American Language Supplement 1
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These 13 authors belonged to one of 7 groups 4 American and 1 Australian, 1 Italian, and 1 South African and produced 32 of the pertinent papers The study by Wu et al. Table 1 summarizes the characteristics of the 14 included trials. All are single-center, randomized controlled studies, performed in 3 countries across 3 continents Africa, Asia, and North America. Eleven of the studies These groups reported the results usually as a thorough examination of the approach they developed. All RCTs were published in the last 10 years, except one published in  , and were published in 7 different journals.
Six of the journals had an impact factor and the average was 2. One journal did not have an impact factor .
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Seven studies regarded children with disabilities  —  and seven involved typically developing children  — . The latter were, nonetheless, included in the review because they evaluated ways to improve or support interventions in peers with disabilities.
One of the studies on children with disabilities regarded profoundly deaf children whose associated disabilities were not described . As mentioned before, this study was included because it involves research on augmentative communication technologies to translate icons into written language.
In the studies regarding children with disabilities, the number of children involved ranged from 10 to 68 median 36 , with a total of children included. Three studies referred to the same patients  — .
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The ages of the children ranged from 1. Table 2 reports additional details on participant characteristics. Five studies  —  involving typically developing children regarded ways of improving the learn ability of AAC systems, and involved between 20 and 60 children median 46 , with a total of children included.
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The other 2 studies  —  regarded peer attitudes towards AAC users, and the number of children involved ranged from 95 to median , with a total of children included. Children with a history of developmental delay, learning, hearing, or uncorrected vision problems, or in whom the local language English or Africaans was not the mother-tongue of the child, were excluded from all 7 studies involving typically developing children.
The Delphi score ranged from 2 to 5 mean 4. No studies concealed the treatment allocation or completely blinded the outcome assessor, the care provider, or the patient. The Jadad score ranged from 3 to 8 mean 5. No studies were described as double-blind, and only one justified the sample size .
Only 1 study described withdrawals and drop outs  and 8 the statistical analysis methods used  ,  —  ,  ,  ,  — . The outcome measures used in the 14 studies differed widely. In 5 studies  —  AAC technologies were used in typically developing children without disabilities, in order to compare different training levels and types of tools used or of interventions performed, and to use results to improve interventions in peers with disability.
Details of group designs of the randomized controlled trials involving children with disabilities are reported in Table 2. Training conditions that included verbal input and the expectation of verbal output were superior to sign alone in facilitating spontaneous spoken words during treatment, and pretreatment verbal imitation ability positively predicted the size of the child-initiated spoken vocabulary.
Exploratory analysis indicated that pretreatment age and IQ may also predict spoken language development during training. The Wu et al. Findings showed an improvement rate in Chinese reading comprehension in deaf children in the intervention group. The proposed system applies the design methodology of sentence prediction and construction to develop the task or domain-specific sentence types.
In autistic children with some joint attention, REPMT facilitated the frequency of generalized turn taking more than PECS, while the opposite occurred in children who began the study with no joint attention. The growth rate of different, spoken, nominative words was faster in the PECS group than in the REPMT group for children who began treatment with relatively high object exploration, while the opposite occurred for children who began treatment with low object exploration. The Yoder and Lieberman  study, by the same authors  ,  , represented an extension of the previous studies, focusing on the generalization of use of symbols.
The study found that young children with autism who received PECS training increased the number of picture exchanges to a greater extent than children receiving REPMT, when in a controlled context that was different from the training context in several dimensions. PECS use may thus be one way to help a child not only to begin to use joint attention towards objects and people, but also to use it to communicate in generalized contexts.
Romski et al  compared three parent-coached language interventions augmented communication input and output and spoken language intervention in young children 24—36 months old with developmental delays who began with fewer than 10 spoken words, and found that augmented language interventions increased target vocabulary and communicative interactions to a greater extent than spoken communication interventions.
The authors concluded that AAC does not hinder, but actually aids, speech production abilities in young children with developmental delay, and does so even over a short period of time.
They state that more research is needed on the interaction between comprehension and production of augmented and spoken words, and that this interaction appears to be more complex than was initially hypothesized. Finally, the study by Romski et al  focused on parental perceptions of language development in toddlers from the previous study  , demonstrating that augmented language intervention also has a positive impact on parental perception of language development in their children. Both studies highlight the important role AAC interventions can play at a very early age for children who are having difficulties with speech and language development.
The Drager et al. Results showed that, initially, transparency was poor for all AAC technologies used, but participants performed better across successive sessions. By the second learning session, children in the contextual scene-screen shot condition performed significantly better than children in the two grid conditions, but by the fourth session the difference was no longer significant. Embedding language concepts within contextual scenes may be an effective approach for young children learning dynamic display AAC technologies.
However, authors conclude that the systems differed by more than one characteristic and the performance of typically developing children may not be fully generalizable to that of older children or children with disabilities. Moreover, functional use in free play remained low, confirming the importance of better exploring the different effects of support provided in order to facilitate learning, generalization, and spontaneous use.
The Basson and Alant study  set out to determine how accurately typically developing, 6 year old, urban, Africaans speaking children who had at been enrolled for at least 6 months in preschool could identify 16 Picture Communication Symbols PCS , with and without training. Results confirmed that a rather low percentage of symbols can be correctly identified on first exposure based only on iconicity. A significant improvement at retest, although greater in the intervention group, was seen in both experimental and control groups, showing that iconicity may be only one of the components that facilitate the learning and memory of AAC symbols, and that exposure and training also play a relevant role.
The number of participants and of symbols considered was limited, and again performance of typically developing children may not be fully generalizable to that of children with disabilities. The authors therefore conclude that different symbols, different grid sizes, different ages and cultural groups, and different training strategies need to be considered in future studies.
The purpose of the McCarthy et al. Results indicate that, after three learning sessions, most typically developing 2 year olds increase their accuracy with the redesigned scanning technique further than with traditional scanning. However, results may not be generalizable to children with disabilities, and other scanning designs and the development of new and innovative access techniques need to be investigated. The Alant et al.
Findings indicate that the use of different colored symbols in sequential exposures impacts the time and accuracy of symbol location, and contributes to understanding how typically developing children locate different types of symbols in a context in which the color of symbols changes. The findings confirm both the complexity of factors affecting visual search and processing and the fact that understanding visual search processes requires a sound analysis of the multiple factors embedded in the process within a specific task or context.
In the study by Schlosser  et al, the effect of animation on transparency, name agreement, and identification of graphic symbols for verbs and prepositions was evaluated in typically developing preschoolers of 3 age groups. The animation effect was significant for transparency, but not for name agreement or identification. The effect was more pronounced for verbs than prepositions.
A developmental effect was observed for each measure. The authors suggested that there is a need to replicate the study with different symbol sets, with child directed control of animation, and with additional symbols on the display. In the Beck et al. In the group of older children and, particularly, in boys, the association of a role-playing experience resulted in higher positive self-reported attitude scores toward peers who use AAC than did the provision of information alone. To our knowledge, this is the first scoping review to investigate outcomes of AAC interventions that focuses only on RCTs and uses a standardized set of criteria for the assessment of the methodological quality and strength of evidence of retrieved RCTs studies.
Previous reviews also considered other study designs, such as non randomized group studies  —  or single case experimental designs  ,  —  ,  , and therefore used a broader approach for selecting papers for the review . The results of the retrieved studies, while providing some information on the effects of AAC interventions, confirm numerous limitations in the use of RCTs to evaluate AAC interventions:.
Because the entire group of retrieved RCTs was characterized by entirely different study outcomes, no attempt was made to aggregate these outcomes across studies. Similarly, effect size estimation was not used since studies differed substantially in design features and quality. AAC intervention is a long term, complex, multimodal process that needs to be incorporated into daily life. Furthermore, each one of these intervention components involves multiple procedures. Most of the published studies were focused on separate effects of single components of AAC intervention, while the intervention itself is, in fact, a multidimensional process whose ultimate effect may be quite different from the sum of its components.
In this context, group designs are difficult to implement because of the small AAC population and the wide variability within it. Children have complex communication disorders, arising from different medical diagnoses, which may lead to differing disabilities. Enrolled populations range in age from infancy to late teens, and vary widely in functional profiles such as movement, cognition, communication, receptive and expressive language, learning characteristics, vision, and hearing.
They also vary in their educational setting mainstream schools or special education , previous and concurrent interventions, and concurrent medical conditions. In addition, children will experience different social relationships and interact with many different people in many different environments. Each of these factors will influence communication and interventions, especially since communication is a process by which people build shared meaning.
Correcting for the effect of these variables in RCTs is extremely difficult. Moreover, AAC intervention increases the complexity of human interaction and acts on several specific domains. The effects of intervention may therefore have an impact on a wide variety of behaviors, and outcomes in one domain may influence outcomes in other domains without the possibility of separating out the effects.
Due to the above limitations, it has been argued that RCTs are not first line in complex interventions  and that they are possibly not appropriate for AAC research involving individuals with disabilities  ,  — . Some of the critical points in obtaining adequate evidence in AAC have, in fact, already been analyzed by various authors, and solutions suggested  —  ,  —  , but these have somehow remained confined to specific journals and the debate has not reached the general medical literature.
The single subject experimental design SSED is considered to be a relevant design option in AAC  , and is, in fact, widely used in the field. SSED considers each subject as his-her own control, and methodologies for analyzing, in detail, the quality of SSED and for synthesizing the results of various studies through meta-analysis have been developed for AAC  ,  , and a different hierarchy of evidence has been proposed . However, other alternatives should also be considered, since the quasi-experimental research design could be an appropriate approach and should be tested in the AAC field .