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TITLE: Augmentative and Alternative Communication Devices as Early Interventions forYoung Children: Clinical Effectiveness

DATE: 13 April 2015

RESEARCH QUESTION

What is the clinical effectiveness of augmentative and alternative communication (AAC) devicesas early interventions for children up to six years of age?

KEY FINDINGS

Two randomized controlled trials and three non-randomized studies were identified regardingthe clinical effectiveness of augmentative and alternative communication devices as earlyinterventions for children up to six years of age.

METHODS

A limited literature search was conducted on key resources including PubMed, The CochraneLibrary (2015, Issue 3), University of York Centre for Reviews and Dissemination (CRD)databases, Canadian and major international health technology agencies, as well as a focusedInternet search. Methodological filters were applied to limit retrieval to health technologyassessments, systematic reviews, meta-analyses, randomized controlled studies and non-randomized controlled studies. Where possible, retrieval was limited to the human population.The search was also limited to English language documents published between January 1,

2010 and April 2, 2015. Internet links were provided, where available.

The summary of findings was prepared from the abstracts of the relevant information. Pleasenote that data contained in abstracts may not always be an accurate reflection of the datacontained within the full article.

SELECTION CRITERIA

One reviewer screened citations and selected studies based on the inclusion criteria presentedin Table 1.

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AAC Communication Devices as Early Interventions 2

Table 1: Selection CriteriaPopulation Children up to age six with developmental disabilities (e.g., cerebral palsy,

acquired brain injury, intellectual disability etc.)

Intervention Augmentative and alternative communication (AAC) devices

Comparator Alternate AAC devices or methods

No interventionOutcomes Clinical effectiveness (improved communication; improved development

towards school preparedness)

Study Designs Health technology assessment reports, systematic reviews, meta-analyses,randomized controlled trials, non-randomized studies

RESULTS

Rapid Response reports are organized so that the higher quality evidence is presented first.Therefore, health technology assessment reports, systematic reviews, and meta-analyses arepresented first. These are followed by randomized controlled trials and non-randomized studies.

Two randomized controlled trials and three non-randomized studies were identified regardingthe clinical effectiveness of augmentative and alternative communication (AAC) devices as earlyinterventions for children up to six years of age. No relevant health technology assessmentreports, systematic reviews, or meta-analyses were identified.

Additional references of potential interest are provided in the appendix.

OVERALL SUMMARY OF FINDINGS

Two randomized controlled trials1,2and three3-5non-randomized studies were identifiedregarding the clinical effectiveness of Picture Exchange Communication Systems (PECS),1,2,3,5and speech generating devices4 as early interventions for children up to six years of age withautism1-3,5or developmental delay.4

Overall, the use of PECS was associated with greater improvements in social-communicativeskills than conventional language therapy3,5and resulted in similar improvements in languageskills compared to pivotal response training.1Use of PECS was inferior to ResponsiveEducation and Prelinguistic Milieu Teaching for improving object interest.2The addition of aspeech generating device to augmented language interventions was associated with improvedmotor movements and language abilities.4Detailed study findings are outlined in Table 2.

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Table 2. Summary of FindingsFirst Author,Publication

Year

Population,Sample Size

Intervention Comparator Findings

Randomized Controlled Trials

Schreibman,2014

1 Children with

autism(nonverbal orminimallyverbal) aged 2to 4 years

n = 39

PECS Pivotalresponsetraining

Increased spokenlanguage skills observed inboth groups

No differences betweengroups

PECS harder to implement

McDuffie,2012

2 Children with

autism aged 18to 60 months

n = 32

PECS RPMT Greater increase in objectinterest in the RPMT group

Non-Randomized Studies

Lerna, 20143 Children withautism(nonverbal) ofpreschool age

n = 14 pergroup

PECS ConventionalLanguageTherapy

Greater improvements inADOS severity scores,GMDS Social domain,VABS Social Abilitiesdomains, and severalsocial-communicativevariables were observed inPECS group at initialassessment

VABS and social-communicative variableimprovements stable at 1year

Whitmore,2014

4 Toddlers with

developmentaldelays

n = NR

Augmentedlanguageinterventionplus SGD

Augmentedlanguageintervention

Motor movements moredevelopmentallyappropriate and languageabilities more accurate inSGD group

Lerna, 2012

Children withautism ofpreschool age

n = 18

PECS ConventionalLanguageTherapy

Greater post-testimprovements in VABS andsocial-communicativevariables in PECS group

ADOS = Autism Diagnostic Observation Schedule; GMDS = Griffiths Mental Developmental Scales; NR = not reported; PECS =Picture Exchange Communication System; RPMT = Responsive Education and Prelinguistic Milieu Teaching; SGD = speechgenerating device; VABS = Vineland Adaptive Behavior Scales.

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REFERENCES SUMMARIZED

Health Technology AssessmentsNo literature identified

Systematic Reviews and Meta-analysesNo literature identified


1. Schreibman L, Stahmer AC. A randomized trial comparison of the effects of verbal andpictorial naturalistic communication strategies on spoken language for young children withautism. J Autism Dev Disord.2014 May;44(5):1244-51.PubMed: PM24272416

Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4005390

2. McDuffie AS, Lieberman RG, Yoder PJ. Object interest in autism spectrum disorder: a

treatment comparison. Autism.2012 Jul;16(4):398-405. Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4106682 PubMed: PM22133872


3. Lerna A, Esposito D, Conson M, Massagli A. Long-term effects of PECS on social-communicative skills of children with autism spectrum disorders: a follow-up study. Int JLang Commun Disord.2014 Jul;49(4):478-85.PubMed: PM24655345

4. Whitmore AS, Romski MA, Sevcik RA. Early augmented language intervention for children

with developmental delays: potential secondary motor outcomes. Augment Altern Comm2014: 200-212.PubMed: PM25109299

Available from:http://www.ncbi.nlm.nih.gov/pubmed/25109299

5. Lerna A, Esposito D, Conson M, Russo L, Massagli A. Social-communicative effects of thePicture Exchange Communication System (PECS) in autism spectrum disorders. Int JLang Commun Disord.2012 Sep;47(5):609-17.PubMed: PM22938071

PREPARED BY:Canadian Agency for Drugs and Technologies in HealthTel: 1-866-898-8439www.cadth.ca
http://www.ncbi.nlm.nih.gov/pubmed/24272416http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4005390http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4005390http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4005390http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4106682http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4106682http://www.ncbi.nlm.nih.gov/pubmed/22133872http://www.ncbi.nlm.nih.gov/pubmed/22133872http://www.ncbi.nlm.nih.gov/pubmed/24655345http://www.ncbi.nlm.nih.gov/pubmed/24655345http://www.ncbi.nlm.nih.gov/pubmed/25109299http://www.ncbi.nlm.nih.gov/pubmed/25109299http://www.ncbi.nlm.nih.gov/pubmed/25109299http://www.ncbi.nlm.nih.gov/pubmed/25109299http://www.ncbi.nlm.nih.gov/pubmed/25109299http://www.ncbi.nlm.nih.gov/pubmed/22938071http://www.ncbi.nlm.nih.gov/pubmed/22938071http://www.cadth.ca/http://www.cadth.ca/http://www.cadth.ca/http://www.ncbi.nlm.nih.gov/pubmed/22938071http://www.ncbi.nlm.nih.gov/pubmed/25109299http://www.ncbi.nlm.nih.gov/pubmed/25109299http://www.ncbi.nlm.nih.gov/pubmed/24655345http://www.ncbi.nlm.nih.gov/pubmed/22133872http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4106682http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4005390http://www.ncbi.nlm.nih.gov/pubmed/24272416

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APPENDIX FURTHER INFORMATION:

Systematic Reviews and Meta-analyses

Unclear Age Range

6. Ganz JB, Rispoli MJ, Mason RA, Hong ER. Moderation of effects of AAC based on settingand types of aided AAC on outcome variables: an aggregate study of single-caseresearch with individuals with ASD. Dev Neurorehabil.2014 Jun;17(3):184-92.PubMed: PM24102440

7. Ganz JB, Earles-Vollrath TL, Heath AK, Parker RI, Rispoli MJ, Duran JB. A meta-analysisof single case research studies on aided augmentative and alternative communicationsystems with individuals with autism spectrum disorders. J Autism Dev Disord. 2012Jan;42(1):60-74.PubMed: PM21380612

8. Ganz JB, Davis JL, Lund EM, Goodwyn FD, Simpson RL. Meta-analysis of PECS withindividuals with ASD: investigation of targeted versus non-targeted outcomes, participantcharacteristics, and implementation phase. Res Dev Disabil.2012 Mar;33(2):406-18.PubMed: PM22119688

9. Parr J. Autism. BMJ Clin Evid.2010;Jan 7PubMed: PM21729335

Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907623

Alternate Age Range

10. Flippin M, Reszka S, Watson LR. Effectiveness of the Picture Exchange Communication

System (PECS) on communication and speech for children with autism spectrumdisorders: a meta-analysis. Am J Speech Lang Pathol.2010 May;19(2):178-95.PubMed: PM20181849

11. van der Meer LA, Rispoli M. Communication interventions involving speech-generating

devices for children with autism: a review of the literature. Dev Neurorehabil.

2010;13(4):294-306.

PubMed: PM20629595


Unclear Age Range

12. Rice LM, Wall CA, Fogel A, Shic F. Computer-Assisted Face Processing InstructionImproves Emotion Recognition, Mentalizing, and Social Skills in Students with ASD. J

Autism Dev Disord.2015 Feb 19.PubMed: PM25694364

13. Hopkins IM, Gower MW, Perez TA, Smith DS, Amthor FR, Wimsatt FC, et al. Avatarassistant: improving social skills in students with an ASD through a computer-basedintervention. J Autism Dev Disord.2011 Nov;41(11):1543-55.
http://www.ncbi.nlm.nih.gov/pubmed/24102440http://www.ncbi.nlm.nih.gov/pubmed/24102440http://www.ncbi.nlm.nih.gov/pubmed/21380612http://www.ncbi.nlm.nih.gov/pubmed/21380612http://www.ncbi.nlm.nih.gov/pubmed/22119688http://www.ncbi.nlm.nih.gov/pubmed/22119688http://www.ncbi.nlm.nih.gov/pubmed/21729335http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907623http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907623http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907623http://www.ncbi.nlm.nih.gov/pubmed/20181849http://www.ncbi.nlm.nih.gov/pubmed/20181849http://www.ncbi.nlm.nih.gov/pubmed/20629595http://www.ncbi.nlm.nih.gov/pubmed/20629595http://www.ncbi.nlm.nih.gov/pubmed/25694364http://www.ncbi.nlm.nih.gov/pubmed/25694364http://www.ncbi.nlm.nih.gov/pubmed/25694364http://www.ncbi.nlm.nih.gov/pubmed/20629595http://www.ncbi.nlm.nih.gov/pubmed/20181849http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907623http://www.ncbi.nlm.nih.gov/pubmed/21729335http://www.ncbi.nlm.nih.gov/pubmed/22119688http://www.ncbi.nlm.nih.gov/pubmed/21380612http://www.ncbi.nlm.nih.gov/pubmed/24102440

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PubMed: PM21287255

14. Yoder PJ, Lieberman RG. Brief Report: Randomized test of the efficacy of pictureexchange communication system on highly generalized picture exchanges in children with

ASD. J Autism Dev Disord.2010 May;40(5):629-32. Available from:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4136745 PubMed: PM19904596

Alternate Age Range

15. Kasari C, Kaiser A, Goods K, Nietfeld J, Mathy P, Landa R, et al. Communicationinterventions for minimally verbal children with autism: a sequential multiple assignmentrandomized trial. J Am Acad Child Adolesc Psychiatry.2014 Jun;53(6):635-46. Availablefrom:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4030683 PubMed: PM24839882

16. Gordon K, Pasco G, McElduff F, Wade A, Howlin P, Charman T. A communication-based

intervention for nonverbal children with autism: what changes? Who benefits? J ConsultClin Psychol.2011 Aug;79(4):447-57.PubMed: PM21787048


Unclear Age Range

17. DeThorne L, Aparicio BM, Karahalios K, Halle J, Bogue E. Visualizing Syllables: Real-Time Computerized Feedback Within a Speech-Language Intervention. J Autism DevDisord.2014 Oct 26.PubMed: PM25344794

18. Alant E, Zheng W, Harty M, Lloyd L. Translucency ratings of Blissymbols over repeatedexposures by children with autism. Augment Altern Commun.2013 Sep;29(3):272-83.PubMed: PM23902408

19. Barker RM, Akaba S, Brady NC, Thiemann-Bourque K. Support for AAC use in preschool,and growth in language skills, for young children with developmental disabilities. Augment

Altern Commun.2013 Dec;29(4):334-46. Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4017351 PubMed: PM24229337

20. Boesch MC, Wendt O, Subramanian A, Hsu N. Comparative efficacy of the picture

exchange communication system (PECS) versus a speech-generating device: effects onsocial-communicative skills and speech development. Augment Altern Commun.2013Sep;29(3):197-209.PubMed: PM23952565

21. Hetzroni OE, Ne'eman A. Influence of colour on acquisition and generalisation of graphicsymbols. J Intellect Disabil Res.2013 Jul;57(7):669-80.PubMed: PM22676327
http://www.ncbi.nlm.nih.gov/pubmed/21287255http://www.ncbi.nlm.nih.gov/pubmed/21287255http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4136745http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4136745http://www.ncbi.nlm.nih.gov/pubmed/19904596http://www.ncbi.nlm.nih.gov/pubmed/19904596http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4030683http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4030683http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4030683http://www.ncbi.nlm.nih.gov/pubmed/24839882http://www.ncbi.nlm.nih.gov/pubmed/24839882http://www.ncbi.nlm.nih.gov/pubmed/21787048http://www.ncbi.nlm.nih.gov/pubmed/21787048http://www.ncbi.nlm.nih.gov/pubmed/25344794http://www.ncbi.nlm.nih.gov/pubmed/25344794http://www.ncbi.nlm.nih.gov/pubmed/23902408http://www.ncbi.nlm.nih.gov/pubmed/23902408http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4017351http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4017351http://www.ncbi.nlm.nih.gov/pubmed/24229337http://www.ncbi.nlm.nih.gov/pubmed/24229337http://www.ncbi.nlm.nih.gov/pubmed/23952565http://www.ncbi.nlm.nih.gov/pubmed/23952565http://www.ncbi.nlm.nih.gov/pubmed/22676327http://www.ncbi.nlm.nih.gov/pubmed/22676327http://www.ncbi.nlm.nih.gov/pubmed/22676327http://www.ncbi.nlm.nih.gov/pubmed/23952565http://www.ncbi.nlm.nih.gov/pubmed/24229337http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4017351http://www.ncbi.nlm.nih.gov/pubmed/23902408http://www.ncbi.nlm.nih.gov/pubmed/25344794http://www.ncbi.nlm.nih.gov/pubmed/21787048http://www.ncbi.nlm.nih.gov/pubmed/24839882http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4030683http://www.ncbi.nlm.nih.gov/pubmed/19904596http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4136745http://www.ncbi.nlm.nih.gov/pubmed/21287255

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22. Lee Y, Jeong SW, Kim LS. AAC intervention using a VOCA for deaf children with multipledisabilities who received cochlear implantation. Int J Pediatr Otorhinolaryngol.2013Dec;77(12):2008-13.PubMed: PM24140395

23. Schafer EC, Mathews L, Mehta S, Hill M, Munoz A, Bishop R, et al. Personal FM systemsfor children with autism spectrum disorders (ASD) and/or attention-deficit hyperactivitydisorder (ADHD): an initial investigation. J Commun Disord.2013 Jan;46(1):30-52.PubMed: PM23123089

24. Wilkinson KM, McIlvane WJ. Perceptual factors influence visual search for meaningfulsymbols in individuals with intellectual disabilities and Down syndrome or autism spectrumdisorders. Am J Intellect Dev Disabil.2013 Sep;118(5):353-64. Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3889128 PubMed: PM24245729

25. Flores M, Musgrove K, Renner S, Hinton V, Strozier S, Franklin S, et al. A comparison of

communication using the Apple iPad and a picture-based system. Augment AlternCommun.2012 Jun;28(2):74-84.PubMed: PM22263895

26. Shih CH. A finger-pressing position detector for assisting people with developmentaldisabilities to control their environmental stimulation through fine motor activities with astandard keyboard. Res Dev Disabil.2012 Sep;33(5):1360-5.PubMed: PM22522194

Alternate Age Range

27. van der Meer L, Kagohara D, Achmadi D, O'Reilly MF, Lancioni GE, Sutherland D, et al.

Speech-generating devices versus manual signing for children with developmentaldisabilities. Res Dev Disabil.2012 Sep;33(5):1658-69.PubMed: PM22554812

Review Articles

28. Myrden A, Schudlo L, Weyand S, Zeyl T, Chau T. Trends in Communicative AccessSolutions for Children With Cerebral Palsy. J Child Neurol.2014 May 11;29(8):1108-18.PubMed: PM24820337
http://www.ncbi.nlm.nih.gov/pubmed/24140395http://www.ncbi.nlm.nih.gov/pubmed/24140395http://www.ncbi.nlm.nih.gov/pubmed/23123089http://www.ncbi.nlm.nih.gov/pubmed/23123089http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3889128http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3889128http://www.ncbi.nlm.nih.gov/pubmed/24245729http://www.ncbi.nlm.nih.gov/pubmed/24245729http://www.ncbi.nlm.nih.gov/pubmed/22263895http://www.ncbi.nlm.nih.gov/pubmed/22263895http://www.ncbi.nlm.nih.gov/pubmed/22522194http://www.ncbi.nlm.nih.gov/pubmed/22522194http://www.ncbi.nlm.nih.gov/pubmed/22554812http://www.ncbi.nlm.nih.gov/pubmed/22554812http://www.ncbi.nlm.nih.gov/pubmed/24820337http://www.ncbi.nlm.nih.gov/pubmed/24820337http://www.ncbi.nlm.nih.gov/pubmed/24820337http://www.ncbi.nlm.nih.gov/pubmed/22554812http://www.ncbi.nlm.nih.gov/pubmed/22522194http://www.ncbi.nlm.nih.gov/pubmed/22263895http://www.ncbi.nlm.nih.gov/pubmed/24245729http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3889128http://www.ncbi.nlm.nih.gov/pubmed/23123089http://www.ncbi.nlm.nih.gov/pubmed/24140395

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