Disability and Rehabilitation: Assistive Technology

ISSN: 1748-3107 (Print) 1748-3115 (Online) Journal homepage: http://www.tandfonline.com/loi/iidt20

A systematic review of the barriers and facilitators

to the provision and use of low-tech and
unaided AAC systems for people with complex
communication needs and their families

A. Moorcroft, N. Scarinci & C. Meyer

To cite this article: A. Moorcroft, N. Scarinci & C. Meyer (2018): A systematic review of the
barriers and facilitators to the provision and use of low-tech and unaided AAC systems for people
with complex communication needs and their families, Disability and Rehabilitation: Assistive
Technology, DOI: 10.1080/17483107.2018.1499135

To link to this article: https://doi.org/10.1080/17483107.2018.1499135

View supplementary material

Published online: 02 Aug 2018.

Submit your article to this journal

Article views: 73

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=iidt20
DISABILITY AND REHABILITATION: ASSISTIVE TECHNOLOGY
https://doi.org/10.1080/17483107.2018.1499135

REVIEW

A systematic review of the barriers and facilitators to the provision and use of
low-tech and unaided AAC systems for people with complex communication
needs and their families
A. Moorcroft , N. Scarinci and C. Meyer
Communication Disability Centre, School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia

ABSTRACT ARTICLE HISTORY

Purpose: Speech-language pathologists may introduce augmentative or alternative communication (AAC) Received 26 February 2018
systems to people who are unable to use speech for everyday communication. Despite the benefits of Revised 25 June 2018
AAC systems, they are significantly underutilized by the people with complex communication needs. The Accepted 8 July 2018
current review aimed to synthesize the barriers and facilitators to the provision and use of low-tech and
KEYWORDS
unaided AAC systems. Augmentative and
Materials and methods: Relevant literature was identified via a systematic search strategy. Included alternative communication
articles (n ¼ 43) were evaluated using the Critical Appraisal Skills Programme. Qualitative framework ana- (AAC); barriers and
lysis was then completed with reference to the International Classification of Functioning, Disability, and facilitators; systematic
Health (ICF). review; International
Results and conclusion: Most barriers and facilitators were coded as contextual factors within the ICF. Of Classification of
most prominence were environmental factors, including attitudes of and supports provided by professio- Functioning; Disability and
nals, family members, and the society at large. Themes were also identified which related to the personal Health (ICF)
factors, including the user’s own attitude, socioeconomic status, and culture. Beyond these contextual fac-
tors, the remaining codes related to body functions such as cognition and movement. There are numer-
ous barriers to the provision and use of low-tech and unaided AAC systems, which may contribute to the
inadequate use of these systems by people with complex communication needs. Suggestions for reduc-
ing these barriers are presented with regards to the person with complex communication needs, their
family, and the professionals involved in their care.

ä IMPLICATIONS FOR REHABILITATION

 AAC systems can reduce participation restrictions for people with complex communication needs.
 The provision and use of AAC systems is influenced by environmental factors, personal factors, and
features of a person’s body function.
 SLPs may need to collaborate with a large multidisciplinary team to successfully introduce
AAC systems.
 SLP, teaching, and nursing students require theoretical and practical experience in AAC throughout
their training to enable the provision and use of these systems.

Introduction Together, these components result in a communication disability

for this child. People with a severe communication disability who
The International Classification of Functioning, Disability and
are unable to use speech for everyday communication are said to
Health (ICF) provides a framework for conceptualizing disabilities
[1]. The ICF proposes a bi-directional relationship between a per- have complex communication needs [3,4]. This disability may be
son’s health condition and their body structures and function, due to physical, psychological and/or cognitive impairments [5].
ability to execute tasks (activities), and involvement in life situa- To alleviate participation restrictions for people with complex
tions (participation). These components of the ICF are contextual- communication needs, it is often necessary to introduce a form of
ized by the environmental and personal factors which may also augmentative or alternative communication (AAC) [6,7]. AAC is an
contribute to the person’s disability [1]. For example, a child with intervention approach centred on adding to (augmentative) or
Down syndrome, which is a health condition, may have reduced replacing (alternative) verbal communication. AAC aims to allow
tongue function (impaired body function) which reduces her the user to meet his or her varied communication needs by a
speech intelligibility at a phrase level (activity limitation) [2]. She means that is as intelligible, specific, efficient, independent and as
may then be unable to participate in playing ‘doctors’ with her socially valued as possible [8]. As detailed in the Speech
friends (participation restriction), a difficulty compounded by the Pathology Australia AAC Clinical Guideline [9], AAC is typically dif-
noisy childcare environment (environmental factor) and her ten- ferentiated into the broad groups of aided and unaided AAC.
dency to avoid communication breakdown (personal factor). Unaided AAC consists of natural nonverbal communication such

CONTACT Alison Moorcroft [email protected] School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, QLD 4072, Australia
Supplemental data for this article can be accessed here.
ß 2018 Informa UK Limited, trading as Taylor & Francis Group
2 A. MOORCROFT ET AL.

as gestures and facial expression, as well as formalized manual AAC [12], there is currently no equivalent review exploring these
signing systems such as Auslan (Australian Sign Language). Aided factors with regards to low-tech or unaided AAC systems. In add-
AAC involves some form of external tool, and is further broken ition, the existing literature suggests there may be environmental
down into high and low-tech categories. High-tech AAC includes and personal factors as well as features of a person’s body struc-
electronic aids such as computerized speech generating devices ture and function that influence outcomes with AAC; hence sup-
and iPad-based communication systems. Conversely low-tech AAC porting the use of the ICF as a conceptual framework for such a
involves non-electronic or paper-based systems such as alphabet review. It is imperative to synthesize the existing literature so that
boards, communication books, Picture Exchange Communication it can be utilized as a foundation for future studies aiming to pre-
Systems (PECS), and aided language displays. Communication is vent the rejection and abandonment of AAC systems. Therefore,
multimodal, in that the user is encouraged to utilize every mode the present study aimed to document and provide a synthesis of
possible to convey their messages and ideas [10]. Unfortunately, the barriers and facilitators to the provision and use of low-tech
despite a client’s need for AAC, challenges often arise which result and unaided AAC systems from the perspective of people with
in the rejection or abandonment of AAC systems by people with complex communication needs, their families, and the professio-
complex communication needs and their families [11]. In fact, nals involved. As defined above, and consistent with the Speech
Johnson et al. [11] surveyed 275 speech-language pathologists Pathology Australia Clinical Guideline [9], unaided AAC is a com-
(SLPs) and reported that only 39.35% of AAC systems introduced munication system that does not require the use of an external
by the participants were used by their clients for more than aid, and low-tech AAC involves non-electronic or paper-based sys-
one year. tems for communication. Although low-tech AAC is often grouped
To assist in understanding why AAC systems are underutilized, with light-tech AAC such as single message electronic devices,
Baxter et al. [12] conducted a systematic review that investigated these types have not been grouped in the current review. Due to
barriers and facilitators to the provision and use of high-tech AAC the progressive nature of AAC learning, ‘use’ of AAC systems will
systems. Studies examined were published between 2000 and be inclusive of proficient use of AAC to support expressive and/or
2010, and participants included children and adults with complex receptive language, as well as modelling by communication part-
communication needs, their families, and SLPs. It is important to ners and early attempts at accessing the system.
note that of the 27 papers included in the review, the majority
included participants who used or supported users of AAC, with Methods
only one study [13] focussing on participants with complex com-
A systematic review was completed by searching the literature,
munication needs who did not use AAC. Therefore, the barriers
screening for eligible studies, assessing the quality of the included
and facilitators presented were primarily from the perspective of
articles, extracting the relevant data, and conducting a framework
people and families who used, rather than rejected or abandoned,
analysis. These processes are detailed below. Schlosser [17]
their AAC system. However, across the participants, Baxter et al.
reports that to enhance the integrity of results, quality systematic
[12] identified factors related to ease of use, reliability, technical
reviews within the field of disability should follow a research
support, the voice and language of the device, the decision-mak-
protocol that is developed a priori. Therefore, a protocol was
ing process, family perceptions and support, staff training, the
developed following guidelines by Butler et al. [18].
speed of generating a message, communication partner
responses, and service delivery issues. These themes can all be
Search and inclusion strategy
considered environmental factors within the framework of
the ICF. As recommended by Butler et al. [18], the acronym PCO
While Baxter et al. [12] identified only environmental factors as (Population, Context, Outcomes) was used to formulate the
barriers and facilitators to the use of high-tech AAC systems, add- research question and search terms. The research question for the
itional studies have suggested that personal factors, and body review was: What are the barriers and facilitators to the provision
structure and function may also be an influence. For example, and use of low-tech and unaided AAC to people with complex
Crisp et al. [14] explored mothers’ perspectives on the use of communication needs and their families? The relevant published
speech generating devices and noted that device use was facili- literature was identified via a systematic search strategy, devel-
tated when it was introduced at an early age. Clarke et al. [15] oped in consultation with an expert librarian. The search was
interviewed children who used AAC and reported that the major- completed in October 2016 and utilized six computerized data-
ity considered AAC systems to be “uncool” and “boring” [15]. It is bases: PubMed, CINAHL, Embase, PsychINFO, ERIC and Scopus.
worthy of note however that this study was published in 2001, Key search terms were:
prior to the advent of iPads and other widely-used and accepted
1. Terms selected to access the stakeholders involved in AAC
mobile technologies. Nonetheless, children in the study also
use (population). These included; ‘spouse’, ‘parent’, ‘sibling’,
raised issues of self-image and identity as a result of using AAC
‘caregiver’, ‘speech pathologist’, ‘user’, and ‘peer’.
systems to communicate [15]; issues which are likely of continued
2. Terms selected to capture the range of low-tech and unaided
relevance in the present day. Furthermore, Armstrong et al. [16]
AAC systems (context). These included; ‘AAC’, ‘nonverbal
surveyed SLPs and explored factors that assisted them when
communication’, ‘Makaton’, ‘Auslan’, ‘Aided Language’, and
deciding whether or not to introduce AAC systems to people with
‘picture exchange’.
Parkinson’s disease. Personal factors considered by the SLPs
3. Terms selected to represent a range of possible perspectives
included the client’s level of literacy, motivation, and age.
(outcomes). These included; ‘barrier’, ‘facilitator’, ‘experience’,
However, the three factors most frequently reported to influence
‘perspective’, ‘accept’, ‘reject’ and ‘abandon’.
the decision making were the client’s motor symptoms, cognitive
ability, and stage of speech deterioration, all of which are consid- Truncation of search terms was used where appropriate (e.g.,
ered body functions within the ICF. parent). See Supplementary Appendix I for full details of the
In summary, although there has been a systematic review of search strategy. To ensure that all the relevant articles were iden-
the barriers and facilitators to the provision and use of high-tech tified, the reference lists of included papers were examined for
 SYSTEMATIC REVIEW OF THE BARRIERS AND FACILITATORS FOR LOW-TECH AND UNAIDED AAC SYSTEMS 3

additional citations. The search was limited to articles published weighting approach to data analysis. Within this approach, studies
in English within the period of 2000–2016. This time frame was of a lesser quality are not excluded from the analysis, which sig-
selected to be in line with that of Baxter et al. [12]. It was deemed nificantly reduces selection bias [26]. Instead, the strengths and
appropriate for use as, while advancements in mobile technology limitations of each study are considered, and data from lesser
have resulted in significant developments in high-tech AAC in quality studies are used to add richness to the findings [27].
since 2000, fewer changes have occurred in low-tech and unaided Therefore, although the CASP does not suggest a scoring system
AAC systems in this time [19]. [23], scores were calculated to approximate the weight of each
All studies identified during database searching were stored in study and inform the quality-weighting approach.
the reference management software Endnote and exported to
Covidence for screening. Screening for included studies was
Analysis and synthesis
achieved in two stages. Firstly, the first author screened retrieved
papers by title and abstract for relevance to low-tech or unaided Following consideration of the Decision Tree posed by Saini and
AAC and the potential for subjective accounts of AAC users and/ Shlonsky [27], qualitative meta-synthesis was selected as the most
or stakeholders. Full text papers were then retrieved and screened appropriate method of data analysis. This method begins with a
for evidence of barriers and facilitators of low-tech or unaided research question and strategies for data collection and analysis
AAC use. Studies were included if they (1) explored the real or that are predefined based on the prior knowledge of the
perceived barriers and/or facilitators to communication using low- researcher. Through the process of comparing and contrasting
tech or unaided AAC; and (2) contained findings in the form of data, the researcher both retains the original meaning of the pri-
qualitative data. Such data are effective in exploring a range of mary studies and develops new interpretations that span across
perspectives, experiences and meanings, and when synthesized multiple studies [25,27].
can be used to inform family-centred practice [20]. Therefore, Whilst initially developed for the analysis of the primary
qualitative studies of all methodologies were considered, as well research, framework analysis has been applied as a tool for con-
as the qualitative portions of mixed methods studies. ducting meta-synthesis of qualitative studies [28]. Within frame-
Articles were excluded if they: work analysis, findings are categorized into an a priori framework,
1. Were literature reviews, commentaries, conference abstracts, then summarized within each dimension of the framework.
or presentations of preliminary results only; Framework analysis involves reading within categories to deter-
2. Involved participants whose primary impairment was that of mine the way findings converge and diverge and making an over-
vision or hearing; arching statement about the findings [29]. For the current review,
3. Involved participants whose complex communication needs framework analysis was conducted using the ICF [1]. This frame-
were not chronic in nature (e.g., temporary intubation during work was utilized in a systematic review by Lindsay [20], as it can
intensive care); assist in understanding the effects of diverse factors on activity
4. Focussed solely on Facilitated Communication, due to the and participation. Furthermore, Light and McNaughton [30] sug-
controversy regarding the validity of this technique [21]; or gest that the ICF is used to guide research in AAC due to its abil-
5. Contained the results pertaining to high-tech AAC sys- ity to capture both the medical and social aspects of disability.
tems only. The ICF also provides a common platform for the collaboration
between researchers and clinicians [31], thus increasing the
Deviation from the research protocol occurred, in that an potential for clinical application of review results.
amendment was made to exclude participants who had complex As recommended by Sandelowski and Barroso [32], meta-syn-
communication needs that were not chronic, and those who used thesis was commenced by reading each article multiple times and
Facilitated Communication. The presence of these participants reflecting on the data. Findings related to the barriers and facilita-
within the search results had not been anticipated. However, the tors to the provision and use of low-tech and unaided AAC were
three authors agreed that including data pertaining to these par- then extracted into Microsoft Word and Excel documents (see
ticipants would detract from the focus of the review. Supplementary Appendix II for data extraction tools). Although
data pertaining to high-tech AAC specifically were not extracted,
Quality assessment data referring to AAC in general (without specification of the AAC
To maximize the validity of synthesized review findings, studies type) were included. Furthermore, data referring more broadly to
meeting the inclusion criteria were subject to a quality assess- the communication experiences of people with complex commu-
ment. The quality of each study was evaluated using the nication needs were extracted, where this data was contextualized
Qualitative Research Checklist of the Critical Appraisal Skills by the study focus on AAC. Finally, data extracted from the two
Programme (CASP) [22] or the CASP Systematic Review Checklist included systematic reviews were original findings only, rather
[23] as appropriate. These tools prompt the reviewer to consider than quotes from the primary studies. The first author completed
the rigour, credibility and relevance of each study [24]. The CASP data extraction, with discussion and cross checking occurring in
has been used in a recent systematic review by Lindsay [20] when frequent meetings with the research team.
examining experiences and perspectives in children with a disabil- The extracted data were then imported into NVivo for the
ity, as well as by Baxter et al. [12] when reviewing the barriers commencement of framework analysis. The ICF is organized into
and facilitators to the use of high-tech AAC. domains (e.g., Environmental Factors), chapters (e.g., Products and
All included articles were critically appraised by the first Technology), second level codes (e.g., Products and Technology
author, and 20.93% of these (n ¼ 9) were randomly selected for for Communication), third level codes (e.g., Assistive products and
re-appraisal by the second and third authors. To ensure consist- technology for communication) and in some instances fourth level
ency, the first author then reviewed her assessment of all articles codes [33]. Data were coded and categorized to the levels of
based on feedback received during the group discussion. As the domains and chapters, with second level codes considered where
exclusion of studies based on quality is a contentious issue [25], particularly relevant to the topic of the review. Beyond this a pri-
results of the quality assessment were used to inform a quality- ori framework, inductive analysis was used to categorize
4 A. MOORCROFT ET AL.

additional data. Inductive analysis was particularly necessary for Methodological quality
the domain of Personal Factors, as these are not specifically
Of the 43 included articles, 32 were utilized for qualitative meth-
coded in the ICF due to the wide variability across cultures [34].
odology, nine were mixed methods studies, and two were system-
Once sorted into categories, the data were charted into a spread- atic reviews. Therefore, 41 articles were assessed for
sheet and summarized. Data within each category were compared methodological quality using the CASP Qualitative Checklist, and
between and within studies, enabling the categories to be sum- two with the CASP Systematic Review Checklist. Mixed methods
marized and collapsed together where appropriate. This process studies were reviewed with the qualitative checklist as only the
formed themes and subthemes, which describe and explain qualitative components of these studies were considered in the
aspects of the data and answer the research question [35]. current review. Quality assessment agreement between the three
Analysis was conducted by the first author, supported closely authors was 88.89%, and consensus for all criteria in each article
by the second and third authors. Frequent research team meet- was reached following a group discussion. Articles were weighted
ings were conducted, wherein the framework, coding, and ana- for analysis according to the agreed assessment results (see
lysis were discussed and debated. Any discrepancies regarding Supplementary Appendix III). Within this process, all data were
the coding or analysis were resolved through discussion until con- considered for analysis; however, only themes emerging from
sensus was reached. articles of higher quality (i.e., those rated 7–10) and supporting
quotes from these articles have been reported in the below body
of text. Themes emerging only from articles of lower quality (i.e.,
those rated 4–6) have been reported in the supplementary mater-
Results
ial (see Supplementary Appendix IV).
Identification and classification of relevant studies
As detailed in Figure 1, the database search yielded 10,281 poten- Characteristics of included studies
tially relevant articles, 40 of which met the inclusion criteria. All
The 43 included articles pertained to 42 independent studies.
full texts were screened by the first author and 20.1% of articles
Goldbart and Marshall [38] and Marshall and Goldbart [39] utilized
(n ¼ 39) were randomly selected for joint rescreening by the the same data set for their papers. However, both articles were
second and third authors, independent of the first author [26]. included, as Goldbart and Marshall [38] included an additional
Screening agreement between the three authors was 87.18%, and stage to their methodology wherein the results were presented to
consensus for all articles was reached following a group discus- people who used AAC, parents, carers, teachers, and SLPs at a
sion. One additional article [36] was identified for inclusion upon conference. This presentation served to increase the credibility of
reviewing the reference lists of the included articles and two the results, as the audience provided feedback on the initial ana-
articles were added from the researcher’s personal library [4,37]. lysis and generated alternative explanations for the data, which
This totalled 43 articles for inclusion in the review. A log of were considered in later analysis [38].
excluded articles with reasons for exclusion is available from the Characteristics of the included articles are detailed in Table 1.
first author on request. The two systematic reviews included a total of 325 participants

Figure 1. Flow chart illustrating the inclusion and exclusion process.

 SYSTEMATIC REVIEW OF THE BARRIERS AND FACILITATORS FOR LOW-TECH AND UNAIDED AAC SYSTEMS 5

Table 1. Descriptive summary of articles included in the systematic review on the barriers and facilitators to the provision and use of low-tech and unaided
AAC systems.
Article Participants AAC Measures & Key Findings Quality Rating
Armstrong, Jans [16] 30 SLPs Low-tech, high-tech Questionnaire 5
SLPs reported both disease specific (e.g. motor
problems) and more general factors (e.g.
carer support) as influencing their introduc-
tion of aided AAC to someone with
Parkinson’s disease.
Balandin, Hemsley [43] 10 adults (5F, 5M, 35-61 AAC picture communication Semi-structured interview 10
years old) with CP board, alphabet Participants identified barriers to successful
and CCN board, writing communication in hospital, including not
having a way or opportunity to communi-
cate, and nurses not understanding or
responding to their communicative attempts.
Participants discussed experiencing physical
and psychosocial consequences because of
these barriers.
Balandin, Hemsley [36] 10 adults (2F, 8M, 28-87 SGD, alphabet & symbol Semi-structured interview 6
years old) with severe board, writing, alpha- Individuals experienced difficulties communicat-
acquired communica- bet board ing with nurses, some of which appeared to
tion impairment be related to lack of AAC resources and a
lack of knowledge of AAC among nurses.
Participants described the resulting conse-
quences and suggested strategies for improv-
ing interactions.
Binger, Kent-Walsh [58] 2 professors, 1 AAC expert, SGD, low-tech communica- Semi-structured focus group 9
and 1 father of an tion boards Changes to the AAC instructional program were
AAC user made based on focus group results. Changes
included presenting components of the pro-
gram in relation to Latino culture, and as
being beneficial for preparing children
for school.
Borg, Agius [70] 1 AAC user (9 years old) and Signing, communication Semi-structured interview (mother) and struc- 7
her mother book, high-tech tured interview (child)
Barriers to AAC use included the need to self-
fund the high-tech system. However, benefits
of both low- and high-tech AAC included
increased communicative intent. The child
preferred to use high-tech over low-
tech AAC.
Brady, Skinner [61] 55 mothers of children with Sign language, PECS Semi-structured interview 8
Fragile X syndrome Mothers reported using strategies to support
their child’s communication and identified
challenges faced in helping their child to
communicate with and without AAC. They
cited their roles as caregiver, teacher, therap-
ist, and advocate for their child.
Bruce, Trief [95] 21 teachers and 8 SLPs work- Tangible symbols Interview 6
ing with children with Students learned the meaning of symbols and
multiple disabilities and exhibited improved behavior, among other
visual impairment benefits. Supports (e.g., frequent opportuni-
ties for practice, symbols selected for moti-
vating activities) and barriers (e.g., resistance
of adults, physical and medical issues of chil-
dren) to student learning were discussed,
and improvements to the interven-
tion suggested.
Calculator [64] 9 families with children with Enhanced natural gestures Enhanced Natural Gestures- Acceptability Rating 7
Angelman syndrome (3-10 Form (ENG-ARF)
years old) With few exceptions, parents described the
Enhanced Natural Gestures instructional pro-
gram as acceptable, effective, reasonable,
and easy to teach others, with minor nega-
tive consequences and side-effects.
Chung and Stoner [96] 144 participants across Eye gaze, gesture, signs, Systematic Review 6
10 studies communication The common phenomenon was the need to
boards, SGDs support children who use AAC through team
collaboration. The categories that emerged
were inputs (e.g., student and family charac-
teristics), activities (e.g., planning and evalu-
ation), and outcomes (e.g., student and peer
outcomes) necessary for supporting
AAC programs.
De Bortoli, Arthur- Unaided, low-tech and high- Semi-structured interview and focus group 9
Kelly [51] tech systems Participants identified a broad range of themes
(continued)
6 A. MOORCROFT ET AL.

Table 1. Continued.
Article Participants AAC Measures & Key Findings Quality Rating
8 female SLPs working with as influences to AAC implementation, includ-
children with disabilities ing the SLPs’ experience and skills, profes-
aged 6 months to 7 years sional development, and collaboration with
teachers and families; as well as home and
school contexts, the role of government
departments, and broader societal factors.
Donato, Shane [55] 4 parents of children aged 0- Visual Language in Autism: 3 focus groups 9
5 years with ASD or GDD, photos, text, drawings, Lack of time, limited services, negative attitudes
4 educators & 5 health signs, gestures, objects, & in society, and inconsistent use were cited as
professionals high-tech common barriers to using visual supports.
Facilitators included having access to infor-
mation and evidence on visual supports,
increased awareness of visual supports, and
the use of mobile technologies.
Finke, Light [97] 181 participants across Not reported Systematic Review 4
12 studies Communication between nurses and patients is
essential for providing quality care and can
be supported using AAC when speech is not
an option.
Goldbart and Marshall [38] 13 parents (2M, 11F) of 11 Signing, communication Interview 10
children (5M, 6F, 3-8 years book/board, PECS, Analysis revealed three global themes regarding
old) with CP (n ¼ 9), ID high-tech parents’ experiences with AAC: (1) an explor-
(n ¼ 6), impaired hearing ation of parents’ perspectives on their child-
(n ¼ 2) and/or epi- ren’s communication and interaction; (2)
lepsy (n ¼ 1). wider societal issues that impacted parents;
and (3) parents’ views and experiences with
regard to the impact on their lives of parent-
ing a child who uses AAC. Within the theme
of parents’ views and experiences, the organ-
izing theme of ‘demands on parents’, is dis-
cussed in depth.
Greenstock and 15 teachers, 22 early years Graphic symbols Semi-structured interview 8
Wright [53] professionals and 16 SLPs Authors proposed a theoretical model which
suggests that practitioners are influenced by
their unique professional reasoning processes,
as well as the ways they perceive their own
professional role and the roles of others.
Hemsley and 6 parents (3M, 3F) of 5 adults Communication board and/ In-depth conversational style interview 10
Balandin [44] with CP or SGD Carers believed that AAC systems could not be
used in hospital. They described communica-
tion between the nurse and patient as very
difficult, and therefore saw it as important to
be present to support the interaction.
Hemsley, Balandin [69] 15 nurses Communication boards, lim- Semi-structured interview 10
ited vocalisations, yes/no Nurses identified that ’time’ impacted on suc-
cessful communication. As a barrier, time was
related to avoiding direct communication,
while as a facilitator it was related to valuing
communication, investing extra time, and
applying a range of strategies.
Hemsley, Kuek [45] 10 parents and their 7 chil- SGD, communication boards, 3 focus groups (parents) and interview (chil- 9
dren (13-18 years old) gestures, other dren)
with CP and CCN non-verbals Results demonstrated that children often want
to communicate directly with hospital staff,
however barriers to this communication
include a lack of access to AAC, staff prefer-
ring to communicate with parents, and a lack
of time to communicate.
Hemsley, Lee [56] 19 hospital allied health staff, Communication boards, eye 12 focus groups 8
14 hospital nursing staff, gaze, signing, gestures, Barriers to effective communication in hospital
and 16 community-based vocalisations, high- included lack of access to the child’s commu-
allied health staff tech AAC nication system, lack of time to communi-
cate, and lack of knowledge and experience
in the use of AAC. SLPs described having no
input into supporting communication for
children as inpatients.
Hines, Balandin [40] 16 parents (4M, 12F) of 13 Sign language, PECS, writing 2 semi-structured interviews per participant 9
adults with autism (31-44 Parents rarely spontaneously mentioned AAC or
years old) other communication interventions and did
not express the need for such services.
However, communication breakdown fea-
tured prominently in their narratives.
Iacono and Cameron [57] 14 SLPs Sign, gesture, pictures, activ- Interview 9
ity displays, visual sched- A major barrier in implementing AAC using best
ules, wait cards, high-tech practice was the limited time of SLPs given
(continued)
 SYSTEMATIC REVIEW OF THE BARRIERS AND FACILITATORS FOR LOW-TECH AND UNAIDED AAC SYSTEMS 7

Table 1. Continued.
Article Participants AAC Measures & Key Findings Quality Rating
the many demands and expectations placed
on them. The attitudes and limited time of
families were also noted as barriers.
Iacono, Lyon [67] 15 adults (9M, 6F, 21-74 E-tran, request cards, com- Semi-structured interview. 9
years old), with develop- munication book/board, Where cognitive limitations precluded direct
mental disability (n ¼ 10) visual shopping list, Book reports (n ¼ 4), sought input from support
or ABI (n ¼ 5). About Me, high-tech people. Participants used multi-modal com-
munication and selected different AAC aids
according to time and place. They had varied
preferences for low versus high-tech AAC
and differed in their reactions to the atti-
tudes of others in the community. Most par-
ticipants demonstrated owning the process
of choosing, developing, or updating their
AAC system.
Johansson, Carlsson [42] 11 people with aphasia Gestures, drawings, commu- Semi-structured interview 10
(7M, 4F) nication aid devices Factors related to the informants, conversation
partners, the conversation itself and the
physical environment impacted on conversa-
tions. Themes were loss and frustration, fear
and uncertainty, shared responsibility based
on knowledge, and longing for the past or
moving forward.
Jonsson, Questionnaire: 65 parents ComAlong communica- Questionnaire, 2 semi-structured interviews per 7
Kristoffersson [65] (22M, 43F) Interview: tion boards participant, logbook, video recordings of par-
4 parents ent-child interaction
Parents’ described used of the boards as a posi-
tive experience in general. Most parents
reported that their children showed an inter-
est in the communication boards and in
some cases started to use the boards
functionally.
Laakso, Markstr€om [47] 19 adults (14M, 5F, 26-76 Letter boards, writing, Semi-structured interview 10
years old) receiving full high-tech The main theme from the data was ’A long and
time home mechanical lonely struggle to find a voice’. This theme
ventilation consisted of six subthemes: managing
changed speech conditions, prioritizing voice,
using communication to get things done, a
third party supporting communication, facing
ignorance, and depending on technology.
Lindsay [49] 7 SLPs and 4 OTs who were Communication boards, note- Semi-structured interview 9
current authorizers for books, high-tech There are several barriers (technical, social, and
AAC devices political) influencing clinicians’ decision to
prescribe AAC devices. Differences in philoso-
phy of technology also influenced the deci-
sion-making process.
Lund and Light [46] 7 men (19-23 years old) with Vocalisations, eye pointing, Semi-structured interview 10
CP, 10 family members head shake/nod, commu- Factors that impeded positive outcomes with
and 2 professionals per nication board/book, eye AAC included: attitude barriers, cultural differ-
participant codes, gestures, high-tech ences, technological barriers, and service
delivery limitations. Contributions to positive
outcomes with AAC included: community
support, parent and family support, personal
characteristics, and appropriate and high-
quality AAC services.
Marshall and Goldbart [39] 13 parents (2M, 11F) of 11 Signing, communication Interview 10
children (5M, 6F, 3-8 years book/board, PECS, Analysis revealed three global themes regarding
old) with CP (n ¼ 9), ID high-tech parents’ experiences with AAC: (1) an explor-
(n ¼ 6), impaired hearing ation of parents’ perspectives on their child-
(n ¼ 2) and/or epi- ren’s communication and interaction; (2)
lepsy (n ¼ 1). wider societal issues that impacted parents;
and (3) parents’ views and experiences with
regard to the impact on their lives of parent-
ing a child who uses AAC. Parents shared
many common concerns, but the data also
revealed some diversity of views.
Martin, Connor- 8 registered nurses working Gesture, facial expression, Semi-structured interview 10
Fenelon [48] with people with an ID body language, behavior, The second of two articles presenting the find-
who are non-verbal vocalization ings of a qualitative study. The overarching
category of ‘knowing the person’ included
the themes of emotional conflict (e.g., feeling
misunderstood), person-centered communica-
tion (e.g., observation, listening), and the car-
ing environment (e.g., the setting).
(continued)
8 A. MOORCROFT ET AL.

Table 1. Continued.
Article Participants AAC Measures & Key Findings Quality Rating
McKelvey, Evans [63] 1 daughter and 6 spouses Low-tech AAC, SGD Semi-structured interview, review of relevant 8
(2M, 5F) of 6 adults with documents
ALS (46-65 years old Data analysis revealed four primary themes:
at death). communication styles, AAC use, decision-
making, and lifestyle changes. Within the
theme of AAC use, spouses described devel-
oping their own communication systems for
communication of both wants and needs,
and social closeness. AAC was described as
essential for individuals with ALS.
Mukhopadhyay and 11 teachers trained as spe- Natural gesture Semi-structured focus group 8
Nwaogu [68] cial educators Teaching non-speaking students with ID is chal-
lenging. AAC systems were not widely used
in Botswana, and teachers lacked the know-
ledge and skills required for AAC use.
Nevertheless, the participants recognized the
importance of AAC.
Murphy [41] 15 people with MND (8M, 7F, Gestures, paper/pen, key Video recordings, narratives and field notes col- 10
45-78 years old) and their words board, alpha- lected over up to 7 occasions.
spouse (n ¼ 10), close rela- bet board AAC was less successful than anticipated. The
tive (n ¼ 2), or participants gave many reasons, which were
friend (n ¼ 1) interpreted by the researcher to include (a)
the need for social closeness, which may not
be possible when using a device; and (b) the
complexity of learning how to use a high-
technology device combined with inad-
equate training.
Oommen and 8 female SLPs experienced in Pictures, sign language, eye Questionnaire, online focus group 9
McCarthy [50] providing both AAC and gaze, SGD Challenges in simultaneous treatment (speech
direct intervention to chil- treatment and AAC) included lack of training,
dren with CAS limited time in therapy, lack of collaboration
among team members, the child’s interest in
therapy, lack of insurance coverage for inten-
sive therapy, and scheduling conflicts
between the clinician and client.
Patel and Khamis- 20 teachers (3M, 17F) of 34 Picture communication Open-ended questionnaire, interview 5
Dakwar [98] students (3–17 years old) boards, gestures, signs, Training improved the attitudes of teachers with
with mild-moderate ID PECS, high-tech regards to AAC, and teachers recognized the
need for families and other staff to receive
training. Teachers also felt more empowered
as a result of the training, and acknowledged
the benefits of meeting with parents and
other staff members to address challenges as
they arose.
Pickl [60] 10 mothers, 1 father, 1 Posture, movement, vocalisa- Observation, informal personal conversations, 10
grandfather and 24 special tions, gestures, signs, com- e-mail discussions, memos, and semi-struc-
education teachers discus- munication boards, SGDs tured interviews (individually or in small
sing 43 children (29M, groups).
14F, 6–16 years old) The results indicate that the quality of parent-
with ID teacher-interaction is central to effective
communication intervention and culturally
sensitive use of AAC. The quality of inter-
action was influenced by the regularity of
contact, and the teachers’ knowledge about
the child’s home culture, communicative abil-
ities in his or her home language, and com-
munication needs within the family.
San and Abdullah [37] 1 mother of a child (M, 3 PECS Interview 5
years old) with a PECS was effective in enhancing communication
mild PDD skills and reducing problematic behaviors.
PECS also had a slight impact on speech pro-
duction of the child.
Serpentine, Tarnai [71] 10 parents of children with Sign language, communica- Interview 10
ASD and no functional tion cards, Parents used a variety of sources to gain infor-
communication PECS, computers mation about interventions, and held differ-
ent expectations of these interventions.
Parents expressed a variety of reasons for
adding or discontinuing interventions, e.g.,
due to lack of improvement or change, hear-
ing about different interventions.
Sheehy and Budiyanto [4] 20 teachers (4M, 16F) Signing Questionnaire, semi-structured interview 8
Teachers hold broadly positive attitudes to the
possibility of signing. There is a complex rela-
tionship between social stigmatization, the
(continued)
 SYSTEMATIC REVIEW OF THE BARRIERS AND FACILITATORS FOR LOW-TECH AND UNAIDED AAC SYSTEMS 9

Table 1. Continued.
Article Participants AAC Measures & Key Findings Quality Rating
nature of signing and a possible class-
room pedagogy.
Smith and Connolly [99] 18 adults (19-42 years old) Communication board, Questionnaire based interview 6
with CP high-tech Participants expressed positive views about
aided communication and ranked it among
their primary mode of communication. Use
was influenced by communication partners
(i.e., unlikely to use AAC with unfamiliar part-
ners) and device features (e.g., poor reliability
and limited vocabulary).
Srinivasan, Mathew [62] 14 female special educators Sign language, visual sched- Questionnaire, interview 9
and 4 female SLPs ules, communication Perspectives included: communication interven-
boards/books, tion should be a structured, child centric pro-
SGDs, computers cess, using a collaborative team model;
parents play an integral role in intervention;
cultural and linguistic issues are imperative in
decision making; use of better materials and
technology can improve intervention; and
better training programs are needed.
Stephenson and 11 parents (1M, 10F) of 10 Gestures, signs, body move- Interview 10
Dowrick [59] children (9M, 1F, 4-9 years ment, vocalisations, & Parents described a wide range of behaviors as
old) with severe ID graphic, photo & communicative. However, they may need
object symbols support to encourage presymbolic communi-
cative behaviors. Where formal AAC had
been introduced by schools, parents were
not always supportive of its use at home.
Stoner, Parette [66] 9 female teachers PECS, high-tech Semi-structured interview, Early Language and 7
Literacy Classroom Observation Toolkit,
Assistive Technology Self-Assessment Survey
Teachers’ thoughts and feelings about a school
wide assistive technology (AT) program
included: (a) perceptions of technology (e.g.,
seeing AT as a supplement rather than
integrated aspect of curriculum); and (b) per-
ceived challenges to implementing technol-
ogy (including need for support, time
constraints, and student characteristics).
Trembath, Iacono [54] 6 adults (4M, 2F, 20-60 years Schedules, chat book, ’Book Semi-structured interview, field notes 9
old) with ASD, 7 support About Me’, photo board, The results revealed strong support for, and the
workers, 2 fam- request cards potential benefits of, AAC for both adults
ily members. with ASD and their communication partners.
There were however inconsistencies in the
actions taken to support the use of the pre-
scribed AAC systems.
Wormnaes and Malek [52] 30 SLPs Tangible symbols, pictures, Questionnaire 7
signs, graphic symbols SLPs must be provided with opportunities to
enhance their competence in AAC. Although
teachers and parents had shown resistance
towards using AAC, many changed their
opinions after realizing the benefits of
its use.
AAC: augmentative and alternative communication; ABI: Acquired Brain Injury; ALS: Amyotrophic Lateral Sclerosis; ASD: Autism Spectrum Disorder; CAS: Childhood
Apraxia of Speech; CP: Cerebral Palsy; ID: intellectual disability; GDD: Global developmental delay; OT: occupational therapist; PDD: Pervasive Developmental
Disorder; PECS: Picture Exchange Communication System; SGD: speech generating device; SLP: speech-language pathologist.

from across 22 studies. The 40 primary studies included a total of disability, childhood apraxia of speech, epilepsy, Parkinson’s dis-
755 participants, consisting of people with complex communica- ease, acquired brain injury (stroke and traumatic brain injury),
tion needs (n ¼ 115), family members (n ¼ 249) or friends (n ¼ 1) motor neurone disease, hemimegalencephaly, aphasia, chronic
of people with complex communication needs, SLPs (n ¼ 133), respiratory failure, and amyotrophic lateral sclerosis.
occupational therapists (n ¼ 7), AAC specialists (n ¼ 4), nurses The included articles referred to a variety of unaided, low-tech
(n ¼ 37), unspecified health professionals (n ¼ 40), support workers and high-tech AAC systems. Of interest to this review were the
(n ¼ 7), teachers (n ¼ 85), special education teachers (n ¼ 49), early reported unaided AAC systems of signing, conventional gestures,
years (0 to 5 year old children) educators and assistants (n ¼ 26), enhanced natural gestures, eye pointing, head movements, mouth
and academics in education or speech-language pathology movements, vocalisations, facial expression, behaviour, and pos-
(n ¼ 2). Of the 42 studies in the current systematic review, 25 per- ture. The reported low-tech AAC systems were alphabet boards,
tained specifically to the children with complex communication picture communication boards and books, writing, drawing, PECS,
needs and 14 to adults, with the remaining three unspecified. tangible symbols, real objects, photographs, visual schedules,
Participants presented with a variety of health conditions includ- community request cards, picture-based shopping lists, and About
ing Fragile X syndrome, Angelman syndrome, autism spectrum Me books. While high-tech AAC was not the focus of this review,
disorder (ASD), Down syndrome, cerebral palsy, intellectual systems including single message devices, communication apps
10 A. MOORCROFT ET AL.

Figure 2. Barriers and facilitators to the provision and use of AAC systems for people with complex communication needs as mapped on to the International
Classification of Functioning, Disability and Health [1].

on iPads, and dedicated speech generating devices were dis- as contextual factors in the ICF (see figure 2). The remaining
cussed in the included articles. small number of codes related to body functions.
Of the 26 studies which included participants with complex Comprehensive lists of the coded barriers and facilitators are
communication needs and/or their family members, only three presented in Tables 2–7, and an example quote is provided
studies discussed people with complex communication needs for each code in the online supplementary material. Discussed
who did not use low-tech or unaided AAC systems. Specifically, in further detail below are those codes that occurred in articles
Hines et al. [40] interviewed 13 families of adults with ASD, and of higher quality and were deemed most pertinent to the
of these, only one family used AAC. Similarly, Murphy [41] research question. For the purposes of this report, ‘AAC’ should
reported on three participants with motor neurone disease who be considered as low-tech and unaided AAC only, unless other-
used low-tech AAC systems on commencement of the study, wise specified.
however were not using these systems when the study was
completed. Furthermore, Johansson et al. [42] reported that
Body functions
some participants did not use AAC but did not specify this
numerically. These studies did not specifically seek to include As detailed in Table 2, the Body Functions that were barriers and
participants who had rejected or abandoned AAC systems; facilitators to the provision and use of AAC systems aligned with
rather, these participants were an incidental inclusion. An add- four chapters of the ICF. The mental functions of cognition, mem-
itional three studies included participants who had not rejected ory, attention, and alertness were of influence. For example, Lund
or abandoned AAC, but for various reasons did not use their and Light [46] reported that participants who used AAC attributed
usual AAC system while in hospital [43–45]. Therefore, it can be their success with the system to their own skills and intelligence,
noted that the barriers and facilitators to the provision and use stating “when asked why he [the AAC user] thought he was a
of AAC systems presented in the current review are predomin- good communicator [with AAC], Anthony indicated his
antly those from the perspective of people and families who intelligence” [46]. Movement functions such as increased spasticity
use the systems, and not those who have rejected or aban- and motor planning deficits prevented users from pointing to
doned a system. symbols or using gestures within their communication [47,48].
Furthermore, where these physical limitations existed, SLPs
reported that some parents were “too busy focused on helping
Application of results to the ICF
their child to walk than developing communication” [49].
The analysis revealed that most barriers and facilitators to the However, SLPs noted that AAC use was facilitated if the person
provision and use of low-tech and unaided AAC could be coded had inadequate voice or speech function for verbal
 SYSTEMATIC REVIEW OF THE BARRIERS AND FACILITATORS FOR LOW-TECH AND UNAIDED AAC SYSTEMS 11

Table 2. Body functions affecting the provision and use of unaided and low-tech AAC systems.
ICF Chapter Barriers Facilitators
Mental Functions  Cognitive, memory, attentional and/or language  Frequent optimal alertness states
impairments  Greater cognitive abilities
 Non-optimal alertness states  Growth in language following the introduction
of the AAC system
Voice and Speech Functions Nil identified  Inadequate voice for verbal communication
 Severe speech impairment
Movement Functions  Physical limitations (gross and fine motor) Nil identified
Sensory Functions & Pain  Tactile defensiveness  Functional vision skills

Table 3. Environmental factors (attitudes) affecting the provision and use of unaided and low-tech AAC systems.
Stakeholder Barriers Facilitators
SLP  Low expectations of user  Realistic goals and expectations
 Misconceptions of AAC and role as SLP  Dedicated to supporting communication
 Prioritised verbal expression  Positive attitude towards other stakeholders
 Personal philosophy of technology
Nurse  Perceived that the person had no need to  Humorous, patient, & persistent
communicate  Willing to take the necessary time
 Believed it was not their job to support  Did not make assumptions
communication
 Made incorrect assumptions
Teacher  Misconceptions of AAC & little understanding  Positive, realistic, motivated to learn
of purpose  Able to collaborate
 Misconceptions about the role of a SLP  Viewed AAC as beneficial
 Perceived that AAC was not within their role  Had experienced previous success with AAC
 Had unrealistic expectations  Listened to another teacher’s experiences, frus-
 Failed to recognize strengths trations, and successes
 Negative attitude towards disability
 Hesitant to learn, lacked interest, and
were inflexible
 Burnt out and at breaking point
School  Did not prioritize communication  Communication intervention focus
 Found it hard to support complex students  Principal was supportive and interested in AAC
 Principal expected teachers to implement strat-
egies & provided required resources
Support Worker  Lacked confidence  Training staff in the importance and relevance
 Did not understand the importance or relevance of AAC
of AAC
 Personal views and judgements
Immediate Family (e.g., parents)  Felt AAC was confronting, stressful, and draining  Motivated
 Misconceptions about AAC & role of a SLP  High expectations of success
 Did not understand purpose of AAC  Liked, supported, and took ownership of the
 Did not accept the need for an AAC system AAC system
 Preference for speech  Increasing parental awareness through training
 Held low expectations of child  Being patient, having a sense of humor, and
 Prioritised their child’s health and physical func- remaining calm
tioning over communication.
 Conflicting attitudes among family members
 Cause of the disability attributed by the parents
(e.g., religious meaning)
 Did not acknowledge the importance of using
AAC across settings
Society  Little social awareness or acceptance of AAC  Inclusive community that accepts the user for
 Perceived that AAC would draw attention to the their abilities
users’ disability and prevent them from integrat-  Ignoring negative societal attitudes
ing into the community  Increasing awareness of AAC
 Negative societal reactions increased as person
became an adult
 Judgement and assumptions

communication, as “this is when it becomes so much more moti- human-made changes. These factors are discussed in
vating to work on successful communication via AAC strat- depth below.
egies” [50].
Attitudes
The attitudes of professionals, family members, and society at
Environmental factors
large were significant barriers and facilitators to the provision and
Barriers and facilitators to the provision and use of AAC systems use of AAC systems (see Table 3). Across multiple studies there
spanned across the multiple environmental factors, including atti- were reports of professionals, including SLPs [41,46] and teachers
tudes, supports and relationships, services, systems, and policies, [51], who “thought that augmentative communication is not part
products and technology, and the natural environment and of their profession” [46]. Furthermore, SLPs surveyed by
12 A. MOORCROFT ET AL.

Table 4. Environmental factors (support & relationships) affecting the provision and use of unaided and low-tech AAC systems.
Stakeholder Barriers Facilitators
SLP  Early in career and lacking experience  High level of expertise in AAC
 Difficulties interpreting communication  Listened to family
 Did not offer AAC to potential users  Found, produced, and/or purchased the
 Unable to receive or provide the necessary train- required resources
ing due to time restrictions
Nurse  Did not have the time to communicate nor read  Rapport and familiarity with user
information on how to best communicate with  Willing to ask for help
their patient  Followed written directives
 Did not know how to use the AAC system or  Interpreted nonverbal cues
access method  Shared effective strategies with other staff
 Could not understand the patient’s communica-  Used/made AAC systems
tion with the system (e.g. sign language, idiosyn-  Positioned the patient to enable access to AAC
cratic movements)
Teacher  Limited experience  Extensive knowledge of AAC
 Made implementation errors  Provided frequent opportunities for practice
 Not aware of what approach other staff  Actively recruited parent input
were using
 Chose not to be involved with AAC at all, wel-
comed but did not implement suggestions, or
implemented the system inconsistently
 Time constraints
Support Worker  Limited time available Nil identified
 New staff lacked the necessary knowledge
and skills
Immediate family (e.g., parents)  Were not pushy or actively involved  Took ownership of the intervention
 Time limited  Advocated and were proactive
 Misused AAC system  Educated other communication partners
 Focussed efforts elsewhere  Managed time
 Implemented outdated (non-AAC) techniques  Made AAC part of routine
 Did not take the system to certain environments  Provided frequent opportunities for use
 Able to predict partner’s message without AAC  Learnt strategies
 Encouraged use across settings
 AAC allowed closeness and relationship with
partner to be maintained
Others (e.g., acquaintances, peers, friends, strangers)  Rushed user  Facilitated inclusion
 Did not know how to use AAC  Were accustomed to their way of communicating
 Could not understand AAC  Knew how to set up the system
 Were illiterate  Took the required time
 Content of message (limited to a nonverbal
social exchange)
Collaboration  Collaboration was ineffective or absent  All stakeholders collaborated effectively
 Lack of information shared between home  Diplomatic, flexible, available, trusting, commit-
and school ted, and able to negotiate and compromise
 Difficulties contacting stakeholders  Shared observations
 Stakeholders disagreed over the use of  Provided positive feedback
the system  Observed those more fluent with the system
 Parents of users provided support and encour-
agement to each other

Wormnaes and Malek [52] reported that they did not use AAC communication was considered to be very beneficial, and report-
because both themselves and the teachers they supported edly stemmed from principals who were interested in AAC [51].
believed that it may impede natural speech. Teachers and support Similar to the professionals, immediate family members (e.g.,
workers also expressed that they did not understand the purpose parents) reportedly held misconceptions about AAC and the role
of AAC, which resulted in the limited use of these systems [53,54]. of a SLP which limited the provision and use of these systems
In addition, some professionals were reported to lack passion and [40,49,50,57]. SLPs perceived that parents saw AAC as a last resort
confidence, and were hesitant to learn about AAC [51,54]. This and did not understand the role of AAC systems [55,57]. Parents
hesitation was exemplified by a SLP reflecting on the comments agreed that their own lack of awareness of the purpose of AAC
of a teacher who said that “maybe next year he’ll find a teacher limited their use of these systems, with one parent reporting that
who is more interested” in programming and training the student when AAC was first introduced, she thought, “are you insane? I
to use AAC [49]. AAC use was however reportedly supported by want my son to talk and you want him to hand over a picture?”
professionals who held realistic goals and expectations, did not [55]. In addition, some parents did not accept the need for AAC,
make assumptions, viewed the systems as beneficial, and were reportedly due to their belief that their child could already com-
dedicated to supporting communication development municate, or conversely did not want to communicate
[46,51,55,56]. For example, one parent described the benefits of [40,49,58,59]. Furthermore, teachers interviewed by Pickl [60] dis-
working with “very dedicated augmentative communication pro- cussed parents who were resistant to AAC due to their perception
fessionals that had a vision and then had incredible dedication of the cause of their child’s disability, and therefore sought alter-
and commitment” to finding out how her son was going to com- native ‘cures’. For example, a parent was reportedly convinced
municate [46]. Within schools, a culture supportive of that “a proper diet” would enable her child with cerebral palsy to
 SYSTEMATIC REVIEW OF THE BARRIERS AND FACILITATORS FOR LOW-TECH AND UNAIDED AAC SYSTEMS 13

Table 5. Environmental factors (services, systems & policies) affecting the provision and use of unaided and low-tech AAC systems.
ICF Level Barriers Facilitators
Production of Consumer Goods  Limited resources e.g., digital cameras, software,  Equipment and resources available
color printers, laminators  Additional funding for disability support workers
 Production required unpaid time to help teachers make AAC
 Lacked time to create resources
 No personnel to assist in production
 Relied on others to personalize and
update system
Associations & Organisations  Long waiting lists for services  Access to multidisciplinary services within a sin-
 Swallowing and behavior prioritized over gle office (enabled debriefing, problem-solving
communication and joint visits)
 Discipline specific prioritization systems  Follow-up procedures
 Consultative model of service delivery (unable to  More intensive services
provide adequate training or conduct one-on-  A longer loan period for AAC systems
one therapy)
 Restricted by a time-limited service that was
insufficient for meeting client goals
 No longer-term follow up
 Rapid turnover in staff & changes
in management
 Funding limitations & service access rules
 Scheduling conflicts
Education Schools Schools
 Class dynamics (high student-teacher ratio, vary-  Small quiet classes
ing abilities of students, multiple children with  Access to interpreter
complex needs)  A supportive team of teachers
 Shortage of professionals within schools to sup-  Available teachers’ assistants and substi-
port teachers tute teachers
 Teachers not provided with information about  AAC incorporated into school curriculum
new students Adult Education
 Limited transfer of AAC programs between  Additional training in how and why to use AAC,
teachers each year the types of AAC available, and how to select
 Staff required to work across multiple locations the most appropriate system
 SLPs as a visitor to the school  Training via manuals, peer debriefing, supervi-
 Difficulties having teachers released from class sion, internal workshops, and formal train-
 Limited use of interpreters ing events
Adult Education
 Limited training for SLPs, nurses, teachers
and parents
 SLPs and teachers received limited pre-service
training in AAC
Health  Insufficient time for communication  Nurses with small care-loads
 Lack of AAC available  Working within a supportive team
 High staff turnover  AAC available
 Poor continuity in nurses assigned to care for
a patient
 Lack of information regarding communication
on admission
 Length of hospital stay (too short to implement
a system)
Political  Government guidelines for AAC prescrip-  A structured, systematic and accountable pre-
tion outdated scription process
 Prescribers unaware of current policy  Streamlining the approval of new systems
 Complex application process for funding
 Prescription requirements (e.g., system to last
5 years)
 Significant delays in having new systems
approved for funding
 Policy gaps e.g., system required at home not
school, services for young adults, inten-
sive services
 Lack of collaboration in policy development
between different government departments (e.g.,
Education & Health)
Media Nil identified  Sign language is incorporated on main-
stream television

“get better and learn to walk and to talk” so saw no need to to communicate, their high expectations of success for their child,
cooperate with therapy approaches [60]. Although to a smaller and the fact that they liked, supported, and took ownership of
extent, the attitudes of immediate family members were some- the system [46,61].
times discussed as facilitators to AAC use. Parents reported that Finally, social norms and societal stigma influenced the use of
their use of AAC was supported by their motivation for their child AAC systems, in part due to the inadequate social awareness or
14 A. MOORCROFT ET AL.

Table 6. Environmental factors (other) affecting the provision and use of unaided and low-tech AAC systems.
ICF Chapter Barriers Facilitators
Products & Technology  Content of the system not negotiated with  Customised systems e.g., personalized vocabu-
stakeholders lary, iconic symbols, appropriate symbol labels,
 AAC did not meet users' needs dual language labeling, cultural adaptations
 Limited range of vocabulary and syntax available  Symbols chosen for frequently occurring and
 Concerns about the system being lost, slow to motivating activities
use, and requiring hard work  System enabled the user to say whatever he or
 Practical difficulties e.g., pen going through she wanted
paper, symbols falling off fridge  Generic AAC that could be used with a variety of
 Large systems (issues with portability & storage) students at different levels
 Lack of auditory feedback  Systems that were convenient, portable, user-
friendly, fast, & readily accessible
 Adequate preparation of resources
 Practical solutions e.g., symbols attached to belt
 Cost
Natural Environment & Human-Made Changes  Insufficient space for positioning system  Quiet environments that were homely, relaxed,
 Inappropriate placement of system and comfortable
 Room not arranged to facilitate communication  The presence of family members in the
 AAC system not with the user environment
 AAC stored in places the user could not see
or reach
 Geographic location (lack of services in small
communities, use AAC only in certain locations
e.g., home not hospital)
 School absenteeism
 Time (seeing the system for use at night)
 The presence of family members in the
environment

Table 7. Personal factors affecting the provision and use of unaided and low-tech AAC systems.
Category Barriers Facilitators
Attitude & Behaviour  Did not recognize need for AAC  User was willing, motivated, patient, confident,
 Preferred to use their limited speech or a differ- persistent, and hard-working
ent type of AAC  Person had high expectations for him or herself
 Easily frustrated and desired social interaction.
 ‘Bored’ with the system or not in the frame of
mind to use it
 Behaviours e.g., crying, inattentiveness, biting or
tossing the symbols, general
‘challenging behavior’
Age & Gender  Adults: gap in services, society less patient Nil identified
 Older children: have already developed means of
communication
 Young children: experiencing periods of
rapid change
 Boys
Socioeconomic Status  Families unable to afford purchase or personal- Nil identified
ization of AAC
 Unable to set up a suitable home environment
 Frequent movement between schools (inter-
rupted continuity of support)
Cultural Background  First language of the person with CCN different  Understand the individual child’s cul-
to the predominant language of the community tural background
 Children from ethnic minority groups (more diffi-
cult to access or accept AAC systems)
 Child’s language not represented in AAC systems
Current Health  Poor health and 'sickness' (reduced learning Nil identified
opportunities, reduced ability to communicate,
shift in parent prioritization of communication)
Current Abilities  Existing non-symbolic communication system  Person had impaired verbal communication skills
effective within family
 Communication without AAC
 Inadequate literacy
 Limited social skills
 Slow progress in learning the system or unable
to apply what had been learned
 Could not get the attention of the communica-
tion partner
 Unclear in their use of AAC
 SYSTEMATIC REVIEW OF THE BARRIERS AND FACILITATORS FOR LOW-TECH AND UNAIDED AAC SYSTEMS 15

acceptance of AAC. In turn, this stigma reportedly influenced the were overwhelmed by the demands of having a child with a dis-
behaviour of professionals. For example, support workers, SLPs, ability and had little time to implement AAC systems within their
and teachers wanted to promote integration into the community busy schedules [38,55,64,65]. For some parents, this resulted in
and were concerned that the use of AAC would draw attention to feelings of guilt and frustration: “It is very frustrating because I
a person’s disability [4,54,55]. Therefore, one support worker can see there is a huge potential but there just aren’t enough
reported limiting use of AAC in the community, as “it’s like put- hours in the day to be able to do it” [38]. However, other parents
ting labels on people when you come with these big books” [54]. reported that they facilitated the use of AAC by managing their
To overcome these barriers and continue using AAC, one parent time, streamlining their efforts, planning in advance, and making
reported ignoring negative societal attitudes, “‘cause I’m going to AAC a part of their everyday routine [64]. Furthermore, both
do what’s best for [my child] and I don’t care what they think parents and professionals agreed that family advocacy and owner-
around me” [55]. In addition, AAC use was reportedly facilitated ship of the intervention was important for the use of AAC systems
by living within inclusive community [46] and increased aware- across settings [38,40,46,54], with one parent noting that “there
ness about the use of AAC [55,62]. are not many kids I think like Nina who would have got where
she is if I hadn’t have been a pushy parent” [38].
Supports and relationships While not specifically stated in the ICF framework, a significant
As detailed in Table 4, the support of professionals both hindered hurdle to the use of AAC systems stemmed from inadequate col-
and supported the use of AAC systems. There were examples of laboration between different support people, including both
professionals across all groups who were inexperienced in sup- parents and professionals. As one parent reflected:
porting people with complex communication needs and who In the early years we had about 40 people involved with [Josh] from
lacked time to seek the necessary training [43,46,51,54,63]. physicians to school personnel and they wouldn’t talk to each other …
Therefore, AAC systems that required the communication partner There are lots of good skills around the table and lots of good problem
to have particular skills (e.g., understanding sign language, know- solving skills, but because of professional ideology and people not
knowing how to work together, the whole process is diminished.” [46]
ledge of idiosyncratic movements, or using auditory scanning)
were not able to be used without a trained communication part- Some SLPs and teachers also recognized the importance of
ner present [45,48,56]. For example, one parent noted that she collaboration, particularly between themselves and the parents of
always had her child’s communication book at hospital “but staff AAC users [49,51,60]. Where collaboration did occur between dif-
are not always keen on using it … The book is hard for the ferent team members, and all parties had buy-in for the AAC sys-
nurses since they have to scan [speak] through the columns [for tem, positive outcomes were reported [46,49,51]. An additional
the child to choose] and they don’t know how to do that” [45]. type of collaboration that was reported to be beneficial was that
Similarly, SLPs noted that they were better able to support the between parents of different children with complex communica-
use of AAC systems once they had gained experience and know- tion needs. Parents described the usefulness of speaking with
ledge in supporting people with complex communication needs other parents who had implemented AAC systems [39] and
[51]. However, even with the appropriate training, some SLPs and reported providing encouragement to others to persevere: “I’m
nurses reported that they lacked time for the implementation of like, ’I know it’s a pain; I’ll even come and help you take the pho-
communication systems [36,57]. For example, one SLP reflected: tos! Like, it’s such a pain but, trust me, you gotta keep
You sit down sometimes and think … you’ve got this client, you could going” [55].
do, but when you have to prioritise … your day-to-day and, yeah, you
just … [do] the essential … but I’m not actually sort of going out Services, systems, and policies
there and seeing it be implemented and, and then training and Services, systems, and policies that influenced the provision and
enhancing that and all of those sort of little things that I think really
use of AAC systems were aligned with six chapters of the ICF (see
need to get done for it to be done properly. [57].
Table 5). Regarding the production of AAC systems, common bar-
Parents and AAC users also noted the limited time of profes- riers reported by both parents and professionals were the lack of
sionals as a barrier to AAC use, particularly within the hospital set- availability of the required resources (e.g., software, colour printer,
ting [36,45]. Nurses did however report supporting laminator) and the labour-intensive nature of making a low-tech
communication by making communication boards, positioning system [51,57,62,65,66]. SLPs reported that the production of AAC
children so they could use their AAC system, and asking family systems often occurred in unpaid time, with one noting that it
members for help when required [56]. Both nurses and parents had become a family affair: “I do the programming, my husband
also considered familiarity and rapport between the care team and my son or daughter do the cutting, my mother, who’s 83,
and AAC user as beneficial. As one parent explained, “it [commu- does the laminating (laughs), and my husband or one of my chil-
nication] is better when they have a team that is regular and the dren do the other cutting” [57]. Therefore, both health professio-
same. It only works when the issue is an ongoing and that team nals and teachers noted that additional funding for disability
is the same and they do get to know [the child’s communication] support workers to assist with the production of AAC systems
and they communicate a lot better” [45]. would be of benefit [55]. Production of AAC systems was also
AAC use was also influenced by the support of family mem- reported to be “supported by the availability of equipment and
bers, particularly the parents of a person with complex communi- resources such as Picture Communication Symbols (PCS) in
cation needs. Professionals reported challenges resulting from Boardmaker software, laminators, email” and “appropriate space
parents who did not take the child’s AAC system with them for making communication resources” [51].
between locations, such as between home and school or the hos- Within associations and organizations, factors such as wait lists,
pital [49,56]. Furthermore, one teacher reported frustrations with prioritization systems, and service access rules influenced the pro-
a family who had misused a communication resource: “We sent it vision and use of AAC systems [38,49,51,61]. For example, some
home with her, and you would not believe what happened  they SLPs were required to provide a time-limited service, however
let her scribble on the pages! So of course I will not send it home reported that “it’s really, really challenging to teach a family
with her again” [60]. However, several parents reported that they within 12 months … how to generate an aided language display
16 A. MOORCROFT ET AL.

from scratch, very, very challenging” [57]. The consultative model Education, Health, and Child and Youth Services) which affected
of service delivery was also considered problematic by some SLPs the provision of AAC systems: “The silos across ministries need to
[49,51], as under this model “kids are abandoning technology be torn down and they actually need to talk the same language
because there’s not enough teaching” [49], and therefore services and talk to each other and share funding or principles” [49].
“need more money for direct therapy instead of just consulting” Finally, with regard to policies within the media, teachers in
[49]. Furthermore, SLPs reported that access to a multidisciplinary one study reported that AAC use may be facilitated if sign lan-
team, the intensity of services, the size of their caseload, and the guage is incorporated in mainstream television: "The television
presence or absence of follow-up procedures was also of influ- programme gives awareness, if [used] maybe nationally the
ence [49,51,55]. acceptance will be more" [4].
Educational services, systems, and policies for both children
and adults also affected the use of AAC systems. In schools, AAC Products and technology
use with each student was reportedly affected by the size of his An additional environmental factor that affected the use of AAC
or her class and the needs and abilities of the other children in systems was features of the systems themselves (see Table 6). For
the class [51,60,67]. SLPs and teachers reported that for teachers example, parents and people with complex communication needs
to use AAC systems with students they required a supportive noted barriers to the use of AAC stemming from limitations in the
team of professionals, including teachers’ aides [53,68]. However, language and syntax available within the system [42,70]. SLPs
parents reported that funding for teacher aide time was limited agreed that unless this content had been adequately negotiated
[55] and teachers from two studies commented on the insufficient by themselves, parents, and teachers, AAC systems could “end up
availability of SLPs within the school setting [49,68]. As one sitting on the shelf” [51]. Conversely, the use of AAC systems was
teacher explained, “we cannot work alone. Schools do have inter- supported when the vocabulary was adequately personalized
vention team [sic], but it cannot function without the support of (including cultural adaptations and dual-language labelling) and
other professionals” [68]. Where additional supports were avail- the system enabled the user to say whatever he or she wanted
able, SLPs reported that further barriers arose when teachers [62,65,67]. Furthermore, people with complex communication
could not be released from class to allow collaboration [53]. SLPs needs, parents, support workers, and teachers commented on
also considered the provision of information to teachers import- issues regarding the practicality of AAC systems that interfered
ant, both when students joined a class and progressed between with their use [41,54,59,67]. As one support worked noted, fea-
grades: “Often I’ll go into the class the next year and the teacher tures such as the size, portability, accessibility, and convenience
hasn't got the program. It’s like starting from scratch again” [51]. of use of the system were of influence:
With regards to adult education, SLPs, nurses, and teachers all You don’t want to be out with a big folder, sticking things on. Little
identified limited training as a barrier to their use of AAC systems cards are very suitable because the person can have them in their
[50–52,68]. Given both SLPs and teachers received little pre- wallet and because they’re always there you’ve got them with you. The
service training in the support of children with complex commu- little cards are excellent because they’re convenient. And if you keep
nication needs, working together was reportedly “like the blind them in that place they get used a lot more than other things I’d say.
[54, p. 899]
leading the blind” [51]. Professionals reported that access to
appropriate training in a variety of modalities would assist them- Additional practical barriers experienced by parents and AAC
selves and others to use AAC systems [45,46,51,54,55,60]. For users included the pen going through paper when writing, pens
example, one teacher commented: “I guess I would like to know not working while the user was lying down, and symbols falling
what there is to help the kids. High or low-tech, I don’t even off the fridge and getting lost [36,41,61]. AAC users also reported
know what to ask for” [66]. preferences for certain AAC systems based on the speed with
Within the health system, AAC use was influenced by factors which they could use the system [36,67]. However, parents, SLPs,
such as the availability of AAC systems, the available time of the and teachers noted that some practical difficulties could be over-
nurse, and the continuity of nurses allocated to a patient come by ensuring the adequate preparation, storage, and accessi-
[48,56,69]. SLPs reported that the length of admission also bility of AAC systems: “You have to make sure that you’ve got a
affected the provision of AAC systems, as “we wouldn’t have time good supply of your visuals and that they’re readily available –
to devise a system to explain something when maybe we’d see [otherwise] you’ve missed that opportunity” [55].
them once or twice and then they’ll be going home” [56]. To pro-
mote the use of AAC systems, nurses reported that they must Natural environment and human-made changes
work within a supportive, multidisciplinary team, as “if the staff Finally, features of the physical environment were reported as bar-
work then the client will work because we’re the ones supporting riers and facilitators to the use of AAC systems (see Table 6).
them” [48]. Within schools, communication was reportedly limited by class-
Political barriers to the provision of AAC were discussed exten- rooms that were not arranged to facilitate interaction [68]. As one
sively in a Canadian study [49]. SLPs and occupational therapists teacher reflected, “the classrooms are small and often over-
reported that government guidelines for the prescription of AAC crowded. How can they interact [sic]? It is sad” [68]. In hospitals,
were “opaque and vague to know what to do” [49], and therefore the barriers to AAC use reported included limited space to pos-
“it’s hard to predict … what things get approved and don’t get ition the AAC system [56], noise within the environment [48], and
approved” [49]. Consequently, the clinicians suggested “a more inadequate light for use of the system at night [36]. Nurses noted
structured, systematic and accountable prescription review proc- that an optimal communication environment would be one that
ess” may be beneficial [49]. In addition, the clinicians discussed is “homely and promotes the dignity of each individual” [48].
policy limitations and problematic gaps in services, including Furthermore, people with complex communication needs,
funding systems for use in the multiple environments, accessing parents, and support workers reported that the physical location
support for young adults, and having new AAC systems approved within which communication occurred (e.g., home versus the
for funding. They also noted a lack of collaboration in policy community) influenced their choice of AAC system, or decision to
development between different government departments (e.g. not use AAC at all [44,54,59,67]. Similarly, SLPs and teachers
 SYSTEMATIC REVIEW OF THE BARRIERS AND FACILITATORS FOR LOW-TECH AND UNAIDED AAC SYSTEMS 17

reflected that some children with complex communication needs between professionals and the child and his or her family was
appeared to use different modes of communication between challenged when their first language was different to the predom-
school and home [49,60,66], and nurses expressed their frustra- inant language of the community [46,49,51,60]. As a SLP reflected,
tions that AAC systems were not always brought to hospitals [69]. “language barriers can be difficult because it’s hard for teachers
Consequently, “one ward nurse said it was ‘such a relief’ when to find out if the things they are doing at school carry over to the
patients did retrieve their own AAC board from home after a few home settings” [51]. Further challenges to AAC use were evident
days in hospital”, as this enabled communication between nurse when the child’s language was not adequately represented in
and patient [69]. However, even when an AAC system was present existing communication systems [62]. Therefore, some teachers
in the environment, people with complex communication needs, suggested dual language labelling of symbol-based systems, and
parents, and professionals noted instances wherein the system others had developed their own sign language which they “had
was not visible to, or within reach of the user and therefore could to adapt because the American Sign Language or the Bliss sym-
not be used [36,55,59,65]. bols do not have any words [in vernacular language] like dosa
and idly [types of food] and amma [mother] or appa [father]” [62].
When language differences did occur, SLPs and teachers reported
Personal factors
that it was important for them to work together and with families
While specific personal factors are not detailed within the ICF, a to understand the child’s cultural background and develop cultur-
variety of different results emerged from the data as personal fac- ally specific communication symbols [51,62].
tors which may influence the provision and use of AAC systems In some cases, SLPs related a family’s cultural background with
(see Table 7). Firstly, the attitude, personality and behaviour of their low socioeconomic status, reporting that immigrant families
the person with complex communication needs influenced their “tend to be poorer, more socially isolated and generally more vul-
use of AAC. For example, parents reported that they did not use nerable to experiencing stress”, therefore making it more difficult
AAC because their child had become bored with, or unmotivated for them to access or accept AAC systems [49]. However, even
to use the system [38,64]. Similarly, parents and teachers both when independent of culture, the socioeconomic background of
reported ceasing to use AAC when the child exhibited challenging families was reported as a barrier to children receiving AAC sys-
behaviours in response to the system [60,71]. As one parent tems. SLPs reported that some families were unable to afford to
reflected, “we try things. If he likes it or is willing to accept it, purchase or personalize a communication system for their child
then we try. If he cries or refuses, then we rather let it be” [71]. [49,51], and teachers from one study noted difficulties introducing
Some adults with complex communication needs also com- AAC systems to children who were homeless as they frequently
mented that they preferred to use their limited speech over AAC, changed schools [66]. Additionally, some parents discussed the
as they felt it was “important to try to say the words without indirect effects of the affordability of housing on their use of AAC
employing communication strategies” [42], or did not see the systems: “I still think he may use it more if we had a more suit-
need for an AAC system [42,47]. However, people with complex able home environment and we were more geared up. That is my
communication needs, parents, teachers, and SLPs reported that project for this year” [38].
the use of AAC systems was facilitated by communicators who Furthermore, for some people with complex communication
were motivated, hard-working, confident, flexible, and patient, needs, poor health and sickness beyond that of their primary
and held high expectations for themselves [39,46,49,50]. For health condition resulted in the limited use of their AAC system.
example, when discussing how a child’s personality affected their People with complex communication needs reported that they
communication, one parent reported that their daughter was very were less able to communicate when sick and therefore took a
persistent in her use of AAC: “She never gives up easily so if peo- more passive role in interactions: “Mum sometimes tells them to
ple don’t understand her straight away she will keep making the ask me instead, and other times just answers. It depends on how
same gestures” [39]. sick I am” [45]. In addition, SLPs and occupational therapists com-
While not discussed extensively in the literature, the age and mented that when children were sick, their parents’ priorities
gender of the person with complex communication needs was shifted beyond communication: “There’s the potential for parents
also noted to influence their ability to access and use AAC sys- to be more concerned about their child’s survival. They consider
tems. Some SLPs commented that children who were older when physical functioning before speech” [49].
AAC was introduced were less likely to use the system, as often The final personal factor identified within the literature as a
they had already developed a means of communication with their barrier and facilitator to the use of AAC systems was the current
family [49]. Furthermore, both SLPs and parents noted a gap in abilities of the person with complex communication needs. For
services for young adults, with one parent noting that “when example, parents and SLPs reported that AAC systems were not
they’re younger there’s a lot of services and then as they get utilized when the person had an existing nonsysmbolic communi-
older it just drops off” [46]. In addition, a parent of a young adult cation system that was effective within his or her family
with complex communication needs reported that negative soci- [49,59,65]. As one parent reflected, her child had “both [photos
etal attitudes become a larger barrier for adult users of AAC, as and line drawings] like a book with pictures of his toys and stuff
“when you’re a cute disabled kid, the world stops and listens but he doesn’t really use it … if he wants something … he’ll
more” but “as you become an adult, they’re not as patient” [46]. grab you if he can’t reach it, otherwise he just does it himself”
Across all studies, gender was only mentioned by a single partici- [59]. Furthermore, AAC users and an occupational therapist
pant as an influencing factor in AAC use or abandonment. While reported that inadequate literacy prevented users from generating
it is unclear from the results of this study which gender the par- messages that could be understood by others [36,49]. Slow pro-
ticipant was referring to as a barrier, the original authors referred gress of the person with complex communication needs in learn-
to a higher rate of unmet need amongst boys [49]. ing the system was reported by SLPs and teachers as an
The cultural and linguistic background of a family was also additional barrier to ongoing use [51,52]. Finally, SLPs commented
noted to impact upon their use of AAC systems. For example, on the importance of social skills, as “no matter what they get if
SLPs, teachers, and family members reported that communication they don’t have the social communication skills in place they are
18 A. MOORCROFT ET AL.

unable to use whatever they are given, whether it’s low or high- involved. Therefore, it is concerning that even some professionals,
tech” [49]. including SLPs [41,46,52] and teachers [51] held misconceptions
about the use of AAC, did not understand why it would be used,
and believed that it was not part of their role. For those professio-
Discussion
nals who were interested but inexperienced in supporting the use
This study aimed to provide a synthesis of the barriers and facili- of AAC systems, many lacked time to seek the necessary training
tators to the provision and use of low-tech and unaided AAC sys- [43,46,51,54,63]. However, as SLPs gain knowledge and experience
tems from the perspective of people with complex in AAC, they are better able to support the introduction of these
communication needs, their families, and the professionals systems [51]. As a result, a variety of studies from different coun-
involved. By analyzing the existing literature with reference to the tries have recommended that SLP students receive additional the-
ICF [1], the results capture body functions, environmental factors, oretical and practical experiences in AAC throughout their
and personal factors of influence in a manner that is accessible training [12,78–81]. It stands to reason that student nurses and
for clinicians to interpret and apply to their practice [30,31]. teachers may also benefit from some degree of training and prac-
The current review identified factors relating to people with tical experience with people who use AAC.
complex communication needs themselves that may impact upon As well as increasing their knowledge about AAC systems, uni-
their use of low-tech or unaided AAC systems. Interestingly, such versity student exposure to people with complex communication
factors were not identified by Baxter et al. [12] when reviewing needs may also influence their attitudes and behaviour with
barriers to the use of high-tech systems. While personal factors regards to people with a disability [82]. McCarthy and Light [83]
such as a person’s age, health, cultural background, and socioeco- reviewed 13 studies of attitudes towards people who use AAC
nomic status are important for clinicians to understand and and noted that individuals who had previous experience with
acknowledge, by their nature they cannot often be changed. people with disabilities reported more positive attitudes than
However, to accommodate for the additional barriers that these those with no prior experience. This difference is related to the
factors may present, clinicians may need to modify the format of intergroup contact hypothesis [84] and experiential learning the-
their intervention [72,73] and collaborate with a broader team of ory [85], which postulate that positive contact with a person from
professionals including translators, psychologists, social workers, a given group can improve consciousness of one’s implicit atti-
and medical physicians. For example, Snell-Johns et al. [73] sug- tudes and shape unconscious behavior [82]. For example, follow-
gest that when supporting underserved families, successful inter- ing contact with an adult with Down syndrome over an eight-
vention may be facilitated by: providing home-based services or week period, a cohort of physiotherapy students demonstrated
offering transportation; using video-recorded, self-paced pro- positive changes in their attitude towards disability, self-ratings of
grams; or delivering services through a multiple-family group for- professional behaviours, and confidence in working with people
mat. Where a person’s impaired body functions prevent them with a disability [86]. Likewise, SLP students who attended lec-
from using AAC or are prioritized over communication, it may be tures that were taught by people with complex communication
of benefit for SLPs to work with physiotherapists and occupational needs reported that these lectures prompted them to confront
therapists to address these limitations before, or in parallel, with and analyze their own attitudes to disability [87]. Therefore, facili-
introducing an AAC system [74]. tating direct personal experiences with people who use AAC sys-
While factors relating to the person with complex communica- tems would likely be of benefit for students who may in future
tion needs are inherent to their outcomes with AAC, environmen- be involved in the introduction of AAC.
tal factors related to their family and the professionals involved in When SLPs do come to prescribing an AAC system for a per-
their care were of greater prominence in the literature and are son with complex communication needs, there are barriers spe-
likely more amenable to change. Barriers related to immediate cific to AAC systems themselves that warrant consideration. This
family members, most often their attitudes or the support they finding in the current systematic review is consistent with that by
provided, were noted in both the current review and Baxter et al. Baxter et al. [12] and Crisp et al. [14], indicating that limitations
[12] to limit the use of AAC systems. For example, parents report- occur with both high and low-tech AAC systems. The graphic and
edly denied the need for AAC for their child, and therefore linguistic content of AAC systems is highly debated, and no one
rejected systems when they were introduced [40,49,58,59]. This system is appropriate for all people with complex communication
denial is consistent with existing literature by Fernandez-Alcantara needs [88–91]. In addition, there may be a role for functions such
et al. [75], in which parents of children with cerebral palsy as humour, entertainment, and artistic expression within AAC sys-
asserted that their child had no disabilities or only a minor disabil- tems [92]. Such features may contribute to a positive attitude
ity, despite their child’s functional level indicating otherwise. towards the system by the person with complex communication
Similarly, parents of children with ASD have been reported to needs [15].
deny their child’s disability, particularly soon after diagnosis [76]. Nevertheless, even with the appropriate training and attitudes,
Therefore, denial may extend beyond AAC specifically to the and the selection of a suitable AAC system, many professionals
child’s disability as a whole. In such circumstances, as well as pro- reported organizational barriers to the implementation of AAC.
viding education around the purpose and benefits of AAC, there For example, whilst the consultative model of service delivery is
may be a role for SLPs to provide psychoeducational support to becoming commonplace and has been shown to be beneficial for
promote family adaptation to their child’s disability before an supporting the receptive and expressive language development
AAC system is introduced [77]. Where this support falls beyond of school-aged children [93], SLPs reported that direct interven-
the SLPs’ scope of practice, it may be necessary for them to col- tion may be more appropriate during the introduction of AAC sys-
laborate with professionals such as psychologists, social workers, tems [49,51]. Additional organizational procedures such as strict
and counsellors. service access rules, the provision of low-intensity or time-limited
From the current review and that by Baxter et al. [12], it is services, and the absence of client follow-up were reported as
apparent that the onus of responsibility for the successful intro- barriers to the provision of AAC systems [49,51,55] which may be
duction of AAC systems falls primarily on the professionals alleviated by organizational change. However, as noted by
 SYSTEMATIC REVIEW OF THE BARRIERS AND FACILITATORS FOR LOW-TECH AND UNAIDED AAC SYSTEMS 19

Lindsay [49] when discussing political barriers to the use of AAC, Conclusions
organizational change is often limited by the funding that is avail-
This study suggests that there are numerous barriers and facilita-
able. In Australia, the model of funding is currently undergoing
tors to the provision and use of low-tech and unaided AAC sys-
significant changes with the introduction of the National
tems. These factors may contribute to the use or non-use of AAC
Disability Insurance Scheme (NDIS). Under this model, funding is
systems by people with complex communication needs. Although
provided to the individuals to purchase services, rather than dir-
the barriers and facilitators fell across the ICF domains of personal
ectly funding organizations. This is intended to enable people
factors, environmental factors, and body functions, it is the envir-
with disabilities and their families to have greater control over the
onmental factors that clinicians, services, and funding bodies have
supports they receive [94]. Therefore, at the current time it is
unclear what influence this model of funding will have on the the ability to address directly. By reducing the barriers and provid-
existing barriers and facilitators to the provision and use of ing additional supports, it is hoped that a greater proportion of
AAC systems. people with complex communication needs will have the oppor-
tunity to achieve autonomous communication.

Limitations and future directions

Disclosure statement
The authors acknowledge the presence of limitations within this
systematic review. Firstly, the risk of bias was increased by not No potential conflict of interest was reported by the authors.
publishing the research protocol for the study [26]. However, all
changes made to the research protocol were noted in the current Funding
article. Publication, location, and language biases may have been
This research was supported by an Australian Government
introduced during the search process, as the grey literature was
Research Training Program (RTP) Scholarship.
not considered, nor were studies published in languages other
than English. In addition, during screening only one author
screened articles at the title and abstract level. The research team ORCID
also noted limitations with the CASP quality appraisal tools, spe-
A. Moorcroft http://orcid.org/0000-0002-7213-6949
cifically the need for a dichotomous response (yes/no) rather than
a rating scale. However, this limitation did not lead to selection
bias as no articles were excluded on the basis of quality.
Furthermore, the review may have been limited by the extraction References
of data that did not explicitly refer to a low-tech or unaided AAC
system. This decision was made by the authors so as not to [1] World Health Organization. International classification of
exclude the broader issues (e.g., service delivery issues) that affect functioning, disability and health. Geneva, Switzerland:
the use of all types of AAC systems. World Health Organization; 2001.
Results may also have been skewed by integrating data from [2] Dykstra AD, Hakel ME, Adams SG. Application of the ICF in
all articles regardless of the country or year of publication. As reduced speech intelligibility in dysarthria. Semin Speech
Wormnaes and Malek [52] suggested, some barriers to AAC use Lang. 2007;28:301–311.
may be unique to developing countries due to sociocultural dif- [3] Raghavendra P, Virgo R, Olsson C, et al. Activity participa-
ferences in attitudes towards disability, professional responsibil- tion of children with complex communication needs, phys-
ities, and economic resources within these countries. Similarly, by ical disabilities and typically-developing peers. Dev
integrating data from articles published in 2000 to 2016, any dif- Neurorehabil. 2011;14:145–155.
ferences in attitude towards disability and AAC across this time- [4] Sheehy K, Budiyanto K. Teachers’ attitudes to signing for
frame were not represented in the analysis. For example, the only children with severe learning disabilities in Indonesia. Int J
professionals who reported avoiding the use of AAC because it Inclusive Educ. 2014;18:1143–1161.
would prevent speech development were SLPs from an Egyptian [5] Thirumanickam A, Raghavendra P, Olsson C. Participation
study conducted in 2004 [52]. Therefore, this attitudinal barrier and social networks of school-age children with complex
may not be applicable across countries or in the present day. communication needs: A descriptive study. Augment Altern
Finally, bias may have been introduced in response to the clin- Commun. 2011;27:195–204.
ical experiences of the first author, who is a novice researcher. [6] Beukelman DR, Mirenda P. Augmentative & alternative
Therefore, she was closely supervised and supported by the communication: Supporting children and adults with com-
second and third authors throughout all stages of the plex communication needs. 4th ed. Baltimore: Brookes Pub;
research project. 2013.
The existing literature as identified in this review has predom- [7] Clarke M, Price K, Griffiths T. Augmentative and alternative
inantly considered the views of people who have persisted with communication for children with cerebral palsy. Paediatr
AAC despite the barriers that they reported. However, people Child Health. 2012;22:367–371.
with complex communication needs, their families, and SLPs are [8] Porter G. Integrating AAC into programs applying the prin-
expected to have substantially different views following their ciples of conductive education. Conduct Educ News.
experiences of rejection and abandonment. Therefore, future 1997;12:2–8.
research is required to address this gap by purposefully exploring [9] Speech Pathology Australia. Augmentative and Alternative
the barriers and facilitators to the use of AAC systems from the Communication Clinical Guideline. Melbourne, Australia:
perspective of those who have experienced the rejection or aban- The Speech Pathology Association of Australia Limited;
donment of such systems. It is imperative to first fully understand 2012.
the rejection and abandonment of AAC systems before then [10] Costantino MA, Bonati M. A scoping review of interventions
developing strategies to reduce this phenomenon. to supplement spoken communication for children with
20 A. MOORCROFT ET AL.

limited speech or language skills. PLoS One. 2014 in public health to develop a taxonomy of operations of
2014;9:e90744. reciprocal translation. Res Syn Meth. 2015;6:357–371.
[11] Johnson JM, Inglebret E, Jones C, et al. Perspectives of [30] Light J, McNaughton D. Designing AAC research and inter-
speech language pathologists regarding success versus vention to improve outcomes for individuals with complex
abandonment of AAC. Augment Altern Commun. communication needs. Augment Altern Commun.
2006;22:85–99. 2015;31:85–96.
[12] Baxter S, Enderby P, Evans P, et al. Barriers and facilitators [31] Raghavendra P, Bornman J, Granlund M, et al. The World
to the use of high-technology augmentative and alterna- Health Organization's International Classification of
tive communication devices: a systematic review and quali- Functioning, Disability and Health: Implications for clinical
tative synthesis. Int J Lang Commun Disord. and research practice in the field of augmentative and
2012;47:115–129. alternative communication. Augment Altern Commun
[13] Parette H, Brotherson M, Huer M. Giving families a voice in 2007;23:349–361.
augmentative and alternative communication decision- [32] Sandelowski M, Barroso J. Handbook for synthesizing quali-
making. Educ Train Ment Retard DevDisabil. tative research. New York: Springer Publishing Company;
2000;35:177–190. 2007.
[14] Crisp C, Draucker CB, Ellett MLC. Barriers and facilitators to [33] World Health Organization. Towards a common language
children's use of speech-generating devices: a descriptive for functioning, disability and health. Geneva, Switzerland:
qualitative study of mothers’ perspectives. J Spec Pediatr ICF; 2002.
Nurs. 2014;19:229–237. [34] American Speech-Language-Hearing Association.
[15] Clarke M, McConachie H, Price K, et al. Views of young International Classification of Functioning, Disability, and
people using augmentative and alternative communication Health (ICF) 2017 [cited 2017 Apr 26]. Available from:
systems. Int J Lang Commun Disord. 2001;36:107–115. http://www.asha.org/slp/icf/
[16] Armstrong L, Jans D, MacDonald A. Parkinson's disease and [35] Gale NK, Heath G, Cameron E, et al. Using the framework
aided AAC: Some evidence from practice. Int J Lang method for the analysis of qualitative data in multi-discip-
Commun Disord. 2000;35:377–389. linary health research. BMC Med Res Methodol.
[17] Schlosser RW. Appraising the Quality of Systematic 2013;13:117.
Reviews. FOCUS Technical Brief. 2007;17. Available from [36] Balandin S, Hemsley B, Sigafoos J, et al. Communicating
http://www.ncddr.org/kt/products/focus/focus7/ with nurses: The experiences of 10 individuals with an
[18] Butler A, Hall H, Copnell B. A guide to writing a qualitative acquired severe communication impairment. Brain
systematic review protocol to enhance evidence-based Impairment. 2001;2:109–118.
practice in nursing and health care. Worldviews on [37] San PH, Abdullah AC. The implementation of picture
Evidence-Based Nursing. 2016;13:241–249. exchange communication system: A mother's perspective
[19] Light J, McNaughton D. The changing face of augmentative of a young child with Pervasive Developmental Disorder.
and alternative communication: Past, present, and future Pertanika J Soc Sci Hum 2013;21:1543–1553.
challenges. Augment Altern Commun. 2012;28:197–204. [38] Goldbart J, Marshall J. ‘Pushes and pulls’ on the parents of
[20] Lindsay S. Child and youth experiences and perspectives of children who use AAC. Augment Altern Commun.
cerebral palsy: A qualitative systematic review. Child. Care 2004;20:194–208.
Health Dev. 2016;42:153. [39] Marshall J, Goldbart J. “Communication is everything I
[21] Schlosser RW, Balandin S, Hemsley B, et al. Facilitated com- think.” Parenting a child who needs Augmentative and
munication and authorship: a systematic review. Augment Alternative Communication (AAC). Int J Lang Commun
Altern Commun. 2014;30:359–368. Disord. 2008;43:77–98.
[22] Critical Appraisal Skills Programme. Critical Appraisal Skills [40] Hines M, Balandin S, Togher L. Communication and AAC in
Programme (CASP) qualitative research checklist. Oxford: the lives of adults with autism: The stories of their older
CASP; 2014. parents. Augment Altern Commun. 2011;27:256–266.
[23] Critical Appraisal Skills Programme. Critical Appraisal Skills [41] Murphy J. ‘I prefer contact this close’: perceptions of AAC
Programme (CASP) systematic review checklist. Oxford: by people with motor neurone disease and their communi-
CASP; 2017. cation partners. Augment Altern Commun. 2004;20:
[24] Hoffmann T, Bennett S, Del Mar C. Evidence-based practice 259–271.
across the health professions. 2nd ed. Chatswood, N.S.W.: [42] Johansson MB, Carlsson M, Sonnander K. Communication
Elsevier Australia; 2013. difficulties and the use of communication strategies: from
[25] Nye E, Melendez-Torres GJ, Bonell C. Origins, methods and the perspective of individuals with aphasia. Int J Lang
advances in qualitative meta-synthesis. Rev Educ. Commun Disord. 2012;47:144–155.
2016;4:57–79. [43] Balandin S, Hemsley B, Sigafoos J, et al. Communicating
[26] Schlosser RW, Wendt O, Sigafoos J. Not all systematic with nurses: the experiences of 10 adults with cerebral
reviews are created equal: Considerations for appraisal. palsy and complex communication needs. Appl Nurs Res.
EBCAI 2007;1:138–150. 2007;20:56–62.
[27] Saini M, Shlonsky A. Systematic synthesis of qualitative [44] Hemsley B, Balandin S. Without AAC: the stories of unpaid
research. New York: Oxford University Press; 2012. carers of adults with Cerebral Palsy and complex communi-
[28] Oliver SR, Rees RW, Clarke, -et al. A multidimensional con- cation needs in hospital. Augment Altern Commun.
ceptual framework for analysing public involvement in 2004;20:243–258.
health services research. Health Expect. 2008;11:72–84. [45] Hemsley B, Kuek M, Bastock K, et al. Parents and children
[29] Melendez-Torres GJ, Grant S, Bonell C. A systematic review with cerebral palsy discuss communication needs in hos-
and critical appraisal of qualitative metasynthetic practice pital. Dev Neurorehabil. 2013;16:363–374.
 SYSTEMATIC REVIEW OF THE BARRIERS AND FACILITATORS FOR LOW-TECH AND UNAIDED AAC SYSTEMS 21

[46] Lund SK, Light J. Long-term outcomes for individuals who [62] Srinivasan S, Mathew SN, Lloyd LL. Insights into communi-
use augmentative and alternative communication: Part III - cation intervention and AAC in South India: a mixed-meth-
contributing factors. Augment Altern Commun. ods study. Commun. Disord Q. 2011;32:232–246.
2007;23:323–335. [63] McKelvey M, Evans DL, Kawai N, et al. Communication
[47] Laakso K, Markstro €m A, Idvall M, et al. Communication styles of persons with ALS as recounted by surviving part-
experience of individuals treated with home mechanical ners. Augment Altern Commun. 2012;28:232–242.
ventilation. Int J Lang Commun Disord. 2011;46:686–699. [64] Calculator SN. Use of enhanced natural gestures to foster
[48] Martin AM, Connor-Fenelon MO, Lyons R. Non-verbal com- interactions between children with Angelman syndrome
munication between Registered Nurses Intellectual and their parents. Am J Speech Lang Pathol.
Disability and people with an intellectual disability: an 2002;11:340–355.
exploratory study of the nurse's experiences. Part 2. J [65] Jonsson A, Kristoffersson L, Ferm U, et al. The comalong
Intellect Disabil. 2012;16:97–108. communication boards: parents’ use and experiences of
[49] Lindsay S. Perceptions of health care workers aided language stimulation. Augment Altern Commun.
prescribing augmentative and alternative communication 2011;27:103–116.
devices to children. Disabil Rehabil Assist Technol. [66] Stoner JB, Parette HP, Watts EH, et al. Preschool Teacher
2010;5:209–222. Perceptions of Assistive Technology and Professional
[50] Oommen ER, McCarthy JW. Simultaneous natural speech Development Responses. Education and Training in
and AAC interventions for children with childhood apraxia Developmental Disabilities 2008;43:77–91.
of speech: lessons from a speech-language pathologist [67] Iacono T, Lyon K, Johnson H, et al. Experiences of adults
focus group. Augment Altern Commun. 2015;31:63–76. with complex communication needs receiving and using
[51] De Bortoli T, Arthur-Kelly M, Mathisen B, et al. Speech- low tech AAC: an Australian context. Disabil Rehabil Assist
language pathologists' perceptions of implementing com- Technol. 2013;8:392–401.
munication intervention with students with multiple and [68] Mukhopadhyay S, Nwaogu P. Barriers to teaching non-
severe disabilities. Augment Altern Commun. speaking learners with intellectual disabilities and their
impact on the provision of augmentative and alternative
2014;30:55–70.
communication. International Journal of Disability,
[52] Wormnaes S, Malek YA. Egyptian speech therapists want
Development and Education. 2009;56:349–362.
more knowledge about augmentative and alternative com-
[69] Hemsley B, Balandin S, Worrall L. Nursing the patient with
munication. Augment Altern Commun. 2004;20:30–41.
complex communication needs: time as a barrier and a
[53] Greenstock L, Wright J. Collaborative implementation:
facilitator to successful communication in hospital. J Adv
working together when using graphic symbols. Child Lang
Nurs. 2012;68:116–126.
Teach Ther. 2011;27:331–343.
[70] Borg S, Agius M, Agius L. A user and their family's perspec-
[54] Trembath D, Iacono T, Lyon K, et al. Augmentative and
tive of the use of a low-tech vs a high-tech AAC system.
alternative communication supports for adults with autism
Stud Health Technol Inform. 2015;217:811–818.
spectrum disorders. Autism 2014;18:891–902.
[71] Serpentine EC, Tarnai B, Drager KD, et al. Decision making
[55] Donato C, Shane HC, Hemsley B. Exploring the feasibility of
of parents of children with Autism Spectrum Disorder con-
the visual language in autism program for children in an
cerning augmentative and alternative communication in
early intervention group setting: views of parents, educa-
Hungary. Commun Disord Q. 2011;32:221–231.
tors, and health professionals. Dev Neurorehabil. 2014; [72] Kulkarni SS, Parmar J. Culturally and linguistically diverse
Apr17:115–124. student and family perspectives of AAC. Augment Altern
[56] Hemsley B, Lee S, Munro K, et al. Supporting communica- Commun. 2017;33:170–180.
tion for children with cerebral palsy in hospital: views of [73] Snell-Johns J, Mendez JL, Smith BH. Evidence-based solu-
community and hospital staff. Dev Neurorehabil. tions for overcoming access barriers, decreasing attrition,
2014;17:156–166. and promoting change with underserved families. J Fam
[57] Iacono T, Cameron M. Australian speech-language patholo- Psychol. 2004;18:19–35.
gists' perceptions and experiences of augmentative and [74] Binger C, Ball L, Dietz A, et al. Personnel roles in the AAC
alternative communication in early childhood intervention. assessment process. Augment Altern Commun.
Augment Altern Commun. 2009;25:236–249. 2012;28:278–288.
[58] Binger C, Kent-Walsh J, Berens J, et al. Teaching Latino [75] Fernandez-Alcantara M, Garcıa-Caro MP, Laynez-Rubio C,
parents to support the multi-symbol message productions et al. Feelings of loss in parents of children with infantile
of their children who require AAC. Augment Altern cerebral palsy. Disability and Health Journal. 2015;8:93–101.
Commun. 2008;24:323–338. [76] Fernan dez-Alcantara M, Garcıa-Caro MP, Perez-Marfil MN,
[59] Stephenson J, Dowrick M. Parents' perspectives on the et al. Feelings of loss and grief in parents of children diag-
communication skills of their children with severe disabil- nosed with autism spectrum disorder (ASD) [Article]. Res
ities. J Intellect Dev Disabil. 2005;30:75–85. Dev Disabil. 2016;55:312–321.
[60] Pickl G. Communication intervention in children with [77] Higginson J, Matthewson M. Working therapeutically with
severe disabilities and multilingual backgrounds: percep- parents after the diagnosis of a child's cerebral palsy: issues
tions of pedagogues and parents. Augment Altern and practice guidelines. Australian Journal of Rehabilitation
Commun. 2011;27:229–244. Counselling. 2014;20:50–66.
[61] Brady N, Skinner D, Roberts J, et al. Communication in [78] Costigan FA, Light J. A review of preservice training in aug-
young children with fragile X syndrome: a qualitative study mentative and alternative communication for speech-lan-
of mothers' perspectives. Am J Speech Lang Pathol. guage pathologists, special education teachers, and
2006;15:353–364. occupational therapists. Assist Technol. 2010;22:200–212.
22 A. MOORCROFT ET AL.

[79] Dietz A, Quach W, Lund SK, et al. AAC assessment and clin- language organizations. J Speech Lang Hear Res. 2003;46:
ical-decision making: the impact of experience [Article]. 298–312.
Augment Altern Commun. 2012;28:148–159. [90] Trembath D, Balandin S, Togher L. Vocabulary selection for
[80] Marvin L, Montano J, Fusco L, et al. Speech-language path- Australian children who use augmentative and alternative
ologists’ perceptions of their training and experience in communication. J Intellect Dev Disabil. 2007;32:291–301.
using alternative and augmentative communication. [91] Worah S, McNaughton D, Light J, et al. A comparison of
Contemporary Issues in Communication Science and two approaches for representing AAC vocabulary for young
Disorders 2003;30:76–83. children. Int J Speech Lang Pathol. 2015;17:460–469.
[81] Ratcliff A, Koul R, Lloyd LL. Preparation in augmentative [92] Light J, Page R, Curran J, et al. Children's ideas for the
and alternative communication: an update for speech-lan- design of AAC assistive technologies for young children
guage pathology training. Am J Speech Lang Pathol. with complex communication needs. Augment Altern
2008;17:48–59. Commun. 2007;23:274–287.
[82] Galli G, Pazzaglia M. Novel perspectives on health profes- [93] Mecrow C, Beckwith J, Klee T. An exploratory trial of the
sionals’ attitudes to disability. Med Educ. 2016;50:804–806. effectiveness of an enhanced consultative approach to
[83] McCarthy J, Light J. Attitudes toward individuals who use delivering speech and language intervention in schools. Int
J Lang Commun Disord. 2010;45:354–367.
augmentative and alternative communication: research
[94] Reddihough DS, Meehan E, Stott NS, et al. The National
review. Augment Altern Commun. 2005;21:41–55.
Disability Insurance Scheme: a time for real change in
[84] Hewstone M, Swart H. Fifty-odd years of inter-group con-
Australia. Dev Med Child Neurol. 2016;58:66–70.
tact: from hypothesis to integrated theory. Br J Soc
[95] Bruce SM, Trief E, Cascella PW. Teachers’ and speech-lan-
Psychol. 2011;50:374–386.
guage pathologists’ perceptions about a tangible symbols
[85] Maudsley G, Strivens J. Promoting professional knowledge,
intervention: efficacy, generalization, and recommenda-
experiential learning and critical thinking for medical stu-
tions. Augment Altern Commun. 2011;27:172–182.
dents. Med Educ. 2000; Jul34:535–544. [96] Chung YC, Stoner JB. A meta-synthesis of team members’
[86] Shields N, Taylor NF. Contact with young adults with dis- voices: what we need and what we do to support students
ability led to a positive change in attitudes toward disabil- who use AAC. Augment Altern Commun. 2016;32:175–186.
ity among physiotherapy students. Physiother Can. doi: 10.1080/07434618.2016.1213766.
2014;66:298–305. [97] Finke EH, Light J, Kitko L. A systematic review of the effect-
[87] Balandin S, Hines M. The involvement of people with life- iveness of nurse communication with patients with com-
long disability and communication impairment in lecturing plex communication needs with a focus on the use of
to speech-language pathology students. Int J Speech Lang augmentative and alternative communication. J Clin Nurs.
Pathol. 2011;13:436–445. 2008;17:2102–2115.
[88] Brewster S. Saying the ‘F word in the nicest possible way’: [98] Patel R, Khamis-Dakwar R. An AAC training program for spe-
augmentative communication and discourses of disability. cial education teachers: a case study of Palestinian Arab
Disability & Society. 2013;28:125–128. teachers in Israel. Augment Altern Commun. 2005;21:205–217.
[89] Drager K, Light J, Fallon K, et al. The performance of [99] Smith MM, Connolly I. Roles of aided communication: per-
typically developing 2 1/2-year-olds on dynamic display spectives of adults who use AAC. Disabil Rehabil Assist
AAC technologies with different system layouts and Technol. 2008;3:260–273.