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Research in Developmental Disabilities 27 (2006) 1–29
Augmentative and alternative communication

interventions for persons with developmental
disabilities: narrative review of comparative
single-subject experimental studies
Ralf W. Schlosser a,*, Jeff Sigafoos b
a
Department of Speech-Language Pathology and Audiology, Northeastern University,
151C Forsyth, Boston, MA 02115, USA
b
University of Texas at Austin, USA
Received 27 January 2004; received in revised form 13 April 2004; accepted 24 April 2004
Abstract
Augmentative and alternative communication (AAC) as an area of clinical and educational

practice involves a myriad of decisions related to the symbols, devices, and strategies from which
each client must choose. These decision-making points can be productively informed through
evidence from comparative intervention studies. The purpose of this review was to synthesize
comparative AAC intervention studies using single-subject experimental designs involving partici-
pants with developmental disabilities. Following a systematic search, each qualifying study was
reviewed in terms of a priori determined appraisal criteria, and summarized in tabular format. Studies
were divided into three groups according to their study of aided approaches, unaided approaches, or a
combination of both. Results are discussed in terms of methodological adequacy of the studies and
their implications for future research and practice.
# 2005 Elsevier Ltd. All rights reserved.
Keywords: Augmentative and alternative communication; Comparisons; Developmental disabilities; Effective-

ness; Efficacy; Efficiency; Interventions; Review; Single-subject experimental designs
* Corresponding author. Tel.: +1 617 373 3785; fax: +1 617 373 2239.
E-mail addresses: R.Schlosser@neu.edu, rwschlosser@earthlink.net (R.W. Schlosser).
0891-4222/$ – see front matter # 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ridd.2004.04.004
2 R.W. Schlosser, J. Sigafoos / Research in Developmental Disabilities 27 (2006) 1–29
Many individuals with developmental disabilities have severe speech and language
impairments (Abbeduto, Evans, & Dolan, 2001) and may thus require intervention to
develop augmentative and alternative forms of communication (Baumgart, Johnson, &
Helmstetter, 1990; Beukelman & Mirenda, 1998; Lloyd, Fuller, & Arvidson, 1997; Romski
& Sevcik, 1996). Augmentative and alternative communication (AAC) is an area of clinical
and educational practice that offers a set of strategies and approaches to supplement or
replace natural speech and/or handwriting (Lloyd et al., 1997). Aided AAC approaches
involve an external aid or device such as a communication board or a speech-generating
device (SGD). Unaided approaches involve only the person’s own body to communicate
such as manual signs or the use of gestures (Lloyd et al., 1997). Once it has been decided
that AAC may be a viable option to consider for an individual, practitioners and
stakeholders need to choose from a myriad of symbol sets/systems, assistive communi-
cation devices, and intervention strategies. Thus, the practitioner is faced with the question
as to which symbols, devices, and strategies to choose over others. Answering these
questions always involves some sort of comparison. For example, one may need to decide
between (a) a gestural mode and a graphic mode, (b) a graphic mode and traditional
orthography, (c) picture exchange and direct selection, (d) scanning method A and
scanning method B, (e) direct instruction and activity-based intervention, and (g) SGDs
and non-electronic communication boards.
These and many other scenarios could be illuminated through comparative efficacy
studies, which are deemed especially helpful to inform these and similar decision-making
scenarios (Schlosser, 1999). Using an evidence-based practice approach to decision-
making, however, requires an appraisal of this research evidence in order to identify the
best and current research evidence (Schlosser, 2003). Using a priori appraisal criteria, the
purpose of this paper is to provide a narrative review of comparative AAC efficacy studies
with single-subject experimental designs involving persons with developmental
disabilities as participants.
1. Method
1.1. Inclusion criteria
The intervention evaluated needed to be within the realm of AAC, defined as ‘‘an area
of clinical practice that attempts to compensate (either temporarily or permanently) for
the impairment and disability patterns of persons with severe expressive communication
disorders (i.e., people with severe speech-language and writing impairments)’’
(American Speech-Language-Hearing Association, 1989, p. 107). While the intervention
needed to be classifiable as involving AAC, it was not necessary that the dependent
measure involved graphic or gestural modes. For example, a study comparing the effects
of simultaneous communication with speech-only treatment would qualify even when
the dependent measure was concerned with natural speech production. The recipient of
the intervention had to be an individual with a developmental disability (e.g., autism,
intellectual disability, and cerebral palsy) regardless of age. Studies involving sign
language or manual signing with individuals who were deaf were excluded, unless the
R.W. Schlosser, J. Sigafoos / Research in Developmental Disabilities 27 (2006) 1–29 3
hearing impairment was only one of several concomitant disabilities that included a
developmental disability. Manual sign instruction involving participants with intellectual
disabilities and hearing impairment, for example, qualified for inclusion whereas studies
involving only deaf children were excluded. Intervention studies targeting individuals
with acquired disorders were excluded (e.g., Angelo, Deterding, & Weisman, 1991; Fox,
Moore Sohlberg, & Fried-Oken, 2001). Similarly, studies comparing strategies for
training or calibrating a device, such as a voice recognition system (e.g., Alcantara et al.,
1990Alcantara, Cowan, Blamey, & Clark, 1990), were excluded. Studies comparing
instructional reading methods were excluded even though they may have involved
pictorial stimuli (e.g., Pufpaff, Blischak, & Lloyd, 2000). Comparison studies focused
on testing the validity of facilitated communication were excluded even when they met
some or all of the other criteria (e.g., Kerrin et al., 1998Kerrin, Murdock, Sharpton,
& Jones, 1998) because these have been recently reviewed elsewhere (Mostert,
2001).
In order to be included, the studies had to aim at a comparison of at least two treatments
or conditions in terms of their effectiveness and/or efficacy. Comparisons of performance
between or among subpopulations were excluded (e.g., Brady & McLean, 1998). Similarly,
comparisons of the effects of communication partners’ behavior on the behavior of
individuals using AAC were excluded. For example, Drasgow, Halle, and Phillips (2001)
evaluated the effects of differential partner reinforcing behavior on the type of request
topographies emitted by children with developmental disabilities. Because their purpose
was not to test the comparative efficacy of two treatments, but rather to examine the impact
of partner behavior on request behavior (personal communication, Erik Drasgow, 9/30/
2003), the study was excluded from the present review. To be included the study also had to
involve a comparative single-subject experimental design (Schlosser, 1999). Quasi-
experimental group designs (e.g., Kahn, 1981) were excluded due their relatively low
incidence in AAC and developmental disabilities (Iacono, 2003). Finally, the study had to
be published in a peer-reviewed journal, as a chapter in a book, or a dissertation and written
in English. Studies published in languages other than English, articles in proceedings (e.g.,
Bravo, LeGare, Cook, & Hussey, 1990) or grant reports (e.g., LeBlanc & Barker, 1982)
were excluded.
1.2. Search methods
Studies were drawn from a number of sources. In preparation for the search, the
authors first retrieved 45 studies from an earlier discussion of methodologic issues on
comparative single-subject experimental designs in AAC (Schlosser, 1999) supple-
mented by studies from the authors’ respective personal databases from a previous meta-
analysis (Schlosser & Lee, 2000) and other research (Sigafoos, 2003). For each of these
studies, an author search was conducted using the Cumulative Index for Allied Health
Literature (CINAHL), the Educational Resources in Education Clearinghouse (ERIC),
MEDLINE1, and PsycINFO. Based on the indexing information of each study, a more
elaborate search strategy was designed by examining whether or not the study was
indexed at all, and if so, what keywords were used to do so. Of the 45 identified studies,
6 studies were indexed in CINAHL, 12 studies were indexed in ERIC, 19 studies were
entered in MEDLINE, and 33 studies were available through PsycINFO. Next, we

examined how many of the entries contributed by each database were contributed by
none of the others (i.e., unique entries). It turns out that PscyINFO contributed 10
unique entries (33% of its entries), MEDLINE added 4 unique entries (21% of its
entries), and ERIC (8.3%) and CINAHL (16.7%) contributed 1 unique entry each. These
findings emphasized the need to use multiple databases for this review. Also, it was
noticed that none of the databases adequately distinguished between manual signs and
sign language using them as if they were one and the same. In AAC, these terms are
distinct from one another (see Lloyd et al., 1997). Based on this experience, the most
successful search strategies combined key words (e.g., communication aids for
disabled) with free text words such as compar*1 or alternating treatments design. Using
other quality filters such as ‘‘comparative study’’ (a Medical Subject Heading term in
MEDLINE), demonstrated to be less reliable for retrieving studies that met our
inclusion criteria.
1.3. Review categories
Each of the studies is reviewed in tabular narrative form in terms of the following
broad categories: (a) author/s, (b) purpose of study, (c) participants, (d) design, (e)
results, and (f) appraisal of evidence. In terms of the appraisal of evidence, each of the
included studies was reviewed in terms of several methodological criteria deemed
essential for determining the certainty of the evidence stemming from comparison
studies (Schlosser, 1999, 2003): (1) bias of participants toward a particular condition due
to prior experiences; (2) adequate control of sequence effects and carry-over effects by
using an appropriate design; (3) the design allows for within-subject replication of
effects; (4) carryover effects/sequence effects are further minimized through procedural
safeguards; (5) a learning criterion was set; (6) a teaching criterion was set; (7) the
equivalence of instructional sets is demonstrated and based on current knowledge of
contributing factors to equivalency; (8) treatments are randomly assigned to instructional
sets; (9) the functional independence of sets is demonstrated; (10) interobserver
agreement data for the dependent measure(s) is/are adequate for the particular target
behaviors; (11) treatment integrity is comparable across conditions; (12) procedures are
held constant except for to be examined differences across conditions; (13) effectiveness
of conditions is demonstrated unequivocally through the attainment of a learning
criterion; and, (14) efficiency comparisons are based on attainment of an a priori learning
criterion for all conditions compared.
1.4. Analysis
The analysis of the above categories served as a basis for the narrative review offered in
Tables 1–10 and the subsequent text, particularly for the appraisal of the evidence
generated from each of the reviewed studies.
1
The asterisk symbol allows for truncation of a term and thereby retrieves all related terms such as
‘‘compared,’’ ‘‘comparison,’’ and ‘‘comparative.’’
Table 1
Comparative studies involving unaided AAC modes: simultaneous communication, sign-alone instruction, and
oral instruction
Study Purpose—to compare
Barrera et al. (1980) O, SA, and SC in terms of natural speech production or expressive signing
Barrett and Sisson (1987) O (required a vocal response), SC (vocal and signed), and modified SC
(vocal) in terms of natural speech production and/or signing
Brady and Smouse (1978) O, SA, and SC in terms of receptive speech
Carr et al. (1984) receptive O vs. SA in terms of receptive dis-criminations (sign and speech)
Clarke et al. (1988—1) SC vs. SA for receptively known words in terms of expressive signing
and natural speech production
Clarke et al. (1988—2) SC vs. SA for receptively known words in terms of sign acquisition
and expressive speech
McDonald (1977) SC vs. O and O with prompts and fading in terms of expressive
vocal imitation
Remington and Clarke (1983) SC vs. SA in terms of expressive sign labeling and receptive speech
Sisson and Barrett (1984) O vs. SC in terms of spoken and/or signed sentence imitation
Wells (1981) O vs. SC on natural speech production (i.e., word articulation)
Wherry and Edwards (1983) O, SA, and SC in terms of receptive speech, natural speech production,
and eye contact
Notes: O, oral instruction; SA, sign-alone instruction; SC, simultaneous communication instruction.
2. Results
A summary of the narrative review for unaided approaches is provided in Tables 1–3. A
summary of the narrative review for aided approaches is offered in Tables 4–8, and the
review of comparisons of unaided with aided approaches is provided in Tables 9 and 10.2
The references for the reviewed studies are available in the ‘‘Included studies’’.
3. Comparison studies involving unaided approaches
The long-standing history of unaided approaches is reflected in the more prominent role
of comparisons among unaided efficacy evaluations. A total of 23 studies were identified
and reviewed. An attempt was made to group the studies according to common intervention
themes.
3.1. Simultaneous communication, sign-alone instruction, and oral instruction
3.1.1. Simultaneous communication versus sign-alone instruction

3.1.1.1. Expressive signing. In several studies, reviewed in Table 1, the effects of
simultaneous communication (SC) versus sign-alone (SA) instruction were investigated
2
Due to page restrictions, Tables 1–10 only provide the first/sole author of the study along with the purpose of
the comparison. The complete tables, including study authors, purpose of comparison, participants, design,
results, and appraisal, may be requested from Ralf Schlosser via e-mail (R.Schlosser@neu.edu; rwschlosser@-
earthlink.net).
(e.g., Barrera, Lobato-Barrera, & Sulzer-Azaroff, 1980; Brady & Smouse, 1978; Clarke,
Remington, & Light 1988; Remington & Clarke, 1983; Wherry & Edwards, 1983). Several
of these studies focused on expressive signing as an outcome variable (Clarke et al., 1988
[Studies 1 and 2]; Remington & Clarke, 1983). Taken together these three studies indicate
that while SA may be as effective as SC, SC tends to be more efficient than SA in yielding
expressive signing.
3.1.1.2. Natural speech production. Wherry and Edwards (1983) and Barrera et al. (1980)
compared SC with SA in terms of natural speech production. The data from these studies
are, however, inconclusive due to a serious lack of methodological rigor.
3.1.1.3. Receptive speech. As far as receptive speech, the existing data from two studies
are not compelling due to serious methodological concerns (Brady & Smouse, 1978;
Wherry & Edwards, 1983).
3.1.2. Simultaneous communication versus oral instruction

3.1.2.1. Expressive signing. In several studies, researchers compared SC with direct oral
instruction in terms of expressive signing (see Table 1). The participants were instructed to
sign and speak in the SC condition while the oral condition necessitated only a spoken
response (Barrett & Sisson, 1997; Sisson & Barrett, 1984). In these cases, comparisons of
SC and oral instruction in terms of expressive signing were not feasible.
3.1.2.2. Natural speech production. The results for natural speech production are
inconsistent across the studies with two studies reporting better outcomes with SC over O
(Barrera et al., 1980; Wells, 1981), one study reporting both being ineffective (Wherry &
Edwards, 1993), and one study reporting mixed results (Barrett & Sisson, 1987). In two
studies (Barrett & Sisson, 1987; Sisson & Barrett, 1984), comparisons in terms of natural
speech production are compromised because spoken responses were not coded separately
from signed responses in SC. Only modified SC, which required a vocal response only,
permitted comparisons with oral instruction. Here, one of the two participants in the Barrett
and Sisson study yielded better results with modified SC than with oral instruction. The
second participant, however, yielded both interventions as effective with oral instruction
being more efficient than modified SC.
3.1.2.3. Receptive speech. Results from two studies suggest that SC is more efficient than
O in yielding receptive speech gains (Brady & Smouse, 1978; Wherry & Edwards, 1983).
However, as previously pointed out, both studies present with serious methodologic
shortcomings.
3.1.3. Sign-alone versus oral instruction

This comparison was the subject of four studies in terms of natural speech production
and receptive speech (Table 1).
3.1.3.1. Natural speech production. Only Wherry and Edwards (1983) compared SA
versus O in terms of natural speech production. Given that both treatments were
ineffective, there were no differences to detect. This finding has to be viewed in light of the
methodologic concerns raised in the appraisal of this study.
3.1.3.2. Receptive speech. In two studies, SA was found more effective than O in
terms of receptive speech (Brady & Smouse, 1978; Wherry & Edwards, 1983). Both
studies, however, display serious methodologic weaknesses and included only one
participant each. Carr, Pridal, and Dores (1984) compared SA and O in terms of
receptive speech discrimination involving participants who were classified as poor
verbal imitators or good verbal imitators. Five of the six poor imitators failed to reach
criterion in O and all of the four good imitators were equally effective and efficient in O
and SA.
3.2. Determining the necessary conditions for simultaneous communication
Studies reviewed in Table 2 were concerned with the conditions under which
SC works more effectively or efficiently. This included introduction of manual signs
for known words rather than unknown words, over-instruction (i.e., extensive sign
instruction), pre-teaching of receptive skills (i.e., mediated sign instruction,
receptive–expressive order) or expressive skills (i.e., expressive–receptive order),
and by mixing some oral-only trials into SC (i.e., differential sign instruction) (Clarke,
Remington, & Light, 1986; Remington & Clarke, 1993a, 1993b; Watters, Wheeler, &
Watters, 1981).
Table 2
Comparative studies involving unaided approaches: determining the necessary conditions for simultaneous
communication
Clarke et al. (1986) Known vs. unknown words on expressive signing, receptive speech,
Conaghan et al. (1992) DH vs. DH plus PR with a control condition, on expressive signing
Duker and Moonen (1986) Complete vs. in-complete delivery of items on expressive signing
Duker et al. (1994) Complete vs. in-complete delivery of items on expressive signing
Goodman and Remington (1993) Specific (gets what requested) vs. non-specific reinforcement on
expressive signing
Linton and Singh (1984) DH, DH plus PR, and a control condition on expressive signing
Remington and Clarke (1993a—I) ES vs. MS on expressive signing, receptive speech and stimulus
over-selectivity
Remington and Clarke (1993a—II) ES vs. MS on expressive signing, receptive speech and stimulus
over-selectivity
Remington and Clarke (1993b) DS vs. ES on expressive signing, receptive speech, and stimulus
overselectivity
Watters et al. (1981) Two orders (RE, ER) on expressive and receptive sign use with SC
Notes: DH, directed rehearsal (repetition of correct response); PR, positive reinforcement; ES, extensive sign
instruction (overinstruction); MS, mediated sign instruction (receptive pre-instruction); DS, differential sign
instruction (SC mixed with only spoken cues); RE, receptive–expressive order; ER, expressive–receptive order.
3.2.1. Known versus unknown words

One study examined whether SC works more effectively and efficiently when
introducing manual signs for known words than signs for unknown words (Clarke et al.,
1986). These comparisons have been made in terms of expressive signing, natural speech
production, and receptive speech.
3.2.1.1. Expressive signing. Results indicated that SC is more efficient in terms of

expressive signing when the signs are introduced for known words rather than for unknown
words. This finding supports the notion that individuals with receptive knowledge of the
referent take a different (i.e., shorter) route to symbol acquisition. Thus, when possible it
may be beneficial to introduce symbols for vocabulary that the individual already
understands receptively.
3.2.1.2. Natural speech production. Only one of the three students improved in terms of
natural speech production for both known and unknown words. The other two participants
were tested on known words only and there were no improvements noted. Thus, the
differential effects of SC on natural speech production for words of varying receptive status
remain unclear.
3.2.1.3. Receptive speech. The effects on receptive speech were not convincing—only
one of the three children improved receptive speech. Clarke et al. (1986) hypothesized that
it may be due to this child not showing stimulus over-selectivity whereas the other children
did. Put another way, the effects of SC on receptive speech may play out differently
depending on child characteristics.
3.2.2. Manipulating reinforcement

Several studies manipulated the amount or type of reinforcement presented to the
learners during SC. This included the adding of positive reinforcement versus no
reinforcement (Conaghan, Singh, Moe, Landrum, & Ellis, 1992; Linton & Singh, 1984),
complete versus incomplete presentation of requested items (Duker & Moonen, 1986;
Duker, Kraaykamp, & Visser, 1994), and specific versus non-specific reinforcement
(Goodman & Remington, 1993).
3.2.2.1. Expressive signing. A subgroup of studies reviewed in Table 2 examined various

roles of positive reinforcement in teaching manual signs via SC instruction. Adding
positive reinforcement to directed rehearsal (DH; repeating the correct response) was more
efficient in terms of expressive sign acquisition (Linton & Singh, 1984) and generalization
across novel phrases, settings, and instructors compared to DH alone (Conaghan et al.,
1992). Once determined that positive reinforcement aides manual sign acquisition it is
important to focus on the types of reinforcement that may yield better outcomes than
others. In a sequence of two studies, Duker and colleagues (1986, 1994) demonstrated that
an incomplete provision of requested items is more effective in eliciting greater expressive
signing than a complete presentation. Although these findings are intuitively appealing,
they are tempered by several methodological shortcomings (request complete Table 2).
Finally, Goodman and Remington (1993) showed that specific reinforcement (i.e.,
presenting to the learner what he or she was signing for) is more efficient than presenting a
non-specific reinforcer (i.e., a reinforcer unrelated). Specific reinforcement is typically

used when teaching requesting, whereas non-specific reinforcement is more consistent
with a naming or labeling task. Although both conditions were effective, the specific
reinforcement strategy produced faster acquisition of expressive signing than the
nonspecific strategy for three of the four participants. This preliminary evidence suggests
that expressive signing may be accomplished more rapidly when teaching a requesting
function rather than a labeling function.
3.2.3. Maximizing SC instruction through procedural variations

A body of four studies evaluated how to further maximize SC instruction through
various procedural variations, including (a) extensive sign instruction (i.e., over-
instruction), (b) mediated sign instruction (i.e., receptive pre-instruction), (c) differential
sign instruction (SC mixed with only spoken cues), (d) receptive–expressive order, and (e)
expressive–receptive order.
3.2.3.1. Expressive signing. Depending on the study, extensive sign instruction was either
more effective or equally as effective as mediated sign instruction; across studies, extensive
sign instruction was more efficient than mediated sign instruction for expressive signing
(e.g., Remington & Clarke, 1993a). In another study, extensive sign instruction was also
found more efficient than differential sign instruction in terms of expressive signing
(Remington & Clarke, 1993b).
Watters et al. (1981) compared two different orders for introducing manual signs to
children with autism. In one order, the participants were pre-taught receptive skills before
moving on to expressive signing. The second order involved the pre-teaching of expressive
skills. While both orders were effective for both of the children, the expressive–receptive
order was more efficient in yielding expressive signing. This less efficient showing for the
receptive–expressive order is consistent with the finding for receptive pre-instruction (i.e.,
mediated signing instruction).
3.2.3.2. Stimulus overselectivity and receptive speech. Stimulus overselectivity, which

precluded the acquisition of receptive speech, however, could not be overcome through any
of the above instructional strategies (Remington & Clarke, 1993a, Studies I and II).
Because of these continued problems, a subsequent study involved yet another variation of
SC procedures in an effort to remedy stimulus overselectivity (Remington & Clarke,
1993b). That is, differential sign instruction was designed as a method whereby SC is
intermixed with some trials of oral-only. This was deemed to shift the overselective
attention of the learners from the visual stimuli (i.e., manual signs) to the auditory stimuli
(i.e., word referents). As predicted, only differential sign instruction overcame stimulus
overselectivity and improved receptive speech.
3.3. Other instructional strategies for introducing manual signs
The group of studies reviewed in Table 3 involved comparisons of various other

instructional strategies for introducing manual signs, including prompting strategies, and
environmental arrangement strategies.
Table 3
Comparison studies involving unaided approaches: other instructional strategies
Bennett et al. (1986) Progressive TD vs. SLP in on expressive signing
Dalrymple and Feldman (1992) SP/DR vs. GG/DR vs. SP and GG vs. a control condition on
expressive signing
Iacono and Parsons (1986) Physical shaping and modeling on receptive signing
Sigafoos and Meikle (1995) Missing-item format vs. the interrupted behavior chain on
expressive signing, and challenging behaviors
Wolery et al. (1993) Progressive TD using massed-trials vs. distributed trials on
expressive signing
Notes: DR, directed rehearsal; GG/DR, graduated guidance and directed rehearsal; progressive TD, progressive
time delay (from 0 to 10 s); SLP, system of least prompts (four levels); SP/DR, sequential prompting and directed
rehearsal.
3.3.1. Prompting strategies

3.3.1.1. Expressive signing. Bennett, Gast, Wolery, and Schuster (1986) compared
progressive time delay (TD) with a system of least prompts (SLP) and found both equally
effective; yet, progressive TD was more efficient in two of the three participants and
equally efficient in the third participant. A subsequent investigation focused solely on the
delivery of the more efficient of these methods, the progressive TD (Wolery, Munson
Doyle, Gast, Jones Ault, & Lichtenberg, 1993). In one condition, TD was applied in a
massed trial format and in the other condition in a distributed trial format during transition
periods. Both were found equally effective without consistent differences in efficiency,
suggesting that TD can be used also during transitional periods.
Dalrymple and Feldman (1992) examined the effects of directed rehearsal (DH) when
added to an existing prompt procedure. One group of participants was taught expressive
signing via sequential prompting in one condition and sequential prompting plus DH in the
second condition, along with a no-treatment control condition. The other group received
the same arrangement except that graduated guidance was used as the prompting
procedure. The addition of DH resulted in increased accuracy, reduced speed, and
enhanced generalization (across trainers, objects, and settings) when added to sequential
prompting and graduated guidance.
3.3.1.2. Receptive signing. Iacono and Parsons (1986) compared physical shaping versus
modeling in the teaching of receptive sign labeling. Although the results indicate that
physical shaping was more effective than modeling, the study is too severely compromised
in terms of internal validity to draw any firm conclusions.
3.3.2. Environmental arrangement strategies

3.3.2.1. Expressive signing and challenging behaviors. Sigafoos and Meikle (1995)
compared the missing-item format with the interrupted behavior chain to increase signed
requesting in two children with autism. They found both to be equally effective. This study
also examined potential side effects of these methods, which rely on creating the need for
communication by giving the child a wrong item or interrupting an ongoing behavior.
However, neither procedure was associated with relatively higher levels of challenging or
stereotyped behaviors.
4. Comparison studies involving aided approaches
The number of comparative studies involving aided approaches (n = 20) is somewhat

less than those identified for unaided approaches. This may be explained by the relative
more recent history of aided approaches. Studies involving aided approaches involve
comparisons as outlined in Tables 4–8.
4.1. Instructional strategies and formats for introducing aided approaches
4.1.1. Instructional strategies

Various instructional strategies were compared to one another for teaching spelling,
receptive graphic symbol learning, expressive graphic symbol use, and the acceptance of
requested items (Berkowitz, 1990; Hetzroni, Quist, & Lloyd, 2002; McNaughton &
Tawney, 1993; Sigafoos & Meikle, 1995; Sigafoos & Reichle, 1992; Vaughn & Horner,
1995) (see Table 4).
4.1.1.1. Spelling. McNaughton and Tawney (1993) found the ‘‘copy-write-compare’’

strategy to be as effective as ‘‘student-directed cueing’’ in terms of spelling with no
consistent differences in efficiency across the two participants.
4.1.1.2. Receptive graphic symbol learning. Berkowitz (1990) compared delayed

prompting versus fading for teaching receptive symbol discrimination and found no
consistent differences in effectiveness between the two strategies. Delayed prompting,
however, turned out to be more efficient than fading. In the only other study in this category,
Hetzroni et al. (2002) compared teacher-presentation versus computer-presentation
Table 4
Comparison studies involving aided approaches: instructional strategies and formats
Berkowitz (1990) Delayed-prompting vs. fading on discrimination of graphic symbols
Hetzroni et al. (2002) Computer vs. teacher presentation on receptive identification
of Blissymbols
McNaughton and Tawney (1993) CWC vs. SDC on the acquisition and retention of spelling vocabulary
Oliver (1983) Group (same or different symbols for everyone) vs. individual formats
and a control on Blissymbol identification
Sigafoos and Meikle (1995) Missing-item format with the interrupted behavior chain in terms
of requests and challenging and stereotypical behaviors
Sigafoos and Reichle (1992) Explicit (specific symbol) vs. generalized requesting (generalized
symbol) on requests
Vaughn and Horner (1995) Choices offered verbally vs. verbally plus photos on acceptance
of food items
Notes: CWC, copy-write-compare; SDC, student-directed cueing (student makes first attempt).
in terms of receptive Blissymbol identification. Because no differences were found, it

seems that computers can be used as effectively as teachers to deliver the instruction as
studied.
4.1.1.3. Expressive graphic symbol use. Several studies contrasted instructional strategies
to facilitate expressive graphic symbol use such as requesting. Sigafoos and Meikle (1995)
found no differences between the missing-item strategy and the interrupted behavior chain
in two children with autism when they were taught to request sets of objects by either using
manual signs (Set 1 only) or by pointing to line drawings (Sets 2 and 3). There had been
concerns about potential negative side effects of interrupting behavior chains. Therefore,
the lack of increased challenging behaviors with this strategy is noteworthy, suggesting that
it is safe to use to evoke aided requesting. In related work, Sigafoos and Reichle (1992)
investigated whether it is more beneficial to introduce a generalized request symbol or an
explicit request symbol. They found no consistent differences between these strategies.
4.1.1.4. Acceptance of requested items. Vaughn and Horner (1995) compared two types
of input modalities in terms of acceptance or refusal of requested items. When choices were
offered through augmented input (photographs plus verbal) as opposed to ‘‘verbal only,’’
the child appeared to accept more of the items. The study, however, is seriously flawed in
terms of internal validity, and its findings are inconclusive.
4.1.2. Instructional formats

Oliver (1983) compared the effects of various instructional formats, a related yet
different and severely understudied issue. The study documented advantages for using the
group instructional format over the individual format. Children taught in the group format
identified more symbols than students taught one-on-one. However, the study presents with
serious methodologic concerns.
4.2. Various graphic symbol sets and systems
In several studies, investigators compared the effectiveness and/or efficiency of various

graphic symbol sets and systems (see Table 5). The majority of these studies examined
outcomes in terms of receptive symbol learning.
Table 5
Comparison studies involving aided approaches: graphic symbol sets and systems
Brady and McLean (1996) Lexigrams vs. TO using match-to-sample in terms of symbol learning
Briggs (1983) PIC, Bliss, and TO using match-to-sample with reinforcement and physical
guidance on symbol learning, time, TTC, and natural speech production
Hetzroni et al. (2002) Symbols of varied translucency-complexity on receptive learning of Blissymbols
Hurlbut et al. (1982) Bliss vs. Rebus-like symbols on the acquisition of labeling, spontaneous use,
stimulus generalization, and response generalization
Kozleski (1991) Various graphic symbol sets/systems (Blissymbolics, Premack tokens, TO,
Rebus, Photopictorial) on requesting
Notes: PIC, Picture Ideogram Communication; TO, traditional orthography.
4.2.1. Receptive graphic symbol learning

Two studies involved a comparison of non-phonetic graphic symbol systems—
Lexigrams, which are black and white symbols composed of arbitray geometric designs—
with traditional orthography (TO), which is phonetic (Brady & McLean, 1996; Briggs,
1983). Brady and McLean (1996) compared Lexigrams with TO. Although participants
learned the Lexigrams effectively while they never reached criterion with TO, these findings
need to be viewed cautiously due to a lack of methodologic rigor. Briggs (1983) found that
PIC was learned more readily than Blissymbols, followed by TO. As in the previous study
none of the children reached criterion with TO. Of the three children that met criterion in
both, PIC and Blissymbols, the efficiency results were mixed; PIC was more efficient for one
child and Blissymbols for the other, and there were no difference for the third. Thus, it seems
that TO is more difficult to acquire for these children than non-phonetic graphic symbol
systems, including those that are arbitrary (i.e., Lexigrams). Rebus-like graphic symbols
were learned as effectively as Blissymbols, but the children took far fewer trials to criterion
with Rebus-like graphic symbols (Hurlbut, Iwata, & Green, 1982). Whether or not these
differences in receptive symbol learning are due to differential iconicity ratings is difficult to
ascertain from these data because iconicity was not manipulated per se and these symbol
sets/systems may differ not only in terms of iconicity but also other variables. Hetzroni et al.
(2002) investigated this issue by using a priori iconicity ratings along with complexity
ratings within Blissymbols. Results suggest that high translucency symbols were learned
faster than low translucency symbols. High complexity symbols were learned faster when
translucency was high, but hindered learning when translucency was low.
4.2.2. Expressive graphic symbol use

Hurlbut et al. (1982) also examined the effects on spontaneous use and found that
Blissymbol use was restricted to previously taught symbols whereas Rebus use often
included transfers from concepts previously taught in Bliss. Kozleski (1991) implemented
the only other study that compared various graphic symbol sets/systems in terms of
expressive use. This author asserted that sets/systems that are associated with a higher
degree of iconicity took fewer trials to criterion than those with lower iconicity. In absence
of a priori iconicity ratings along with other methodologic shortcomings, however, this
explanation cannot be upheld.
4.3. Access, selection techniques, and symbol organization
The group of studies summarized in Table 6 dealt with positioning and access issues,
selection techniques, and symbol organization.
4.3.1. Positioning and access

McEwen and Karlan (1989) evaluated the effects of varying positions in a wheelchair or
other adaptive seating device for accessing communication displays. They found
noteworthy differences between some of the positions. The sidelyer position was least
efficient while there were no differences among the three more efficient positions (i.e.,
chair, stander, prone-wedge). It is important to identify a position that facilitates access to
displays before considering different selection techniques.
Table 6
Comparison studies involving aided approaches: selection techniques and display types
Angelo (1992) Three scanning modes (automatic, inverse, and step) on response
accuracy and speed
Belfiore et al. (1993) High vs. low indices of difficulty on the response duration of head
pointer movements across defined tasks such as sequencing two symbols
Everson and Goodwyn (1987) Three single switches (flap, pad, pillow) on scanning time and accuracy
Horn and Jones (1996) Scanning vs. direct selection in terms of response accuracy and time,
and acquisition rate
Lim et al. (1998) Pointing to a ‘‘help’’ card vs. opening a booklet first before pointing on
requesting assistance
McEwen and Karlan (1989) Four adaptive positioning devices (chair, stander, prone-wedge,
sidelyer) on latency for switch access to board locations
Reichle et al. (2000) Three display types (fixed, dynamic active, dynamic passive) on
accuracy and latency in matching to sample
4.3.2. Selection techniques

In three studies, researchers compared different means for selecting graphic symbols
(Angelo, 1992; Everson & Goodwyn, 1987; Horn & Jones, 1996). Horn and Jones (1996),
for example, compared a scanning technique with direct selection in one child with
cerebral palsy. Direct selection was used more effectively than inverse circular scanning in
terms of response accuracy, acquisition rate, and response time. Unfortunately, there were
several methodologic concerns with this study. Once it has been determined that scanning
is appropriate for a given child, the question becomes what type of scanning technique
should be selected. Angelo (1992) compared three types of scanning, including inverse
scanning, automatic scanning, and step scanning. Two of three children with spastic
cerebral palsy (CP) and athetoid CP, respectively, were most accurate with inverse
scanning. The three children with spastic CP did worst with automatic scanning whereas
the three children with athetoid CP were least accurate with step scanning. A related issue
pertains to the type of switch to be used for scanning. Everson and Goodwyn (1987)
compared the flap switch with the pillow switch and the pad switch in terms of accuracy
and speed. Because no consistent differences across participants were identifiable, it
appears that these decisions need to be made on an individual basis.
4.3.3. Symbol organization

Two studies looked into the role of variables that affect the efficiency in selecting
symbols depending on how the symbols were organized on a display. Belfiore, Lim, and
Browder (1993) examined the effects of physical distance between two symbols that need
to be combined through direct selection. The adult participant required less time to
sequence the symbols when presented with the low difficulty task (i.e., short distance) than
with the high difficulty task. This suggests that symbols that are high frequency
combinations should be placed close together on the display. Lim, Browder, and Sigafoos
(1998) investigated the role of high versus low physical effort needed to access a ‘‘Help’’
symbol in order to communicate a request for assistance. There were no differences
detected between the children pointing to a ‘‘help’’ flashcard and opening a book to select
the ‘‘help’’ symbol. It is possible that the two conditions were either not different enough in
terms of response effort and/or that the methodologic problems failed to detect actual
differences.
An issue closely related to symbol organization is that of the type of display selected for
organizing vocabulary. In one study, three display types for organizing vocabulary on
SGDs (i.e., fixed, dynamic active, dynamic passive) were compared in terms of response
time and accuracy (Reichle, Dettling, Drager, & Leiter, 2000). Response time was the
fastest and accuracy was the greatest for the fixed and dynamic active display types. These
differences became more pronounced after distracter symbols were added. Methodologic
concerns render these findings, however, inconclusive.
4.4. Beneficial components of an AAC system
Several studies looked into the role of the components of speech output and word
prediction as part of an AAC system. Essentially, the studies pursued the question as to the
effects of having a component available to a learner as opposed to not having it available.
4.4.1. With or without speech output

Four studies reviewed in Table 7 share the common focus of investigating the effects of
speech output in comparison to instruction without speech output (Blischak, Schlosser, &
Miller, 2000; Parsons & LaSorte, 1993; Schlosser, Belfiore, Nigam, Blischak, & Hetzroni,
1995; Schlosser & Blischak, 2004; Schlosser, Blischak, Belfiore, Bartley, & Barnett, 1998;
Sigafoos, Didden, & O’Reilly, 2003).
4.4.1.1. Spelling. In terms of spelling, more favorable results were found in a preliminary
study with one child with autism in conditions where speech output was present (Schlosser
et al., 1998). In a systematic replication (Schlosser & Blischak, 2004), all four children
reached criterion across conditions. Although three children reached criterion first with
Table 7
Comparison studies involving aided approaches: role of components of AAC systems
Blischak et al. (2000)—1 Partner natural speech vs. synthetic speech on graphic symbol learning
Blischak et al. (2000)—2 Natural speech from device vs. synthetic speech on graphic
symbol learning
Parsons and La Sorte (1993) Synthetic speech vs. no speech output on spontaneous natural
speech production
Schlosser et al. (1995) Speech output vs. no speech output on graphic symbol learning
Schlosser et al. (1998) Three feedback conditions (speech-synthesizer on; print-display;
and both) on spelling
Schlosser and Blischak (2004) Three feedback conditions (speech; print, speech-print) on spelling
Sigafoos et al. (2003) Speech output vs. no speech output on the maintenance of requesting
and vocalizations
Tam et al. (2002) Typing with and without word prediction in three word list locations
in terms of text entry accuracy and rate
print or speech-print feedback, one child was most efficient with speech-print followed by
speech feedback. Based on the findings of both studies, these authors proposed two distinct
profiles of feedback efficiency. Children that exemplify the primarily visual profile spell
words most efficiently when feedback involves print. Children that fit the auditory profile
spell words most efficiently when feedback involves speech. Given the current state of
research and the proposed profiles, children’s performance needs to be assessed on an
individual basis to determine the feedback conditions that appear most efficient for a given
child.
4.4.1.2. Receptive graphic symbol learning. Individuals using aided communication

often need to learn to associate graphic symbols with their referents. What is the role of
speech output, if any, in facilitating this learning? All three participants in the Schlosser
et al. (1995) study reached criterion when provided with synthetic speech output,
indicating that instruction with speech output was effective. Although two of the
participants also reached criterion without speech output, the addition of speech output
resulted in more efficient learning. In a follow-up study, Blischak et al. (2000) addressed
the question whether it was merely the quantity of the feedback that made a difference
rather than the type of feedback (i.e., synthetic speech). So, they designed a study whereby
the quantity of feedback was equated by having the communication partner supply as much
feedback (with natural speech) as provided by the device in the other condition (with
synthetic speech). Despite this equation in quantity, the three participants learned more
effectively and efficiently with synthetic speech. In a second experiment, the investigators
had the device produce both natural and the synthetic speech. Again, the participants
learned best with synthetic speech. This suggests, that it is not just the quantity of feedback
but also the type of feedback (i.e., synthetic speech) that facilitates graphic symbol
learning.
4.4.1.3. Expressive graphic symbol use. Sigafoos et al. (2003) taught three children to
request using an SGD. Once the learners had acquired the requesting behavior, a
maintenance phase was implemented in which the presence of speech output was
manipulated. The aim was to determine whether speech output is necessary to maintain the
requesting behavior. Results suggest no differences between the two conditions. Yet,
methodologic issues may have contributed to this finding.
4.4.1.4. Natural speech production. Parsons and La Sorte (1993) found that computer-
assisted instruction with additional synthetic speech output resulted in greater spontaneous
natural speech production than without speech output in six children with autism. Sigafoos
et al. (2003) found no consistent differences in vocalization patterns during the
maintenance phase in which the speech output was turned on and off. Methodological
limitations, however, delimit the internal validity of both of these studies.
4.4.1.5. With or without word prediction. Tam, Reid, Naumann, and O’Keefe (2002)
evaluated the effects of word prediction on text accuracy and rate during typing. In one
condition, word prediction was available to the students (using three different locations for
the word prediction list) and in another condition word prediction was not available.
Table 8
Comparison studies involving aided approaches: communication boards vs. SGDs
Dyches et al. (2002) A SGD with a communication board on requesting in generalization
community settings
Soto et al. (1993) A SGD with a communication board on the acquisition of explicit requests
and preferences
Van Acker and Grant (1995) A communication board vs. a computer-based system with speech output
on requesting of preferred and disliked objects
Note: SGD: speech generating device.
Although word prediction failed to improve rate it did improve accuracy depending on the
location of the word prediction list. Together, these studies on speech output and word
prediction illustrate the importance of selecting appropriate components as part of an AAC
system.
4.5. Communication boards versus speech-generating devices
Three studies evaluated the relative effects of non-electronic communication boards

versus SGDs or SGD software (see Table 8; Dyches, Davis, Lucido, & Young, 2002; Soto,
Belfiore, Schlosser, & Haynes, 1993; VanAcker & Grant, 1995). These two AAC systems
differ along more than the presence or absence of speech output (e.g., proprioceptive
feedback) and any differences found cannot be attributed to speech output alone (Schlosser,
1999). In the Soto et al. (1993) study, both an SGD and a communication board were found
equally effective in terms of requesting for a young adult with profound intellectual
disabilities. Yet, methodologic issues render these findings inconclusive. Even though
preference assessments suggest that the participant may have preferred the SGD when
given a choice, these preference data are inconclusive because the data were only collected
post-acquisition. The study by Dyches et al. (2002) detected no differences between the
two systems in terms of requesting and other variables under generalization conditions. It is
difficult to determine, however, whether there were no actual differences or whether the
methodological shortcomings failed to detect differences. The study by Van Acker and
Grant (1995) found differences in favor of a computer-based SGD in terms of differential
requesting of preferred and disliked objects. Unfortunately, methodological shortcomings
render these findings inconclusive.
5. Comparison studies involving aided and unaided approaches
The research base involving both aided and unaided approaches is more recent and as of
yet less substantive than for aided or unaided approaches alone. Nonetheless, a few studies
are available as summarized in Tables 9 and 10 (Anderson, 2002; Chambers & Rehfeldt,
2003; Iacono & Duncum, 1995; Iacono, Mirenda, & Beukelman, 1993; Rotholz,
Berkowitz, & Burberry, 1989; Sundberg & Sundberg, 1990; Wraikat, Sundberg, &
Michael, 1991).
Table 9
Comparative studies involving aided vs. unaided approaches
Anderson (2002) Manual signing vs. PECS instruction on expressive learning, maintenance,
challenging behavior, eye-contact and vocalizations
Chambers and Rehfeldt (2003) PECS vs. manual signing in terms of requesting
Rotholz et al. (1989) Manual signing vs. a communication book on requesting in a
ast-food restaurant
Sundberg and Sundberg (1990) Manual signing with graphic symbols on accuracy and rate for tacts and
intraverbals, and generalization to receptive speech
Wraikat et al. (1991) Manual signing with graphic symbols in terms of accuracy and efficiency
for tacts and INTRA, and receptive speech
Note: INTRA: intraverbal.
5.1. Aided versus unaided approaches
One group of studies compared unaided with aided approaches (see Table 9; Anderson,
2002; Chambers & Rehfeldt, 2003; Rotholz et al., 1989; Sundberg & Sundberg, 1990;
Wraikat et al., 1991). Three of these studies involved manual signing and communication
boards or books, which are accessed through direct selection. The study by Rotholz et al.
(1989) found the communication book to be more effective than manual signing. The study
by Sundberg and Sundberg (1990) indicated that for three participants manual signing and
pointing to symbols on a board were both effective (the fourth participant attained criterion
with manual signs only) for tacts (i.e., pointing to a symbol or making a sign when shown
an object) and intraverbals (i.e., pointing to a symbol or making a sign when an object name
was spoken), but manual signing was more efficient for two of the three participants (for
the third participant, the board was slightly more efficient than manual signing). Wraikat
et al. (1991) also compared graphic symbols with manual signing yielding mixed results in
terms of effectiveness and efficiency. Variations were evident across individuals and
behavioral relations studied. In interpreting these seemingly discrepant findings across the
three studies, the reader needs to keep in mind the methodologic shortcomings (they render
these data inconclusive) along with the differences in participants, in the communicative
functions being taught, and in the settings across these studies.
Two studies have compared PECS versus manual sign instruction in children with
autism (Anderson, 2002; Chambers & Rehfeldt, 2003). Anderson (2002) found that with
PECS, learners generalized the rule of matching novel symbols to new items whereas no
generalization occurred in signing. Manual signing also resulted in more eye contact than
PECS. PECS, however, resulted in faster acquisition rates than manual sign instruction.
During free choice items were made available assigned to the PECS condition and items
assigned to the signing condition. Learners initiated more with PECS than with signing.
Because the items were equated for reinforcement value this was interpreted as a modality
preference for PECS. The vocalization results favored signing, but were compromised due
to the lack of a comparable baseline. Chambers and Rehfeldt (2003) also found faster
acquisition of requests using PECS versus manual signs in four adults with severe/profound
intellectual disabilities. Design and other limitations render the findings inconclusive.
Table 10
Comparative studies involving aided vs. unaided approaches: unaided vs. combined approaches
Iacono and Duncum (1995) SC vs. SC with a SGD in terms of the number of words/word combinations
produced
Iacono et al. (1993) SC vs. SC with a SGD on expressive use of two-word semantic combinations
5.2. Unaided versus combined approaches
The second group of studies compared the use of unaided approaches to combined
approaches, consisting of unaided approaches plus SGDs (Iacono et al., 1993; Iacono &
Duncum, 1995) (see Table 10). Essentially, the two studies were concerned with evaluating
what would happen if a SGD was added to the use of simultaneous communication. Even
though both studies involved young children with intellectual disabilities and similar
dependent measures, no clear pattern has emerged from the data.
6. Discussion
6.1. Methodological adequacy
This review documents several methodological issues that impact on the certainty of
evidence emerging from comparative studies, including (a) design issues, (b) measurement
issues, and (c) procedural issues.
6.1.1. Design issues

Some single-subject experimental designs lend themselves more readily than others for
drawing valid conclusions about the relative efficacy of two or more interventions,
resulting in a design hierarchy that impacts on the certainty of the results generated
(Schlosser, 1999, 2003). The parallel treatments design (PTD) ranks highest because it
allows for intrasubject replications across equated sets by combining an adapted
alternating treatment design (AATD; see next) with the features of a multiple-probe design.
This intrasubject replication has the potential to enhance the internal validity of a
comparison. Despite its appeal in terms of internal validity, the PTD has been employed in
only a few studies (Bennett et al., 1986; Schlosser et al., 1995; Wolery et al., 1993). The
PTD is closely followed by the AATD, which allows for the creation of equal but
independent sets and thereby minimizes threats to internal validity such as carryover
effects. The AATD is a solid design and it is noteworthy that it is frequently employed in
comparative studies. All remaining designs are suboptimal. The traditional alternating
treatments design (ATD), for example, follows the adapted version of the same design
because the same sets are used for each treatment; this causes concern about carryover
effects. Despite these shortcomings it continues to be used as evident in the tables.
Another group of designs allows for counterbalancing, but only across participants. This
introduces demands for a larger n consistent with other group designs (Schlosser, 1999). The
A–B–BC–B–BC/A–BC–B–BC design (Parsons and La Sorte, 1993), for example, offers

counterbalancing but is less suitable than the previous designs because the counterbalancing
is done across rather than within subjects. ABAB-designs (e.g., Duker et al., 1994; Rotholz
et al., 1989) are not suitable for a comparison of two interventions because one of the
conditions is presented as a baseline, which raises concerns about order effects.
6.1.2. Measurement issues

There are also measurement issues to consider when evaluating the certainty of research
evidence, including treatment integrity and interobserver agreement. Although most of the
studies reported interobserver agreement data for the dependent measure, a majority of
studies failed to report treatment integrity data. This makes it difficult to attribute the
changes observed to the treatments because it is unclear whether the treatments were
carried out as planned (Schlosser, 2002).
6.1.3. Procedural issues

The appraisal of studies (detailed tables are available upon request) clearly demonstrate
the importance of procedural safeguards such as counterbalancing the sequence of
conditions across days or sessions, randomizing the sequence, inserting an adequate time
interval between conditions, and enhancing discriminability of conditions through verbal
and nonverbal means. Further, it is crucial that instructional sets be equated based on
current knowledge of factors contributing to learning difficulty. Because our knowledge-
base is not static, the factors contributing to learning difficulty may change over time. For
example, it is now clear that the receptive status of referents impacts on the ease of
acquisition of manual signs (perhaps also of graphic symbols). Yet, several studies failed to
equate sets based on the receptive status of referents (e.g., Barrera et al., 1980; Bennett
et al., 1986; Conaghan et al., 1992; Dalrymple & Feldman, 1992; Linton & Singh, 1984).
Thus, comparative efficacy studies such as these require replications, as the field uncovers
new factors contributing to learning difficulty (Schlosser, 1999).
6.2. Directions for future research
A first step might be to conduct systematic replications of those studies identified to be

of questionable internal validity. Until the above-discussed methodological weaknesses are
addressed in replication studies, practitioners cannot place a lot of confidence in the
trustworthiness of the respective findings. Among the studies that need to be replicated are
those that present with the following appraisal characteristics: (a) with inadequate designs
or (b) without treatment integrity, or (c) interobserver agreement data, or (d) biased
participants, or (e) without a learning or teaching criterion, (f) instructional sets that were
not matched or matched based on an inadequate recognition of variables contributing to
learning difficulty per today’s knowledgebase.
In single-subject experimental designs the number of participants across which an effect
is replicated contributes to its external validity. About 22% of all studies reviewed included
only one participant and 88% of the studies included four or fewer participants. This
suggests that the majority of comparative efficacy studies do not meet the n criteria set forth
by the American Psychological Association for empirically-supported treatments (e.g.,
Chambless, 2002). It is important that the affected studies be replicated with a larger n and
newly designed studies consider these criteria during the planning stage.
The research comparing aided approaches with manual signing has documented some
of the consequences of differences that are inherent in these two respective approaches. For
example, the finding that with PECS learners with autism were able to generalize the rule
of matching novel symbols to new items (and with manual signing they were not)
(Anderson, 2002) is to be expected given that PECS users can rely on recognition memory
with only one novel symbol in front of them when selecting symbols. With signing, on the
other hand, the learner has to produce the sign out of ‘‘thin air’’ so to speak. While it is
important to document these approach-specific consequences, future research should
explore the boundaries of these consequences. For example, if learners were presented with
more than one novel symbol as part of PECS, at what point would this advantage of
recognition memory fade to the extent that it renders generalization performance
comparable to manual signing? Another approach-specific consequence is the finding that
manual signing resulted in more eye contact than PECS (Anderson, 2002). PECS does not
require the seeking of the communication partner’s eye contact when handing over a
picture. The simple receipt of the picture can help the learner be assured that the message
was received. With signing this cannot be assumed; perhaps the communication partner
was looking away while the learner was signing. The only way to ensure the partner’s
attention is to seek the partner’s eye contact. Future research should examine the long-term
effects of using PECS on learner’s development of eye contact.
Most studies focused on comparing acquisition, generalization or maintenance of
communication skills. Only one study focused on a preference for communication devices
after acquisition (Soto et al., 1993). Considering that many studies found relatively
differences in acquisition rates, a more important clinical measure may be a learner’s small
preference for using some type of device over another (e.g., manual sign versus PECS). A
comparison of this type requires attention to unique methodological details. For example,
prior to assessing preference, experience with respect to both systems must be equated. In
addition, the learner would have to be equally proficient with both systems. Procedures
must also be developed so as to ensure there is no bias towards the use of a device over
another. For example, the mere presence of a device may evoke a selection of that response
and may therefore not necessarily reflect a learner’s preference. Future research should
examine how best to assess preference for various AAC systems during and after
acquisition training as this may prove useful is assisting clinicians with the difficult task of
selecting AAC systems for individual clients.
7. Conclusion
The intent of this review was to inform the decision-making of practitioners when faced
with clinical or educational situations that allow for more than one solution. In such
situations, it is recommended that practitioners follow the EBP process, beginning with the
development of a well-built question, the searching for evidence, followed by an appraisal
of evidence (Schlosser, 2003). This is where this review may be helpful. The practitioner
can determine relatively quickly whether there has been any comparative research related
22
Table 11
Recommendations for various instructional goals based on appraised research evidence
Approach Instructional goal Research evidence suggests Appraisal
Certainty N Participant type
R.W. Schlosser, J. Sigafoos / Research in Developmental Disabilities 27 (2006) 1–29

Unaided To improve (a) expressive signing, Use simultaneous communication Suggestive 4 (a, b) Severe intellectual
(b) natural speech production, rather than sign-alone (a, b, and c) disabilities (a, b)
and (c) receptive speech
1 (a, b)
2 (c) Autism (c)
To increase or expedite expressive Add positive reinforcement when using Preponderant 6 (a) Moderate to profound
signing acquisition directed rehearsal as an instructional method intellectual disabilities
and hearing impairments (a)
4 (b) Mild to profound
intellectual disabilities
and hearing impairments (b)
Introduce known words (i.e., words that a Suggestive 3 Severe intellectual disabilities
learner understands receptively) rather than
unknown words when using simultaneous
communication as an instructional method
Use progressive time delay rather than the Suggestive/ 3 Severe intellectual disabilities
system of least prompts preponderant and hearing impairment
Provide learners with the referent represented Suggestive 4 Severe intellectual disabilities
by the produced sign rather than a reinforcer
that is unrelated to the sign
Use overinstruction rather than receptive Suggestive 4 Severe intellectual disabilities
pre-instruction
2
To overcome stimulus overselectivity Intermix simultaneous communication Suggestive 5 Intellectual disabilities
and facilitate receptive speech during with oral-only trials rather than relying
simultaneous communication on overinstruction
Aided To increase receptive graphic Use delayed prompting rather than fading Suggestive 4 Autism
symbol discriminations
Table 11 (Continued )

To increase receptive graphic Use computer presentation or a teacher Preponderant 3 Communication
symbol identifications presentation impairments
To evoke expressive graphic Teach generalized or explicit requests Conclusive 4 Intellectual
symbol use (i.e., requesting) disabilities
To improve receptive graphic Choose Picture Ideogram Communication Suggestive 6 Moderate to severe
symbol acquisition symbols over Blissymbols, and traditional disabilities
orthography
Use Rebus-like graphic symbols or Blissymbols Suggestive 3 Multiple disabilities
To expedite receptive graphic Select Rebus-like graphic symbols over Suggestive 3 Multiple disabilities
symbol acquisition Blissymbols
When using Blissymbols, choose high Preponderant 3 Communication
translucency symbol rather than low impairments
translucency; avoid low translucency symbols
with high complexity
To facilitate access to Choose among three positions (chair, stander, Suggestive 2 Cerebral palsy (CP)
communication displays prone-wedge) over the sidelyer position
To select symbols from a display Use inverse scanning rather than automatic or step Suggestive 3 Spastic CP
scanning regardless of type of CP; avoid using
automatic scanning for children with spastic CP
and step scanning for children with athetoid CP
3 Athetoid CP
To choose an appropriate In absence of consistent differences, rely on Suggestive 3 CP
switch for scanning an individualized assessment
To arrange symbols so that Move symbols representing high frequency Preponderant 1 Multiple disabilities
they facilitate combinations combinations closer together
To program a device with In absence of consistent differences, conduct Conclusive 4 Autism
the most beneficial feedback individualized assessments
23
modes for spelling
24
Table 11 (Continued )
To expedite receptive graphic Provide instruction with synthetic speech Conclusive 3 Severe to profound
symbol learning output rather than no speech output intellectual disabilities
Provide instruction with synthetic speech output Conclusive 4 Severe to profound
feedback/input rather than with natural speech intellectual disabilities
Aided vs. To expedite expressive use Teach the Picture Exchange Communication Conclusive 6 Autism
unaided System (PECS) rather than manual signing
To increase initiations during free Teach PECS rather than manual signing Conclusive 6 Autism
choice
To increase eye contact Teach manual signing rather than PECS Conclusive 6 Autism
To minimize challenging behaviors Introduce PECS or manual signing Conclusive 6 Autism
during communication instruction
To facilitate expressive use of In absence of consistent differences, conduct Suggestive 2 Young children
two-word semantic combinations individualized assessments to determine with intellectual
through unaided or aided/unaided best modes disabilities
combined approaches
to the well-built question of interest by scanning the relevant tables. To facilitate this
process and encourage research uptake, several recommendations were derived from the
results and appraisals of Tables 1–10 and summarized in Table 11 according to
instructional goals. Evidence that was considered ‘‘inconclusive,’’ based on the threats to
internal validity (see descriptions in the ‘‘appraisal’’ column of the respective tables), did
not render any practical recommendations. However, evidence that was rated as suggestive
or better (i.e., preponderant, conclusive) resulted in proposed recommendations. This
progression of internal validity has been used in AAC by several authors (Granlund &
Olsson, 1999; Schlosser & Sigafoos, 2002). Suggestive evidence indicates that certain
AAC outcomes are plausible, and are within the realm of possibility. This rating is based on
minor flaws in design or adequate (or better) design with inadequate interobserver
agreement or treatment integrity. Preponderant evidence indicates that certain AAC
outcomes are not only possible, but also they are more likely to have occurred than they
have not. This rating is based on (a) minor flaws in design with adequate (or better)
interobserver agreement or treatment integrity, or (b) strong design with questionable
interobserver agreement or treatment integrity. Conclusive evidence indicates that certain
AAC outcomes are undoubtedly the result of the interventions being compared. This rating
is based on a strong design along with adequate (or better) interobserver agreement and
treatment integrity. In addition to the certainty of evidence rating, the reader is also given
the number of participants on which these recommendations rest along with the diagnosis
or classification of the participants involved. This allows the reader to determine the
external validity these recommendations may have. In this review several methodologic
shortcomings were uncovered that should be taken into account in the planning and
implementation of future comparative efficacy research in AAC. Speaking of future
research, several worthy directions for future research were identified.
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Research in Developmental Disabilities 27 (2006) 1–29

Augmentative and alternative communication

Augmentative and alternative communication (AAC) as an area of clinical and educational

Keywords: Augmentative and alternative communication; Comparisons; Developmental disabilities; Effective-

1.1. Inclusion criteria

1.2. Search methods

entered in MEDLINE, and 33 studies were available through PsycINFO. Next, we

1.3. Review categories

3. Comparison studies involving unaided approaches

3.1. Simultaneous communication, sign-alone instruction, and oral instruction

3.1.1. Simultaneous communication versus sign-alone instruction

3.1.2. Simultaneous communication versus oral instruction

3.1.3. Sign-alone versus oral instruction

3.2. Determining the necessary conditions for simultaneous communication

3.2.1. Known versus unknown words

3.2.1.1. Expressive signing. Results indicated that SC is more efficient in terms of

3.2.2. Manipulating reinforcement

3.2.2.1. Expressive signing. A subgroup of studies reviewed in Table 2 examined various

non-specific reinforcer (i.e., a reinforcer unrelated). Specific reinforcement is typically

3.2.3. Maximizing SC instruction through procedural variations

3.2.3.2. Stimulus overselectivity and receptive speech. Stimulus overselectivity, which

3.3. Other instructional strategies for introducing manual signs

The group of studies reviewed in Table 3 involved comparisons of various other

3.3.1. Prompting strategies

3.3.2. Environmental arrangement strategies

4. Comparison studies involving aided approaches

The number of comparative studies involving aided approaches (n = 20) is somewhat

4.1. Instructional strategies and formats for introducing aided approaches

4.1.1. Instructional strategies

4.1.1.1. Spelling. McNaughton and Tawney (1993) found the ‘‘copy-write-compare’’

4.1.1.2. Receptive graphic symbol learning. Berkowitz (1990) compared delayed

in terms of receptive Blissymbol identification. Because no differences were found, it

4.1.2. Instructional formats

4.2. Various graphic symbol sets and systems

In several studies, investigators compared the effectiveness and/or efficiency of various

4.2.1. Receptive graphic symbol learning

4.2.2. Expressive graphic symbol use

4.3. Access, selection techniques, and symbol organization

4.3.1. Positioning and access

4.3.2. Selection techniques

4.3.3. Symbol organization

4.4. Beneficial components of an AAC system

4.4.1. With or without speech output

4.4.1.2. Receptive graphic symbol learning. Individuals using aided communication

4.5. Communication boards versus speech-generating devices

Three studies evaluated the relative effects of non-electronic communication boards

5. Comparison studies involving aided and unaided approaches

5.1. Aided versus unaided approaches

5.2. Unaided versus combined approaches

6.1. Methodological adequacy

6.1.1. Design issues

A–B–BC–B–BC/A–BC–B–BC design (Parsons and La Sorte, 1993), for example, offers

6.1.2. Measurement issues

6.1.3. Procedural issues

6.2. Directions for future research

A first step might be to conduct systematic replications of those studies identified to be

R.W. Schlosser, J. Sigafoos / Research in Developmental Disabilities 27 (2006) 1–29

R.W. Schlosser, J. Sigafoos / Research in Developmental Disabilities 27 (2006) 1–29

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