AAC and Literacy intervention a review of the literature

Professor Janice Murray Manchester Metropolitan University

February, 2018

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Professor Janice Murray, Manchester Metropolitan University, February, 2018

AAC and Literacy intervention – a review of the literature

The Communication Trust commissioned this literature review as part of a more extensive

AAC and literacy intervention project, funded by the DfE. The aim of the review was to

collate research informed evidence of literacy intervention practices used to support

children who also used augmentative and alternative communication (AAC) systems. This

scoping review gives an account of the issues involved. Within the constraints of the project

brief, its contents are as far ranging as possible but do not claim to be exhaustive. Literature

reviewed included publication dates from 1980 to 2017. Literacy assessment in AAC was not

the focus of this review; therefore, little mention of it is given here. For more information on

assessment see, e.g., Berninger, & Gans, (1986); Dahlgren Sandberg, Smith, & Larson,

(2010); Erickson, Clendon, et al, (2008); Geytenbeek, Heim, Knol, Vermeulen, & Oostrom,

(2015); Iacono & Cupples, (2004); King, Binger & Kent-Walsh, (2015); Lund & Light, (2007a);

Nathan, Stackhouse, Goulandris & Snowling, (2004); Smith, (2005); Soto & Zangari, (2009)

Vandervelden & Siegel, (2001).

Defining literacy

Literacy refers to both reading and writing activities. Conceptually, we are considering either

a top-down or a bottom-up approach to literacy. A top-down approach starts by considering

higher order processes which operate by building up a bank of knowledge based on

experiences, expectations and shared knowledge. Bottom-up processes start by focusing on

print, and the letter sounds and word structures. Taught in isolation, a bottom up approach

may lack context or language cues to support comprehension of the words. The literature

suggests that to be a competent, independent reader and speller, both top down and

bottom up experiences are important (Smith, 2005).

Several models exist for explaining levels of literacy, many of which imply stages of

development and skill (e.g., Erikson & Koppenhaver, 2007; Stackhouse & Wells, 1997). Not

all authors agree with stages, suggesting that this merely reflects teaching approaches,

rather than truly describing the processes involved in becoming a skilled reader or speller

(Smith, 2005). Stages of literacy ability may be conceptualised into four broad areas: (i) pre-

literacy, (ii) emergent literacy, (ii) shared literacy, and (iv) independent literacy (Erikson &

Koppenhaver, 2007). More traditionally within the UK, literacy may be conceptualised as

four stages: (i) pre-literacy, which includes recognition of how to hold a book (front to back),

(ii) logographic, which includes whole word recognition and the capacity to spell own name,

(iii) alphabetic, which includes the ability to apply letter-sound rules to decode new words,

sounding out letters and then blending them. At this point, semi-phonetic spelling is

apparent and often vowels are omitted, e.g., burglar – bgl, (iv) orthographic, which includes

the ability to decode chunks of text such as prefixes and suffixes. Spelling has become more

logical, following conventional spelling rules (Stackhouse & Wells, 1997).

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Professor Janice Murray, Manchester Metropolitan University, February, 2018

The primary goal of reading instruction is to teach students to read silently and with

comprehension. Whilst reading can be considered from several theoretical perspectives

(e.g., linguistic, psycholinguistic, sociocultural), here we define reading as the cognitive

activity of deriving meaning from text (Koppenhaver, Foley & Williams, 2009, as cited in

Soto and Zangari, 2009). Koppenhaver et al (2009) consider reading to be a form of situated

cognition, or in other words an experience that requires students to engage within the

context of learning, through language skills as well as comprehending the elements of print.

Stages of reading development focus on observable changes in the child’s response to text.

Smith (2005) summarised reading as a process in progress through a slightly different four

stages. The pre-alphabetic phase, similar to the pre-literacy phase, offers children

experience of reading, e.g. that print carries meaning. The alphabetic phase is where

children start to decode the relationship between the grapheme and the phoneme,

although the primacy of the whole word memory store (sight words) is still evident. The

fluency stage is a consolidation phase where there is a rapid increase in sight word

recognition, speeding up the process of reading. Finally, the reading to learn stage occurs

when the student can process print at speed and automatically. Crucially, the process of

reading is subordinate to the purpose of reading.

Stages of spelling can also be considered and demonstrate an overlap with elements of the

reading process. Again, spelling neatly falls into four descriptive stages. Firstly, the pre-

alphabetic phase is typified by random sequences of letters that bear no relationship to the

sounds in a target word. Then, alphabetic spelling is demonstrated by the inclusion of

vowels and a great increase in the plausible and phonetically informed spelling attempts.

Spellings at this point may not always be conventional (rule bound). The next stage,

orthographic/semi-conventional spelling, shows conventional spelling patterns appearing

with word attempts. This phase provides clear evidence of children drawing on their stored

knowledge of words and letter sounds. Lastly, derivational relations spelling incorporates

spelling patterns that recognize morphological routes, supporting consistent and complex

spelling patterns (Smith, 2005).

Before moving on, it is worth considering writing skills as part of this review. Many aspects

of writing link directly to the spelling stages but the opportunity to produce text through

writing should not be underestimated. In the preparation phase, children produce marks on

the page (writing), yet are often unable to ‘read’ it out loud. Children writing as they speak

would mark the consolidation phase. The demarcation between writing and speaking is

often characterised by the formality of language content and structure used. The

differentiation phase is characterised by differences in spoken and written output. Finally,

the systematic integration phase is demonstrated by flexibility of language structure and

content, according to the context of use and the people involved, e.g., more informal

written and spelling style used in text messages or email. These skills are typically mastered

by the end of primary school (Smith, 2005).

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Professor Janice Murray, Manchester Metropolitan University, February, 2018

Defining Augmentative and Alternative Communication (AAC)

Augmentative and Alternative Communication (AAC) is the term used to describe various methods of communication that are used to get around difficulties with speech or communication. AAC includes systems such as pictures, gestures and pointing, as well as techniques involving computer technology. Some kinds of AAC are actually part of everyday communication, such as waving goodbye or giving a ‘thumbs up’ instead of speaking, or pointing to a picture or gesturing, whilst in a foreign country where you cannot speak the language. Some people have to rely on AAC most of the time. (definition taken from the ‘What is AAC?’ Focus On Series, Communication Matters http://www.communicationmatters.org.uk/sites/default/files/downloads/focuson/What%20is%20AAC.pdf ) Within this review of literacy development, conventional literacy is considered the ability to

read and spell using traditional orthography. This view of literacy is not inclusive of AAC

symbol sets, such as graphic symbol or picture vocabularies, as a form of literacy. Such AAC

resources may support the development of helpful skills and knowledge that contribute to

literacy development but are not regarded as a form of literacy (Dahlgren Sandberg, Smith,

& Larson, 2010; Erickson, & Sachse, 2010; Hetzroni, 2004; Koppenhaver & Williams, 2015;

Light, McNaughton, Weyer, & Karg, 2008; Soto & Zangari, 2009; Staples, & Edmister, 2012).

Defining intervention

Literacy assessment and intervention must be based on profiles of what students using AAC

can do and how their current strengths can be developed and extended. Interventions

deemed successful are ones where outcomes are valid from the perspective of each

stakeholder. Stakeholders may include the young person using AAC and their family, but

also the education and therapy staff. This is often achieved through a process of social

validation, whereby the goals, methods and outcomes are recognised as having social

significance for everyone involved. Interventions that are socially valid, in addition to being

effective, have more credibility than interventions that lack application within a social

learning context, e.g., embedding sight words in a story structure compared to reading a list

of sight words, (Soto & Zangari, 2009). Whilst there is agreement that developing literacy is

desirable, the routes to learning literacy remain much more contentious. The literature

seems split between a top-down emphasis on meaning centred approaches, offering a

motivational context for learning, or a bottom-up approach developing the skill set for

literacy. Over the last few decades there has been an increasing agreement that no one

approach suffices. Key to meeting the needs of children and young people who use AAC in

their literacy journey is the educator and the opportunities they offer students to engage

with literacy experiences (Smith, 2005).

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Professor Janice Murray, Manchester Metropolitan University, February, 2018

Who are the children and young people we are considering in this review?

The children and young people of particular consideration here are those aged between 0-

25 years, with severe speech and physical impairments. Some may also have associated

learning disability. All use augmentative and alternative communication technologies for

some or all of their conversation, language learning and educational access. Each child has

unique skills and challenges, making delivery of a universal design for literacy education

challenging, if it is to be effective. The following sections aim to offer insights into the range

of unique literacy skills and challenges that should be taken into account when delivering

literacy intervention for children and young people who use AAC.

What do we know about literacy skill and development in children and young people who

use AAC?

Current evidence overwhelmingly indicates that young children with severe speech and

physical impairment have the learning capabilities for early reading and writing skill

acquisition (Erikson and Koppenhaver, 2007) and that emergent literacy is not age

dependent but is based on experiences with text. Several accessible resources exist to

support early literacy experiences (see website resources section), however, these offer

only part of the solution and much remains unknown about how best to support children

and young people with AAC and literacy needs to become independent readers and spellers

(e.g., Bedrosian, 1999; Hanser & Erikson, 2007; Hunt-Berg, 2005; Johnston et al, 2009).

Learning to read (and spell) is extremely difficult for children who use AAC (Dahlgren

Sandberg, 2001). Many children and young people with severe speech and physical

impairment fail to develop the level of literacy ability commensurate with their cognitive

abilities and potential (Smith, Dahlgren-Sandberg, Larsson, 2009). Literacy is the key to

educational and vocational opportunities, as well as to the use of more complex AAC

systems (Bedrosian, 1999; Foley, & Staples, 2003; Koppenhaver & Williams, 2010). What we

have yet to fully comprehend is what factors influence the success of literacy acquisition in

children and young people who use AAC. The next section considers a number of elements

that may provide us with some answers, or perhaps better questions to ask in relation to

the children and young people we may be supporting.

What do we know about the children and young people who use AAC?

Children with little or no speech and controlled motor abilities are able to decode and

identify words and actively take part in shared book reading activities when provided with

appropriate instruction and access to Assistive Technology. The language and emergent

literacy skills development offered through interactive storybook reading are important for

all children but especially those who may rely on AAC, as such early experiences lay the

foundation for later conventional literacy development. We know that children with severe

speech and physical impairment get significantly fewer early literacy experiences, e.g., the

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Professor Janice Murray, Manchester Metropolitan University, February, 2018

quality and quantity of literacy experience is different. For example, how do you support a

child with physical involvement and no speech to share a storybook, and share the joint

reading of that story (Kent-Walsh, Binger, & Hasham, 2010; Koppenhaver, Erickson, Harris,

McLellan, Skotko, & Newton, 2001; Liboiron, & Soto, 2006; Nordberg, Dahgren Sandberg, &

Miniscalco, 2015; Tonsing, Dada, & Alant, 2014)? When a child is encouraged to participate,

mechanical aspects of storybook reading, such as page turning, are often emphasised rather

than the language and communication opportunities for the child to predict outcomes,

contribute to the storylines, or retell the story. This is further complicated by the fact that

aided AAC systems are often less accessible to the child during storybook reading and this

impacts on the quality and quantity of literacy experiences that are on offer in later

education stages (Da Fonte, Pufpaff & Taber-Doughty, 2010). For example, reviews of

available baseline measures shows variability in our capacity to determine each child’s skill

and need related to their reading comprehension levels, specifically morphology. We lack

effective grammar assessment tools and consequently have limited intervention strategies

(Binger & Light, 2008).

We know that many children have auditory and visual processing challenges, which impact

on attention and memory skills, reducing the opportunity to learn from each experience

they encounter. We have some early evidence, reinforced by later studies, to suggest that a

differentiated but systematic reading instruction programme can help children improve

word processing and recognition (Berninger & Gans, 1986; Binger, Maguire-Marshall, &

Kent-Walsh, 2011; Light, McNaughton, Weyer, & Karg, 2008).

Smith (2005) identified four intrinsic factors contributing to reading difficulties in children

who use AAC. These are physical differences, sensory and perceptual differences, linguistic

differences and cognitive differences. Koppenhaver and colleagues added engagement as a

fifth factor (Koppenhaver, Foley & Williams, 2009, as cited in Soto and Zangari, 2009).

Physical differences impact upon reading opportunity with the majority of individuals who

use AAC having congenital physical challenges reducing opportunity to interact with the

environment or be involved in activities that support reading development. Alternative

assistive technology adaptations may act as alleviators in the process of reading experience,

however, related issues such as head control, time-consuming access (through gaze or other

switch based systems) and related fatigue negatively impact upon this process.

Sensory and perceptual differences predominantly consider two systems, hearing and

vision. Both may have a profound effect on learning to read and spell. Hearing difficulties

vary greatly amongst children who use AAC but tend to be an ever present factor.

Appropriate amplification for the individual or within classroom systems can minimise

effects but may still necessitate sign-interpretation at all times to support full participation

in literacy activities.

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Professor Janice Murray, Manchester Metropolitan University, February, 2018

Visual impairment affects up to 60% of those with cerebral palsy. Also those with cortical

visual impairment have to cope with degraded print information but often display

inconsistent performance in print processing tasks. For example, atypical eye movements

may hinder text processing causing the person to lose their place when processing text. The

impact of this was described in a study of adults with cerebral palsy, using a standardised

reading measure who came out with a UK-equivalent, Year 8 (England & Wales, or First

Year, Scotland & Northern Ireland, i.e., 12-13 years old) reading level for extended text.

When the same text was presented one line at a time, the score leapt to a Year 10 level (i.e.,

14-15 years) (Koppenhaver, Foley & Williams, 2009, as cited in Soto and Zangari, 2009). This

underscores the need to consider tools and strategies to alleviate visual challenges for all

children who use AAC.

Differences in linguistic competence may result from a struggle to acquire skills in language

knowledge, phonemic awareness, decoding skills, the inner voice and text decoding skills.

Restricted vocabulary development and life experience restrict the application of contextual

cues to support effective reading with comprehension. Reduced experience of semantic and

syntactic components of text constrain sentence or paragraph level comprehension (Sutton,

Soto, & Blockberger, 2002; Trudeau, Sutton, Morford, Cote-Giroux, Pauze, & Vallee, 2010;

Vandervelden, & Siegel, 2001; Wilkinson, Carlin, & Thistle, 2008).

Skilled reading and spelling skills requires cognitive and metacognitive resources. These are

often impaired in children and young people who use AAC (Dahlgren Sandberg, 2006).

Assessing the existing skills of children with severe speech & physical impairment is very

difficult. Koppenhaver and colleagues insist that the presence of severe cognitive

impairment should not be used as an explanation for excluding students from reading

instruction (Koppenhaver, Foley & Williams, 2009, as cited in Soto and Zangari, 2009).

Student engagement should include time reading with the backdrop of pleasure and

positive attitudes to the outcomes of reading. As reading may be so effortful, many children

who use AAC may never get to the point where this is how they feel about reading for

enjoyment. (Koppenhaver, Foley & Williams (2009) in Soto and Zangari, 2009; Edmister, &

Wegner, 2015).

This review of intrinsic factors highlights that each child and young person may have subtly

different motor, sensory, speech and cognitive challenges, making a universal intervention

solution likely to fail. The evidence presented suggests that differentiated instruction works

best.

The educational and home environments constitute extrinsic factors that may be

contributing to delayed literacy achievement. We know that children are better placed for

effective literacy development if they have been immersed in language and literacy rich

experiences before entering school. Unfortunately, children with AAC needs have far less

time available for participating in such experiences due to the complexity of their other

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Professor Janice Murray, Manchester Metropolitan University, February, 2018

needs (Blockberger, 1995; Broberg, Ferm, & Thunberg, 2012; Bruno, & Dribbon, 1998; Light,

& Smith, 1993). Coupled with our knowledge that parental beliefs and attitudes have an

effect on the quantity and quality of use of AAC systems and on how these systems relate to

literacy development, it is unsurprising to find that young AAC users tend to not get off to a

good start with literacy (Clendon, Gillon, & Yoder, 2005; DeVeney, Cress, & Lambert, 2016).

Based on this premise, the approach to literacy intervention in the educational context is

critical. Reading instruction in a typical education context is multifaceted, with both

instructional, modelling and scaffolding supports from the educators, promoting a sense of

accomplishment through challenging and varied reading and writing activities for their

students. Active involvement in the learning process or contextualised learning encourages

social participation and a sense of achievement (Smith, 2005; Stauter, Myers, & Classen,

2017).

In a systematic review by Koppenhaver & Williams (2010), we find that we remain uncertain

of the appropriate instruction dosage for effective literacy development. All papers cited

described that different amounts of literacy intervention time afforded students under

different (research) experimental conditions. The studies included ranged from seven hours

to many hundreds of hours over an academic year to develop particular literacy skills. This is

unsurprising, given that we have already acknowledged the heterogeneity of intrinsic

factors influencing learning trajectories. Counting of hours spent on particular activities is

perhaps not an appropriate focus. During these hours, detailing the ways in which students

are receiving differentiated instruction to achieve success in any aspect of literacy might

yield greater understanding of the students’ progress and on-going learning needs.

Motivational learning opportunities may result in greater social participation and literacy

development, e.g., tapping out component parts of words rather than sounding them out,

working with words, shared reading, self-selected reading (Emms, & Gardner, 2010; Erikson

& Koppenhaver, 2007).

As already stated, completing baseline assessment of literacy ability is complicated,

requiring consideration of the influence of many characteristics within the learner and the

learning environment that they experience. Current evidence recognises the need to

develop reliable baseline measures to determine the amount of progress and the influence

of teaching methodologies on individual children’s progress. Emerging evidence suggests

that we need to consider the role of augmented input as an important ingredient to help

children and young people learn new vocabulary and increase expressive and receptive

language skills (e.g., Binger & Light, 2007). There are some paradoxes in the research

literature too. Whilst some studies indicated that the use of (teacher led) prompts,

questions and scaffolds did support language and literacy development over time (Barker,

Akaba, Brady, & Thiemann-Bourque, 2013), other studies suggested that the amount and

type of teacher questioning and prompting reduced language and literacy development

Barton, Sevcik, & Ann Romski, 2006; Romski, Sevcik, et al, 2010). A final point from the

literature suggests that use of AAC by peers (who did not need to use the system) was

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Professor Janice Murray, Manchester Metropolitan University, February, 2018

positively related to language and participatory outcomes for children and young people

who use AAC.

In conclusion, we should be mindful of the fact that we are not merely considering very

young children at the early stages of literacy development. Many of the elements debated

here still apply to older children and young people, suggesting that literacy development

needs further exploration in terms of our aspirations and expectations of those with severe

speech and physical impairment (Foley, & Pollatsek, 1999; Hunt-Berg, 2005; Lund, & Light,

2007a).

What are the implications in terms of existing Assistive Technologies and technological

developments?

Within the field of Assistive Technologies (AT), many resources and technologies exist to

alleviate motor and access challenges. Several software options support early literacy

development (example resources and links are listed below in the website resources

section). One of the more commonly used frameworks (Four-Blocks, Erickson &

Koppenhaver, 2007) takes both a bottom-up approach, e.g., learning sight words, and a top-

down approach, e.g., theoretical constructs embedded within a reading and writing

programme.

Millar and colleagues (2004) demonstrated that children and young people who use AAC

receive significantly less literacy instruction than their non-disabled peers. They delivered

two components of literacy instruction to promote phonemic awareness skills in children

who use AAC. The components comprised (i) direct instruction and (ii) a writing workshop,

which embedded writing instruction within group writing activities. They concluded that a

literacy instructional programme that combines direct instruction with embedded,

meaningful activity may facilitate greater literacy experience and greater literacy success.

Perhaps as a consequence of emerging research evidence, there is an emerging array of AT

hardware and software to support the more motivational aspects of contextualised

learning, where young people can work collaboratively to problem solve the literacy activity

(example resources and links are listed below in the website resources section). Many of

these resources offer personalisation features to ensure that the particular literacy learning

needs of each child can be addressed. In particular, beginning writers are given affordances

to utilise core vocabulary which is based on research evidence (Clendon, & Erickson, 2008;

Clendon, Sturm, & Cali, 2013; Wood, Appleget, & Hart, 2016).

Pleasingly, there is growing recognition of the need to consider the memory processing

demands of on-line activities, especially when the children may have additional physical/co-

ordination fatigue issues. We know that the memory and language representation demands

of AT, and specifically AAC systems, is different from traditional methods of speech, reading

and writing activities. Young AAC users are operating on multiple levels of learning for

simple communication and literacy acts (meta-skills) (Murray, & Goldbart, 2011; Stadskleiv,

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Professor Janice Murray, Manchester Metropolitan University, February, 2018

von Tetzchner, Batorowicz, van Balkom, Dahlgren Sandberg, & Renner, 2014; Thistle, &

Wilkinson, 2013).

The field of AT, including AAC, is able to draw from an emerging evidence base defining the

literacy learning needs and learning styles of children and young people who use AAC.

What are the implications for the education of the educators?

The literature suggests that quality literacy instruction occurs when there is a collaborative

team around the young person who uses AAC. This has been evidenced in a number of

ways. Teachers, Speech and Language Therapists, Occupational Therapists and assistant

educators working together, completing shared training activities, and maintaining high

expectations resulted in improved literacy outcomes (e.g., Binger, Kent-Walsh, Ewing, &

Taylor, 2010; Douglas, 2012; Grether, & Sickman, 2008; Kent-Walsh, Murza, Malani, &

Binger, 2015). Also identified was the delivery of appropriate and timely family training and

support. Family inclusion in the decisions made about approaches to reading and spelling

experiences increased their expectations and aspirations for their young person (e.g., Bruno,

& Dribbon, 1998; DeVeney, Cress, & Lambert, 2016; Kent-Walsh, Binger, & Hasham, 2010).

Collaborative working ensures that the team (including family members) have a collective

understanding of the functional, cognitive, and participatory challenges for the child, and

consider curriculum delivery adaptations accordingly. For example, AAC modelling alongside

literacy activities to ensure the child has access to language that can be translated into the

written word, or, to use AAC to scaffold support for grammatical constructions (e.g., Binger,

& Light, 2007; Binger, Maguire-Marshall, & Kent-Walsh, 2011; Light & McNaughton, 1993).

Collaborative working also supports effective baseline measurement. Currently, few

standardised measures have been developed with this group of young people in mind.

Within the UK there are several types of resource to support appraisal of the child and

young persons current reading and writing skills (e.g., literacy flow chart, pathways to

literacy: CALL Scotland, www.callscotland.org.uk/; CandLE, http://www.candleaac.com/ ;

Therapy Box https://www.therapy-box.co.uk/educational-apps ; Tobii Dynavox

https://www.tobiidynavox.com/en-GB/products/software/ ).

Key to all children’s literacy development is keeping a final literacy destination in mind,

being aspirational and realistic with achievable steps along the way. Collaborative working

supports everyone to recognise milestones in the process of achieving the final goal, e.g.,

improved core strength increases access alternatives and potentially reduces fatigue, thus

increasing concentration for literacy activities. As children and young people who use AAC

may follow a range of paths to literacy, traditional literacy education methods may be

insufficiently differentiated to be able to describe small steps of improvement. All educators

should receive training in reading and writing instruction, which will in turn make them

knowledgeable and confident in their teaching abilities and methods for children who use

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Professor Janice Murray, Manchester Metropolitan University, February, 2018

AAC (e.g., Binger, Kent-Walsh, Ewing, & Taylor, 2010; Broberg, Ferm, & Thunberg, 2012;

Dada, & Alant, 2009; Light & McNaughton, 1993).

Mileau teaching appears to support greatest achievements in literacy development by

offering a combination of strategies, including (child) experiences of formal literacy

instruction with informal learning activities, e.g., skill development in reading and writing

might be addressed within story reading activities with preschoolers who use AAC (Blischak,

1995; Blockberger, & Johnston, 2009; Erickson, & Sachse, 2010). Purposeful, age

appropriate experiences are essential, dovetailed to current literacy levels by appropriate

and motivational adaptations, (e.g., reading comprehension materials matched with a

problem solving activity, switch toys to facilitate involvement in a story, computerised

stories that support experience of pre-literacy skills of, for example, beginnings and endings,

experiences demonstrating that print carries meaning). The use of prompting hierarchies

involving a time delay (for the child to respond, Todman, 2000) are considered an effective

way of measuring the level of support a young person may need to achieve a specific

literacy task, or spontaneously use the target literacy skill. Prompting hierarchies typically

proceed from least to most intrusive. Extensive examples of different ways to apply prompts

and scaffolds in relation to storybook reading, and more generic literacy activities are

available within the AAC and literacy intervention literature (e.g., Binger, Kent-Walsh, Ewing,

& Taylor, 2010; Binger, Maguire-Marshall, & Kent-Walsh, 2011; Blockberger, 1995;

Edmister, & Wegner, 2015; Erickson, & Koppenhaver, 2007; Mirenda, & Dattilo, 2009; Smith,

2014; Stauter, Myers, & Classen, 2017). These studies range in focus from grammatical and

morphological prompts, sound-letter matching, to word construction with vocabulary

support. The majority focus on reading/input strategies and there is a suggestion that much

work still needs to be done looking at writing/spelling/output prompts (Koppenhaver, &

Williams, 2010).

This review has demonstrated that a small but informative research evidence base exists to

support educators of children and young people who use AAC to acquire literacy skills. The

resources cited (with the exception of the website resources) have all been through an

academic review procedure. The dilemma within practice and education, is that much good

work is happening but may not have been included here because, for example, the aim of

the research was unclear, no baseline was conducted or the project report was insufficiently

detailed to allow replication. This is not to say that the work completed in such projects was

not purposeful, and useful to the children and young people.

What is not covered here?

This literature review attempted to scope the research evidence that exists to enhance

literacy intervention where AAC is a factor of consideration. Interpretation of this review

should proceed with some caution, as much of the research relates to small sample sizes

and describes the complexities of the children’s disabilities. As a reader, what may be most

useful to consider is what of this content is readily transferable to the children and young

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people you may support, rather than all comments are generalizable to all. The findings

imply that there are three key areas ripe for further research. These include (i) identify

appropriate training content and support for educators, (ii) exploring the dosage of

intervention support for different aspects of literacy education, and how they relate to

individual learning needs, and (iii) descriptions of the characteristics of children who use

AAC and their particular literacy needs .

This literature review has extensively considered intervention principles and approaches. It

did not appraise the impact of appropriate and well-informed literacy assessment for

children and young people who use AAC. This would be an important element to determine

in any young person’s literacy education.

Website resources (correct at the time of publication)

AAC Scotland – website resource for AAC, language & literacy www.aacscotland.org.uk/

Sally Clendon, literacy site

https://www.pinterest.co.uk/salclendon/

CALL Scotland – specialised AAC service, education & literacy resources

www.callscotland.org.uk/ Communication Matters – UK AAC charity, supporting AAC awareness

www.communicationmatters.org.uk/ CandLE – Communication and Learning Enterprises (Marion Stanton) – education & literacy strategies to support people who use AAC

http://www.candleaac.com/ Karen Erickson and David Koppenhaver, Centre for Literacy and Disability Studies

http://www.med.unc.edu/ahs/clds/resources/downloadable-resources Jane Farrell, literacy site

http://www.janefarrall.com/literacy/ Liberator Ltd – text based resources https://www.liberator.co.uk/resources/vocabulary Caroline Musselwhite, literacy intervention

http://www.engagingalllearners.ca/ip/conversation-with-caroline-musselwhite/documents/1_literacy_instruction.pdf Carol Zangari, AAC & literacy site

http://praacticalaac.org/tag/literacy/ Therapy Box – literacy and educational resources https://www.therapy-box.co.uk/educational-apps Tobii Dynavox - Accessible Literacy for All (ALLTM) and Pathways for Core (vocabulary) https://www.tobiidynavox.com/en-GB/products/software/

References and bibliography

Barker, R. M., Akaba, S., Brady, N. C. and Thiemann-Bourque, K. (2013) 'Support for AAC Use in Preschool, and Growth in Language Skills, for Young Children with Developmental Disabilities.' Augmentative and Alternative Communication, 29(4), 2013/12/01, pp. 334-

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346. Barton, A., Sevcik, R. A. and Ann Romski, M. (2006) 'Exploring visual-graphic symbol acquisition by pre-school age children with developmental and language delays.' Augmentative and Alternative Communication, 22(1), 2006/01/01, pp. 10-20. Bedrosian, J. (1999) 'Efficacy Research Issues in AAC: Interactive Storybook Reading.' Augmentative and Alternative Communication, 15 (1) Berninger, V. W. and Gans, B. (1986) 'Assessing word processing capability of the nonvocal, nonwriting.' Augmentative and Alternative Communication, 2(2), 1986/01/01, pp. 56-63. Binger, C. and Light, J. (2007) 'The effect of aided AAC modeling on the expression of multi-symbol messages by preschoolers who use AAC.' Augmentative and Alternative Communication, 23(1) pp. 30-43. Binger, C. and Light, J. (2008) 'The Morphology and Syntax of Individuals who use AAC: Research Review and Implications for Effective Practice.' Augmentative and Alternative Communication, 24(2), 2008/01/01, pp. 123-138. Binger, C., Maguire-Marshall, M. and Kent-Walsh, J. (2011) 'Using aided AAC models, recasts, and contrastive targets to teach grammatical morphemes to children who use AAC.' Journal of Speech, Language, and Hearing Research, 54(1) pp. 160-176. Binger, C., Kent-Walsh, J., Ewing, C. and Taylor, S. (2010) 'Teaching educational assistants to facilitate the multisymbol message productions of young students who require augmentative and alternative communication.' American Journal of Speech-Language Pathology, 19(2) pp. 108-120. Bishop, K., Rankin, J. and Mirenda, P. (1994) 'Impact of graphic symbol use on reading acquisition.' Augmentative and Alternative Communication, 10(2), 1994/01/01, pp. 113-125. Blischak, D. (1994) 'Phonologic awareness: Implications for individuals with little or no functional speech.' Augmentative and Alternative Communication, 10(4), 1994/01/01, pp. 245-254. Blischak, D. (1995) 'Thomas the Writer: Case Study of a Child with Severe Physical, Speech, and Visual Impairments.' Language, Speech, and Hearing Services in Schools, 26(1) pp. 11-20.

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Communication, 19(4), pp. 207-221.

Broberg, M., Ferm, U. and Thunberg, G. (2012) 'Measuring Responsive Style in Parents who use AAC with their Children: Development and Evaluation of a new Instrument.' AAC: Augmentative and Alternative Communication, 28(4) pp. 243-253. Bruno, J. and Dribbon, M. (1998) 'Outcomes in AAC: Evaluating the Effectiveness of a Parent Training Program.' Augmentative and Alternative Communication, 14(2) pp. 59 - 70. Calculator, S. (1997) 'Fostering Early Language Acquisition and AAC Use: Exploring Reciprocal Influences between Children and their Environments.' Augmentative and Alternative Communication, 13(3) pp. 149 - 157. Campbell, P. H., Milbourne, S., Dugan, L. M. and Wilcox, M. J. (2006) 'A review of evidence on practices for teaching young children to use assistive technology devices.' Topics in Early Childhood Special Education, 26(1) pp. 3-13. Clendon, S. and Erickson, K. (2008) ‘The vocabulary of beginning writers: implications for children with complex communication needs.’ Augmentative and Alternative Communication, 24(4) 281-293. Clendon, S., Gillon, G. and Yoder, D. (2005) 'Initial Insights into Phoneme Awareness Intervention for Children with Complex Communication Needs.' International Journal of Disability, Development and Education, 52(1), Mar 2005, 2014-02-07, pp. 7-31. Clendon, S., Sturm, J. and Cali, K. (2013) ‘Vocabulary use across genres: implications for students with complex communication needs.’ Language, Speech, and Hearing Services in Schools, 44(1) pp. 61-72.

Dada, S. and Alant, E. (2009) 'The effect of aided language stimulation on vocabulary acquisition in children with little or no functional speech.' American Journal of Speech-Language Pathology, 18(1) pp. 50-64. Da Fonte, M., Pufpaff, L. and Taber-Doughty, T. (2010) Vocabulary use during storybook reading: Implications for children with augmentative and alternative communication needs. Psychology in the Schools, 47(5) pp. 514-524. Dahlgren Sandberg, A. (2001) 'Reading and spelling, phonological awareness, and working memory in children with severe speech impairments: A longitudinal study.' Augmentative and Alternative Communication, 17(1), 2001/01/01, pp. 11-26. Dahlgren Sandberg, A. (2006) 'Reading and spelling abilities in children with severe speech impairments and cerebral palsy at 6, 9, and 12 years of age in relation to cognitive development: a longitudinal study.' Dev Med Child Neurol., 48(8) pp. 629-634. Dahlgren Sandberg, A. and Hjelmquist, E. (1996) 'A comparative, descriptive study of

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reading and writing skills among non-speaking children: A preliminary study.' European Journal of Disorders of Communication, 31(3) pp. 289-308. Dahlgren Sandberg, A., Smith, M. and Larson, M. (2010) 'An Analysis of Reading and Spelling Abilities of Children Using AAC: Understanding a Continuum of Competence.' Augmentative and Alternative Communication, 26(3) pp. 191-202.

DeVeney, S., Cress, C. J. and Lambert, M. (2016) 'Parental directiveness and responsivity toward young children with complex communication needs.' International Journal of Speech-Language Pathology, 18(1) pp. 53-64. Douglas, S. N. (2012) 'Teaching paraeducators to support the communication of individuals who use augmentative and alternative communication: A literature review.' Current Issues in Education, 15(1) pp. 1-14. Edmister, E. and Wegner, J. (2015) 'Repeated Reading, Turn Taking, and Augmentative and Alternative Communication (AAC).' International Journal of Disability, Development, and Education, 62(3), May 2015, 2015-12-14, pp. 319-338. Emms, L. and Gardner, H. (2010) 'Study of two graphic symbol-teaching methods for individuals with physical disabilities and additional learning difficulties.' Child Language Teaching and Therapy, 26(1) pp. 5-22. Erickson, K. and Koppenhaver, D. (2007) ‘Children with Disabilities: Reading and Writing the Four-Blocks Way.’ Greensville, North Carolina: Carson-Dellosa Publishing Company. Erickson, K. and Sachse, S. (2010) 'Reading Acquisition, AAC and the Transferability of English Research to Languages with More Consistent or Transparent Orthographies.' Augmentative and Alternative Communication, 26(3), 2010/09/01, pp. 177-190. Erickson, K. A., Clendon, S. A., Cunningham, J. W., Spadorcia, S., Koppenhaver, D. A., Sturm, J. and Yoder, D. E. (2008) 'Automatic word recognition: The validity of a universally accessible assessment task.' AAC: Augmentative and Alternative Communication, 24(1) pp. 64-75. Foley, B. and Pollatsek, A. (1999) 'Phonological processing and reading abilities in adolescents and adults with severe congenital speech impairments.' Augmentative and Alternative Communication, 15(3), 1999/01/01, pp. 156-173. Foley, B. E. and Staples, A. H. (2003) 'Developing Augmentative and Alternative Communication (AAC) and Literacy Interventions in a Supported Employment Setting.' Topics in Language Disorders, 23(4) pp. 325-343. Geytenbeek, J. J. M., Heim, M. J. M., Knol, D. L., Vermeulen, R. J. and Oostrom, K. J. (2015) 'Spoken language comprehension of phrases, simple and compound-active sentences in non-speaking children with severe cerebral palsy.' International Journal of Language and Communication Disorders, 50(4) pp. 499-515.

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Grether, S. M. and Sickman, L. S. (2008) 'AAC and RTI: Building Classroom-based Strategies for Every Child in the Classroom.' Seminars in Speech and Language, 29(2) pp. 155 - 163. Hanser, G. A. and Erickson, K. A. (2007) 'Integrated Word Identification and Communication Instruction for Students with Complex Communication Needs: Preliminary Results.' Focus on Autism and Other Developmental Disabilities, 22(4), 2007, 2014-03-21, pp. 268-278. Hetzroni, O. E. (2004) 'AAC and literacy.' Disability and Rehabilitation, 26(21-22) pp. 1305-1312. Hjelmquist, E., Sandberg, A. D. and Hedelin, L. (1994) 'Linguistics, AAC, and metalinguistics in communicatively handicapped adolescents.' Augmentative and Alternative Communication, 10(3), 1994/01/01, pp. 169-183. Hunt-Berg, M. (2005) 'The Bridge School: Educational Inclusion Outcomes over 15 Years.' Augmentative and Alternative Communication, 21(2), 2005/06/01, pp. 116-131. Iacono, T. and Cupples, L. (2004) 'Assessment of Phonemic Awareness and Word Reading Skills of People With Complex Communication Needs.' Journal of Speech, Language and Hearing Research, 47(2) pp. 437-449. Iacono, T. A. (2004) 'Accessible Reading Intervention: A Work in Progress.' AAC: Augmentative and Alternative Communication, 20(3) pp. 179-190. Johnston, S. S., Davenport, L., Kanarowski, B., Rhodehouse, S. and McDonnell, A. P. (2009) 'Teaching sound letter correspondence and consonant-vowel-consonant combinations to young children who use augmentative and alternative communication.' Augmentative and Alternative Communication, 25(2) pp. 123-135.

Kent-Walsh, J., Binger, C. and Hasham, Z. (2010) 'Effects of parent instruction on the symbolic communication of children using augmentative and alternative communication during storybook reading.' American Journal of Speech-Language Pathology, 19(2) pp. 97-107. Kent-Walsh, J., Murza, K. A., Malani, M. D. and Binger, C. (2015) 'Effects of Communication Partner Instruction on the Communication of Individuals using AAC: A Meta-Analysis.' Augmentative and Alternative Communication, 31(4), 2015/10/02, pp. 271-284. King, A. M., Hengst, J. A. and DeThorne, L. S. (2013) 'Severe speech sound disorders: An integrated multimodal intervention.' Language, Speech, and Hearing Services in Schools, 44(2) pp. 195-210. King, M. R., Binger, C. and Kent-Walsh, J. (2015) 'Using Dynamic Assessment to Evaluate

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the Expressive Syntax of Children who use Augmentative and Alternative Communication.' Augmentative and Alternative Communication, 31(1), 2015/01/02, pp. 1-14. Koppenhaver, D. and Williams, A. (2010) ‘A Conceptual Review of Writing Research in Augmentative and Alternative Communication.’ Augmentative and Alternative Communication, 26(3) pp. 158-176.

Koppenhaver, D., Evans, D. and Yoder, D. (1991) 'Childhood reading and writing experiences of literate adults with severe speech and motor impairments.' Augmentative and Alternative Communication, 7(1), 1991/01/01, pp. 20-33. Koppenhaver, D. A., Erickson, K. A., Harris, B., McLellan, J., Skotko, B. G. and Newton, R. A. (2001) 'Storybook-based communication intervention for girls with Rett syndrome and their mothers.' Disability and Rehabilitation, 23(3-4) pp. 149-159.

Liboiron, N. and Soto, G. (2006) 'Shared Storybook Reading with a Student who uses Alternative and Augmentative Communication: A Description of Scaffolding Practices.' Child Language, Teaching and Therapy, 22(1) pp. 69 - 95. Light, J. and Smith, A. K. (1993) 'Home literacy experiences of preschoolers who use AAC systems and of their nondisabled peers.' Augmentative and Alternative Communication, 9(1), 1993/01/01, pp. 10-25. Light, J. and McNaughton, D. (1993) 'Literacy and Augmentative and Alternative Communication (AAC): The Expectations and Priorities of Parents and Teachers.' Topics in Language Disorders, 13(2), 1993, 2014-03-21, pp. 33-46. Light, J., Binger, C. and Smith, A. K. (1994) 'Story Reading interactions between preschoolers who use AAC and their mothers.' Augmentative and Alternative Communication, 10(4), 1994/01/01, pp. 255-268. Light, J., McNaughton, D., Weyer, M. and Karg, L. (2008) 'Evidence-based literacy instruction for individuals who require augmentative and alternative communication: a case study of a student with multiple disabilities.' Seminars in Speech and Language, 29(2) pp. 120-132. Lund, S. K. and Light, J. (2007a) 'Long-term outcomes for individuals who use augmentative and alternative communication: Part III – contributing factors.' Augmentative and Alternative Communication, 23(4), 2007/01/01, pp. 323-335. McNaughton, D. and Tawney, J. (1993) 'Comparison of two spelling instruction techniques for adults who use augmentative and alternative communication.' Augmentative and Alternative Communication, 9(2), 1993/01/01, pp. 72-82. McNaughton, S. and Lindsay, P. (1995) 'Approaching literacy with AAC graphics.' Augmentative and Alternative Communication, 11(4), 1995/01/01, pp. 212-228.

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Millar, D. C., Light, J. C. and McNaughton, D. B. (2004) 'The Effect of Direct Instruction and Writer's Workshop on the Early Writing Skills of Children Who Use Augmentative and Alternative Communication.' Augmentative and Alternative Communication, 20(3), 2004/09/01, pp. 164-178. Mirenda, P. and Dattilo, J. (2009) 'Instructional Techniques in alternative communication for students with severe intellectual handicaps.' Augmentative and Alternative Communication, 3(3) pp. 143 - 152. Müller, I., Buchholz, M. and Ferm, U. (2010) 'Text messaging with picture symbols - experiences of seven persons with cognitive and communicative disabilities.' Journal of Assistive Technologies, 4(4), 2010, 2012-05-10, pp. 11-23. Murray, J., & Goldbart, J. (2011). Emergence of working memory in children using aided communication. Journal of Assistive Technologies, 5, 213–232. doi:10.1108/17549451111190623 Nathan, L., Stackhouse, J., Goulandris, N. and Snowling, M. J. (2004) 'The Development of Early Literacy Skills Among Children With Speech Difficulties, A Test of the "Critical Age Hypothesis".' Journal of Speech, Language, and Hearing Research, 47(2) pp. 377-391. Nordberg, A., Dahgren Sandberg, A. and Miniscalco, C. (2015) 'Story retelling and language ability in school-aged children with cerebral palsy and speech impairment.' International Journal of Language and Communication Disorders, early online pp. 1-13. Rackensperger, T. (2012) 'Family Influences and Academic Success: The Perceptions of Individuals Using AAC.' Augmentative and Alternative Communication, 28(2), 2012/06/01, pp. 106-116. Rankin, J., Harwood, K. and Mirenda, P. (1994) 'Influence of graphic symbol use on reading comprehension.' Augmentative and Alternative Communication, 10(4), 1994/01/01, pp. 269-281. Romski, M. A., Sevcik, R. A., Adamson, L. B., Cheslock, M., Smith, A., Barker, R. M. and Bakeman, R. (2010) 'Randomized Comparison of Augmented and Nonaugmented Language Interventions for Toddlers with Developmental Delays and their Parents.' Journal of Speech, Language and Hearing Research, 53(April 2010) pp. 350 - 364. Sandberg, A. and Liliedahl, M. (2008) 'Patterns in early interaction between young preschool children with severe speech and physical impairments and their parents.' Child Language, Teaching and Therapy, 24(1) pp. 9 - 30. Sandberg, A. D. (1998) 'Reading and spelling among nonvocal children with cerebral palsy: Influence of home and school literacy environment.' Reading and Writing, 10(1) pp. 23-50.

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Sandberg, A. D. and Hjelmquist, E. (1996) 'Phonologic awareness and literacy abilities in nonspeaking preschool children with cerebral palsy.' Augmentative and Alternative Communication, 12(3), 1996/01/01, pp. 138-154. Smith, A. K., Thurston, S., Light, J., Parnes, P. and O'Keefe, B. (1989) 'The form and use of written communication produced by physically disabled individuals using microcomputers.' Augmentative and Alternative Communication, 5(2), 1989/01/01, pp. 115-124. Smith, A. L. and Hustad, K. C. (2015) 'AAC and Early Intervention for Children with Cerebral Palsy: Parent Perceptions and Child Risk Factors.' Augmentative and Alternative Communication, 31(4), 2015/10/02, pp. 336-350. Smith, M. M. (2005) Literacy and augmentative and alternative communication. Boston: Elsevier Academic Press. Smith, M. (2014) 'Supporting Vocabulary Development in Children Who Use Augmentative and Alternative Communication.' Journal of the Speech Language Hearing Association Taiwan, 33(10) pp. 35-59. Smith, M. (1992) 'Reading abilities of nonspeaking students: Two case studies.' Augmentative and Alternative Communication, 8(1), 1992/01/01, pp. 57-66. Soto, G. (2005) '“Inclusive Education and Participation: Current Issues In AAC”.' Augmentative and Alternative Communication, 21(2), 2005/06/01, pp. 81-81. Soto, G. and Hartmann, E. (2006) 'Analysis of narratives produced by four children who use augmentative and alternative communication.' Journal of Communication Disorders, 39(6) pp. 456-480. Soto, G., Hartmann, E. and Wilkins, D. P. (2006) 'Exploring the elements of narrative that emerge in the interactions between an 8-year-old child who uses an AAC device and her teacher.' Augmentative and Alternative Communication, 22(4), 2006/01/01, pp. 231-241. Soto, G., Yu, B. and Kelso, J. (2008) 'Effectiveness of multifaceted narrative intervention on the stories told by a 12-year-old girl who uses AAC.' Augmentative and Alternative Communication, 24(1), 2008/01/01, pp. 76-87. Soto, G., Solomon-Rice, P. and Caputo, M. (2009) 'Enhancing the personal narrative skills of elementary school-aged students who use AAC: The effectiveness of personal narrative intervention.' Journal of Communication Disorders, 42(1) pp. 43 - 57. Soto, G. M. and Zangari, C. (2009) Practically speaking: language, literacy, and academic development for students with AAC needs. Baltimore, Md: Paul H. Brookes Publishing. Stackhouse, J. and Wells, B. (1997). Children’s Speech & Literacy Difficulties: A psycholinguistic framework. London: Whurr Publishers Ltd.

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Stadskleiv, K., von Tetzchner, S., Batorowicz, B., van Balkom, H., Dahlgren Sandberg, A., and Renner, G. (2014). Investigating executive functions in children with severe speech and movement disorders using structured tasks. Frontiers in Psychology, 5, 1–14. doi:10.3389/fpsyg.2014.00992 Staples, A. and Edmister, E. (2012) 'Evidence of two theoretical models observed in young children with disabilities who are beginning to learn to write.' Topics in Language Disorders, 32(4) pp. 319-334. Stauter, D. W., Myers, S. R. and Classen, A. I. (2017) ‘Literacy Instruction for Young Children with Severe Speech and Physical Impairments: A Systematic Review.’ Journal of Occupational Therapy, Schools & Early Intervention, 10(4) pp. 389-407. Sutton, A., Soto, G. and Blockberger, S. (2002) 'Grammatical issues in graphic symbol communication.' Augmentative and Alternative Communication, 18(3), 2002/01/01, pp. 192-204. Taylor, R. and Iacono, T. (2003) 'AAC and scripting activities to facilitate communication and play.' Advances in Speech Language Pathology, 5(2) pp. 79 - 93. Thistle, J., & Wilkinson, K. (2013). Working memory demands of aided augmentative and alternative communication for individuals with developmental disabilities. Augmentative and Alternative Communication, 29, 235–245. doi:10.3109/07434618.2013.815800

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assessment for children who use augmentative and alternative communication.' Augmentative and Alternative Communication, 17(1), 2001/01/01, pp. 37-51. Wilkinson, K. and Albert, A. (2001) 'Adaptations of fast mapping for vocabulary intervention with augmented language users.' Augmentative and Alternative Communication, 17(2), 2001/01/01, pp. 120-132. Wilkinson, K., Carlin, M. and Thistle, J. (2008) 'The Role of Color Cues in Facilitating Accurate and Rapid Location of Aided Symbols by Children With and Without Down Syndrome.' American Journal of Speech-Language Pathology, 17(2) pp. 179-193. Wood, C., Appleget, A. and Hart, S. (2016) ‘Core vocabulary in written personal narratives of school age children.’ Augmentative and Alternative Communication, 32(3) pp. 198-207 Wood Jackson, C., Wahlquist, J. and Marquis, C. (2011) 'Visual supports for shared reading with young children: The effect of static overlay design.' AAC: Augmentative and Alternative Communication, 27(2) pp. 91-102.