age 7 to 10
SGD Requesting skills Evaluationofteachingchildrentouse
an iPad-based SGD for making re-
Improvement in performing
Maintenance of the acquired skill
Positive results Positive
Rev J Autism Dev Disord
Table 1 (continued)
Authors Participant(s) Setting Type of AAC Target communication skills Target outcome(s) Summary of results Generalization Maintenance
age 9 to 13
SGD Multi-symbol message use Efficacy of a least-to-most prompting
procedure for increasing use of
Increase in multisymbol message
Positive results Positive
age 8 to 10
SGD Requesting skills Efficacy of systematic instruction on
teaching multistep requesting skills
Increase in multistep requesting
using a tablet-based SGD.
Generalization was demonstrated
Positive results -
age 6 to 8
Home SGD Requesting skills Efficacy of teaching requesting skills
using different types of AAC.
Impact on acquisition, rate of
acquisition, consistency of requests
Request of preferred, available items
using different AAC app display
formats; these must be customized
to each child’sneeds
ages 6 to
SGD Reading and spelling skills Efficacy of an SGD software in
teaching sight word reading skills
Increase in accuracy of identification
of sight words
Positive results Positive
age 5 to 13
PECS and SGD Communication skills Comparison of a high-tech SGD with
PECS in teaching social and com-
Both types of intervention were
effective, with no significant
difference between the two
age 7 to 10
SGD Requesting skills Effectiveness of an SGD in teaching
Success in performing multistep
requesting sequences, after
modifications for two
Positive results Positive
to 8 years;
SGD Requesting skills Effectiveness of behavior-based in-
struction combined with SGD on
acquisition of functional communi-
Increase of both SGD-based and vo-
cal requesting in all 3.
Generalization achieved for two
Mixed results Mixed results
age 5 to 6
SGD Communication skills Effects of functional communication
Decrease in levels of challenging
behaviors after intervention
*Requesting skills here were NOT a variable in this study, but only the means of measuring frequency of communication
DD developmental disabilities
ID intellectual disability
SCI severe communication impairment
SGD speech-generating device
SL sign language
PECS Picture Exchange Communication System
Rev J Autism Dev Disord
The use of multi-symbol messages refers to the ability of
the child to combine multiple symbols on an AAC device in
order to produce more complex forms of communication.
Most children with ASD experience difficulty in processing
and expressing multi-word messages (Smith & Grove, 2003),
and tend to rely on single symbols to communicate when
using AAC devices (Sutton & Morford, 1998). It is of note
that the use of multi-symbol messages has not been explored
in many studies on ASD. In this review, reading and spelling
skills refer to sight word reading. Table 2shows the target
communication skills and the AAC methods used in the stud-
For the purposes of this review, outcomes were classified
into 5 broad categories, according to the target communication
skills taught throughout the interventions. These 5 outcome
categories will be discussed thoroughly throughout the
“Results”section. A study was considered to have a positive
outcome when all the participants showed improvement in the
target communication skill, a negative outcome when none of
the participants showed improvement, and a mixed outcome
when some participants demonstrated improvement while
others did not.
Requesting skills was one of the most common target
communication skills assessed in the review studies, and the
12 relevant studies reported either positive results (83%,
n=10) or mixed results (17%, n=2); no study reported a neg-
Ganz et al. (2009) reported that children using PECS to
learn how to make requests all learned how to exchange pic-
tures for items very quickly. Choi et al. (2010)reportedthat
when children each used a different type of AAC (SGDs and
PE), almost all managed to achieve high scores in requesting,
rejecting,and re-requesting items. Only one requiredaddition-
al training in rejecting and re-requesting in order to reach the
training criterion set by the researchers.
In one study, all 7 participants, starting from zero perfor-
mance at baseline, demonstrated improvement in their
requesting skills once the 4th phase of PECS training was
completed (Cummings et al., 2012).
Another study with positive results regarding requesting
skills was that of Van der Meer et al. (2012), who observed
that two participants managed to perform requests using their
preferred AAC system with ease (Van der Meer et al., 2012).
Two other children in that study were excluded from this
review as they were under 5 years. In a follow-up study, the
same two participants initially failed to make requests, al-
though this skill had been acquired previously. Following
the intervention, both were successful in producing two-step
requests, using an SGD, manual signing, and picture ex-
change, although modifications were made for one (Van der
Meer et al., 2013).
Waddington et al. (2014) evaluated a requesting procedure
using an SGD for children with ASD. All the participants
managed to make multi-step requests, although with fluctua-
tion in their performance, requiring procedural modifications
in order for them to perform the requesting sequence. In an-
other study, two children were able to meet the research
criteria for making requests with an SGD, using 4 different
displays of the same device (Gevarter et al., 2017).
Three further studies that evaluated an SGD reported pos-
itive results regarding the requesting skills performance of the
participants. Specifically, Alzrayer et al. (2017)observedthat
all 4 children managed to combine symbols from the SGD to
varying degrees, and in another study, 3 children were suc-
cessful in combining and using symbols for requesting, al-
though with procedural modifications for two of them
(Alzrayer et al., 2019). Muharib, Alzrayer, et al. (2019a)re-
ported that the 3 children in their study were able to make
different kinds of requests (incomplete vocal requesting, com-
plete vocal requesting, and non-vocal requesting), to varying
degrees. Not all the children managed to make and maintain
all the kinds of requests, and only non-vocal requesting ability
was acquired and maintained by all 3.
Mixed results were reported by 2 of the studies reviewed.
One of these involved 84 minimally verbal children with ASD
who had little previous experience with PECS. After PECS
training, the spontaneous requesting skills of the group in-
creased significantly (RR=2.17, 95 1.75–2.68, p<0.001), but
some participants still made zero requests (Gordon et al.,
2011). Boesch et al. (2013) conducted a stimulus preference
assessment employing both PECS and an SGD to determine
which items were preferred by children with ASD. Strong
effects in requesting items were observed with both PECS
and the SGD using single picture cards, but when children
were required to choose between two or more symbols, they
had no success with either SGD or PECS.
Communication skills were assessed in 10 studies, 7 of
which (70%) reported positive, and 3 (30%) mixed results.
Ganz et al. (2009) used PECS for two male children with
ASD both of whom showed an increased level of spoken
words during the intervention, having produced no words at
baseline. It should be noted, however, that one child occasion-
ally used echolalia when producing speech (Ganz et al., 2009).
In a study of 8 children with ASD who participated in
interventions with the Makaton system, all increased their
scores significantly in both receptive language (W = 0, p <
0.01) and expressive language (W = 1, p < 0.01, according to
Wilcoxon Value) (Lal, 2010).
Positive results were also reported by Van der Meer et al.
(2013); one boy and one girl used at least one of the available
AAC methods (PE, manual signing, and SGD), with high
rates of communicative response, which were also evident at
follow-up sessions. One boy with a dual diagnosis of cerebral
palsy and ASD, who had previous experience with SGDs,
showed an increase in communication skills after being intro-
duced to a specific SGD, especially in the areas of refusing
Rev J Autism Dev Disord
and obtaining items, as measured by goal attainment scaling
(GAS) and a communication matrix (Desai et al., 2014).
Kasari et al. (2014) conducted a large-scale study with 61
minimally verbal children with ASD. They used SGD, along
with two naturalistic behavioral interventions. According to
Schreibman et al. (2015), naturalistic interventions are “…
implemented in natural settings, involve shared control be-
tween child and therapist, utilize natural contingencies, and
use a variety of behavioral strategies to teach developmentally
appropriate and prerequisite skills.”Significant gains were
observed in the spontaneous communication of the children
when the SGD was used, compared with exposure to natural-
istic behavioral interventions only. These gains in communi-
cation included different types of words and functions and not
merely words for requesting.
Positive effects on communication were observed in a
large-scale study, conducted with 35 children with ASD, com-
paring an SGD with PECS in teaching social communication
behaviors. No significant difference was demonstrated be-
tween PECS and the SGD in terms of effectiveness, as both
Table 2 Target communication skills and augmentative and alternative communication (AAC) systems used in the studies on children with autism
spectrum disorder (ASD) included in the review
Authors Communication skills taught Type of
1. Ganz et al. (2009) Requesting items (a)/use of speech and intelligible words (b) PECS -
2. Choi et al. (2010) Requesting-rejecting sequence (for items) (a) SGD/PE Vantage, Tech Speak,
3. Lal (2010) Development of language and social behavior (b) Makaton -
4. Gordon et al.
Spontaneous communication (b)/spontaneous communication for requesting
objects/spontaneous requesting for social purposes (a)
5. Cummings et al.
Exchanges/requesting skills (a) PECS -
6. Flores et al. (2012) Frequency of communication behaviors (b) (through requesting skills*) SGD/PECS iPad with Pick a word
7. Van der Meer et al.
Requesting skills (a)/preference assessment for 3 different AAC methods (c) MS/PE/SGD iPod Touch with Proloquo2Go
8. Boesch et al.
Requesting skills (a) SGD Logan “Proxtalker”device
9. Van der Meer et al.
Requesting skills (a)/communication skills (b)/preference for AAC and social
10. Desai et al.
Communication skills (b) SGD iPad with GoTalk Now
11. Kasari et al.
Spontaneous communication utterances (or: spoken spontaneous language)
SGD iPad/ Dynavox
12. Waddington et al.
Requesting skills (via three-step communication sequence) (a) SGD iPad with Proloquo2Go
13. Finke et al.
Use of multi-symbol messages (d) SGD iPad with Proloquo2Go
14. Alzrayer et al.
Requesting skills (multistep) (a) SGD iPad with Proloquo2Go
15. Gevarter et al.
Requesting skills (a) SGD iPad with AutisMate
16. Caron et al.
Sight-word reading (e) SGD Tablet device with T2L
17. Gilroy et al.
Improvement of social communication behaviors(b) SGD/ PECS Samsung Galaxy Tablet with
AAC app based on PECS
18. Alzrayer et al.
Requesting skills (multistep) (a) SGD iPad with Proloquo2Go
Alzrayer, et al.
Requesting skills (a) SGD iPad with Proloquo2Go
20. Muharib, Correa,
et al. (2019b)
Challenging behaviors (b) (through requesting preferred stimuli) SGD iPad with GoTalkNow
*Requesting skills here were NOT a variable, but only the means of measuring frequency of communication
(a) Requesting skills, (b) communication skills, (c) preference assessment, (d) multi-symbol message use, (e) reading/spelling skills
Rev J Autism Dev Disord
methods had equal success in enhancing the communication
behaviors of the participants (Gilroy et al., 2018).
Mixed results in communication skills development were
reported by 3 studies. PECS use had positive results for most
of the 84 children in the study of Gordon et al. (2011), in terms
of enhancement of spontaneous communication, but some
remained at zero after the intervention. The most positive re-
sults were observed in those children with the least intense
autistic symptoms. The increase in spontaneous communica-
tion skills concerned spontaneous object requesting and not
communication for social purposes.
Flores et al. (2012) also reported that using SGDs or PECS
produced positive results in the communication skills of some
children, but not all of them. They note that no preference
assessment was conducted before the intervention, which
might have affected the results of the study. In the study of
Muharib, Correa, et al. (2019b), the main objective was de-
creasing the challenging behaviors of children with ASD
through establishing communication with an SGD. In one of
the two participants, the challenging behaviors were mini-
mized to zero, but the other continued to exhibit some chal-
lenging behaviors throughout the intervention.
Multi-symbol message use was assessed in one study,
with positive results for all participants. The least-to-most
(LTM) prompting procedure was followed by 6 participants,
to achieve multi-symbol message production. SGD was used,
and from no multi-symbol messages at baseline, after the in-
tervention phase, where LTM was introduced, all participants
were able to successfully produce multi-symbol messages
(Finke et al., 2016).
Reading and spelling skills results were positive in one
study, in which the reading and spelling skill observed was
sight word reading, which is the automatic recognition of
words that appear frequently. This study investigated whether
the use of dynamic text alongside speech output and pictures
from an SGD is effective in increasing sight word acquisition.
At baseline, the 5 participants had low levels of accuracy
when reading target words (less than 36% in total), but they
scored almost 81% in total in the intervention phase, in which
they were introduced to an AAC application with “Transition
to Literacy”software (Caron et al., 2018).
Q2: Success of Different Forms of AAC in Enhancing
Success in vocabulary enhancement using various AAC
modes was somewhat successful for children with ASD and
was mentioned in only a few studies. Of the 20 studies that
met the review criteria, only two were related to vocabulary
assessment and acquisition in children with ASD (Flores et al.,
2012; Caron et al., 2018), and even in those, vocabulary en-
hancement and acquisition were not considered as variables,
so this question cannot be answered by this review.
Q3: Types of AAC
The communication modes were considered in the studies as
independent variables. As shown in Table 1, most studies (16/
20) used SGDs for their intervention. Some used SGDs only,
while others used SGDs and another form of AAC, to com-
pare their effectiveness. PECS was used in 4/20 studies,
Makaton in two, and sign language in one.
The specific devices used in the studies are shown in
Table 2. Among the various SGDs that were utilized, most
(almost 64%) were non-dedicated, meaning they were soft-
ware applications that could be loaded onto a tablet or
smartphone device (e.g., iPad, Samsung Galaxy tablet). The
most popular of these is “Proloquo2Go”(Assistiveware,
2016). Evidence from another systematic review (Alzrayer
et al., 2014) shows that “Proloquo2Go”is the most frequently
researched non-dedicated SGD. Among the most important
features of this application are the high-quality synthesized
speech output, the wide range of pre-stored vocabulary, and
the ability to customize icon size and number of icons
displayed per page (Sennott & Bowker, 2009). Along with
non-dedicated SGDs based on software applications (e.g.,
“Pick a word,”“Proloquo2Go,”“GoTalkNow,”
“DynaVox”), some dedicated SGD devices were utilized also,
including “Vantage,”“Tech Speak,”“SpringBoard,”and
Q4: Follow-up and Generalization
Of the 20 studies, 9 (45%) reported generalization probes, and
12 (60%) evaluated the maintenance of acquired skills.
Generalization outcomes were positive in 8 out of 9studies
(approximately 90%) and mixed in 1 out of 9 (approximately
10%). The various generalization probes concerned novel
communication partners, new activities, new AAC devices,
or new preferred items, etc. Positive results were observed
for maintenance in 8 out of 12 studies (approximately 66%),
and mixed results in 4 out of 12 studies (approximately 33%).
For more detailed descriptions of these measures, readers must
refer to the research articles that are cited in Table 1.
Q5: Demonstration of Preference for Particular AAC
Preference assessment was examined in two studies, both of
which had positive outcomes. Preference for a specific AAC
device or system was measured using the children’srequests.
In one study, two children with ASD indicated a preference
for using one AAC system over the others; specifically, the
boy chose the SGD over other AAC systems 91% of the total
time, and the girl chose PE more often (69% of the total time),
although she had been choosing the SGD at baseline (68% of
the time) (Van der Meer et al., 2012). The same children
Rev J Autism Dev Disord
participated in a follow-up study, in which each maintained
the same preference (SGD for the boy and PE for the girl)
(Van der Meer et al., 2013).
Overall, as shown in Table 1, most of the studies demonstrated
positive outcomes from AAC intervention, in terms of
achievement of targeted skills. Intervention outcomes were
classified into 5 broad categories: requesting skills, communi-
cation skills, preference assessment for AACs, multi-symbol
message use, and reading and spelling skills. Other variables
were also taken into consideration, such as modes of commu-
nication, intervention settings, and the number of participants
in each study. Our initial research hypotheses and the effects
of these variables are discussed below.
Our first research question was whether the forms of AAC
used in each study were successful in teaching requesting
skills to children with ASD. The results from most of the
studies that examined the effects of AAC (PECS, SGDs, man-
ual signing, and PE other than PECS) in enhancing requesting
skills were positive. Some studies focused on the accomplish-
ment of single requests, while in others conducting multiple
requests was the main objective. The study of Gordon et al.
(2011), which included the largest number of participants
(84l) showed mixed results using PECS, and some children
did not manage to make any requests after the intervention. It
is of note the participants had little familiarity with PECS and
that training occurred only at baseline and in the intervention
phase. It is possible that the outcome may have been different
if the PECS training had been applied prior to the intervention.
Teaching and enhancing requesting skills is one of the most
common objectives in studies that use AAC devices. In some
cases, it is the only skill that is being taught, by caregivers and
researchers alike (Sigafoos et al., 2002; Mirenda, 2008).
Future research should promote more complex types of com-
munication, alongside requesting in general, taking multiple
factors into account.
The second research question was whether using AAC
modes was successful in enhancing the vocabulary of children
with ASD. Unfortunately, our study was unsuccessful in prov-
ing that AACs did affect (either in a positive or in a negative
way) vocabulary development, as most studies on AAC
tended to focus on other variables. The reason for this rather
contradictory result is still not entirely clear, but we acknowl-
edge that research on vocabulary enhancement and/or assess-
ment for children with ASD using AAC devices is very lim-
ited and future studies should be focused on this aspect of
The third research question concerned the types of AAC
devices or methods employed by researchers with children
with ASD, and whether they represent adequately the range
of devices available. Table 2shows that those AAC modes
were PECS, the Makaton language program, PECS, PE other
than PECS, sign language, and SGDs (both dedicated and
non-dedicated). These represent most of the AAC methods
available for children with ASD who have communication
deficits, and in some cases, more than one AAC mode was
used in the same study (Choi et al., 2010; Flores et al., 2012;
Van der Meer et al., 2012; Van der Meer et al., 2013;Gilroy
et al., 2018).
An important observation comes from Tables 1and 2re-
garding the researchers’choice of AAC modes. Specifically,
studies conducted in the past implemented low-tech or no-tech
AAC modes (such as PECS, Makaton, manual signing, and
more rarely, SGDs) while more recent studies are utilizing
high-tech AAC devices (tablet-based SGDs) almost exclu-
sively. This preference for high-tech non-dedicated SGDs
among researchers is likely due to the fact that personal com-
puters, tablet devices, and smartphones are widely used now-
adays, and more and more children are familiar with this type
of technology. Users of AAC are looking for devices that are
low cost, lightweight, easily accessible, and, most important-
ly, accepted by society (Shane et al., 2012).
In addition, high-tech devices are really attractive to chil-
dren with ASD, who become highly motivated to perform
activities on electronic computers (Stromer et al. (2006).
This is an indication that high-tech AAC devices can be suit-
able for children with ASD and other developmental disabil-
ities who require alternative means of communication. A sys-
tematic review on aided AACs conducted by Ganz, Earles-
Vollrath, et al. (2012a)identified24studies,9ofwhichused
PECS, 7 picture-based systems other than PECS, and 8 studies
that implemented SGDs. In our review, 80% of the studies
were based on the use of an SGD, mostly non-dedicated.
Generalization and maintenance of acquired communica-
tion skills constitute the fourth question of this review.
Generalization when using AAC devices is the ability to trans-
fer acquired skills to different contexts and/or using different
means of communication. Almost half of the studies reported
generalization probes (novel communicative partners, new ac-
tivities, AAC devices or preferred items, etc.), with mainly
positive results. The only study with mixed results was that
of Muhariband colleagues (Muharib, Alzrayer, et al., 2019a),
where not all participants managed to generalize requesting
skills, although all were able to display requesting skills dur-
ing the intervention generalization probe.
Maintenance refers to the ability to retain acquired skills
long after the intervention. Maintenance was tested in a larger
number of the studies and results were mainly positive. Mixed
results were reported by Choi et al. (2010), where 1/4 partic-
ipants failed to achieve high scores during follow-up sessions,
and by Gordon et al. (2011), where follow-up scores were
high only for spontaneous speech. In addition, follow-up
scores were found not consistent across all AAC options
Rev J Autism Dev Disord
(Van der Meer et al., 2013), and Muhariband colleagues
(Muharib, Alzrayer, et al., 2019a) observed that only1/3 par-
ticipants managed to maintain their newly acquired skills. It
must be noted that although generalization and maintenance
assessments seem to have mainly positive results, readers
should also refer to each study separately, where more infor-
mation about these measures is given.
Preference for a specific AAC mode is considered to be an
important variable by some researchers when designing inter-
ventions (Van der Meer et al., 2011). Preference assessment
was conducted only in two studies (Van der Meer et al., 2012;
Van der Meer et al., 2013). These studies involved the same
two participants and they each expressed a clear preference for
a specific different AAC mode in the primary study, which
they maintained in the follow-up study. Assessing the prefer-
ences of children with ASD when using AAC is important, as
the use of the preferred mode can affect the intervention out-
come (Van der Meer et al., 2011). It is important to note that as
preference may change over time, re-assessment might need
to be made periodically.
Although AAC is mainly implemented for increasing com-
munication in children with ASD, its effects on the academic
skills, challenging behaviors, and social skills of these chil-
dren should also be explored (Ganz, Earles-Vollrath, et al.,
2012a). Muhariband colleagues (Muharib, Correa, et al.,
2019b) examined the decrease in challenging behaviors of
two children with ASD, using AAC for requesting preferred
items. The intervention was successful for one child, who
exhibited no challenging behavior during the intervention,
but more participants would be needed to elicit conclusions.
Overall, this review indicates that using AAC systems has
positive outcomes in enhancing the communication skills of
children with ASD, but the findings should be viewed with
some caution. There is a lack of uniformity in the sample sizes
of the studies, some of which referred to interventions with
small samples of children, while in others the AACs were
implemented for larger groups. A meta-analysis of the results
could be a better indicator of the AAC effects.
Studies are needed on AAC intervention with larger sam-
ples of children with ASD, with clear indications of their level
of functioning before the intervention, and with a range of
outcome measures. Future studies should investigate addition-
al questions, including the effects of AAC systems on the
academic skills and social skills of children with ASD. The
outcomes of each AAC strategy could also be compared, and
the use of different types of symbols, as different methods
may work in different ways for each individual with ASD,
and for different age groups. Finally, the training in the use
of AAC systems and the variation in the methods of specialists
should also be considered as variables in future systematic
reviews, because there might be some differential effects on
the communicative performance of the children. For all these
reasons, meticulous future research is imperative.
Funding This study was self-funded
Ethical Approval All procedures in studies involving human partici-
pants were in accordance with the ethical standards of the institutional
and/or national research committee and with 1964 Helsinki declaration
and its later amendments or comparable ethical standards
Informed Consent Informed consent was obtained from all individual
participants included in the study
Conflict of Interest The authors declare no competing interests.
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