INT J LANG COMMUN DISORD, XXXX–XXXX 2011,
VOL. 00, NO. 00, 1–15
Review
Barriers and facilitators to the use of high-technology augmentative and
alternative communication devices: a systematic review and qualitative
synthesis
Susan Baxter†, Pam Enderby†,‡, Philippa Evans† and Simon Judge§
†School of Health and Related Research, University of Sheffield, Sheffield, UK
‡Institute of General Practice and Primary Care, Northern General Hospital, Sheffield, UK
§Barnsley District General Hospital Foundation Trust, Barnsley, UK
(Received February 2011; accepted August 2011)
Abstract
Background: There has been a rapid growth in recent years of available technologies for individuals with communi-
cation difficulties. Research in the area is currently underdeveloped with practitioners having a limited body of
work on which to draw to guide the process of intervention. Concerns have been raised that this newly developed
technology may have limited functional usage.
Aims: This review aims to investigate the potential barriers and facilitators to high-technology AAC provision and
its ongoing use. The aim of the analysis is to explore factors underpinning use rather than effectiveness, thus it
synthesized data from predominantly qualitative and survey studies reporting the views and perceptions of AAC
users or staff providing the devices.
Main Contribution: The review highlights the range of factors that can impact on provision and use of high-
technology AAC, which practitioners should consider and address as appropriate in the intervention process.
These include: ease of use of the device; reliability; availability of technical support; voice/language of the device;
decision-making process; time taken to generate a message; family perceptions and support; communication
partner responses; service provision; and knowledge and skills of staff. The work outlines how qualitative synthesis
review methods may be applied to the consideration of published material that is not reporting outcomes data,
and how this may provide valuable information to inform future studies.
Conclusions: Practitioners should be aware of barriers and facilitators to successful use when making recommen-
dations, and consider how barriers where present might be overcome. Aspects of service delivery such as ongoing
technical support and staff training may require further consideration. The synthesis of evidence describing views
of users and providers, and the implementation of high-technology AAC systems, can provide valuable data to
inform intervention studies and functional outcome measures.
Keywords: augmentative and alternative communication, systematic review, assistive technology.
Introduction
People of all ages with severe communication
impairments may be able to benefit from using
augmentative and alternative communication (AAC)
methods including signing, use of symbols and voice
output devices. The range of technology to enable
communication is increasing rapidly and can now assist
a broader range of individuals with diverse communica-
tion challenges. However, without support people with
communication difficulties cannot exploit the potential
that these technologies bring. This is a challenge to
speech and language therapists as these technologies
Address correspondence to: Susan Baxter, School of Health and Related Research, Regent Court, 30 Regent Street, Sheffield S14DA, UK;
email: S.K.Baxter@sheffield.ac.uk
should be integrated into general speech and language
therapy (SLT) services beyond that of specialist AAC
provision.
The United Nations Convention on the Rights of
Persons with Disability (United Nations 2006) refers
to the right of disabled people to have access to their
chosen form of communication including AAC (Article
21 Freedom of expression and opinion, and access to
information). The convention is due to be made law
in the UK, which should support the rollout of a more
integrated approach to provision of assistive technol-
ogy in general services. Funding for AAC remains
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online c© 2011 Royal College of Speech & Language Therapists
DOI: 10.1111/j.1460-6984.2011.00090.x

2 Susan Baxter et al.
problematic inmost developed countries, evenwhere the
provision of funding to support wheelchairs is explicit
and causes no barrier to access. The result is a postcode
lottery in the provision of these crucial AAC services.
Estimates suggest 365000 people in the UK may need
AAC (Blackstone 1990), but there is no definitive
research assessing actual need. There is therefore a
requirement for evidence to support managers of SLT
services and speech and language therapists themselves
in clarifying best practice when extending their service
to cover the provision of AAC.
AAC strategies and devices have great potential
to improve the lives of individuals with communica-
tion difficulties by promoting independence, facilitating
the development of social relationships and enhancing
educational opportunities (Johnston et al. 2004). While
there has been a rapid growth in the available options
and technologies in recent years, it has been reported that
practitioners face challenges in successfully implement-
ing AAC. Authors have highlighted that there is a
paucity of research evidence to underpin recommen-
dations (Campbell et al. 2002, Schlosser 2003); and
that users may have limited access to available systems
or services (McNaughton and Bryan 2007, National
Joint Committee for the Communication Needs of
Persons with Severe Disabilities 2002, Kent-Walsh
2008). Concerns have also been raised that devices
may have limited functional usage, with Jacobs (2004),
for example, reporting that gains in communication
typically were not generalized to everyday settings.
AAC can involve adding to (augmenting) natural
speech or writing, or can be utilized as an alterna-
tive to spoken communication or writing. It includes
unaided modes that rely on a user’s body to convey
messages, e.g. gestures, signs and facial expressions.
Also, it includes aided communication modes that
require additional materials or devices. Within the
category of aided AAC there is a commonly used
further subdivision of powered high- versus low-
technology-aided options. Low-technology systems or
devices encompass communication books or boards
(non-powered), written words on paper, photographs,
line drawings and pictograms. High-technology systems
include voice output communication aids (VOCAs),
which are termed ‘speech-generating devices’ in North
America; and software on personal computers or laptops
used as a communication aid (providing recorded or
synthesized voice or written output). In addition, it
encompasses technology providing access to personal
computers or laptops enabling them to be used as a
communication aid.
Reviews regarding the effectiveness of AAC have
tended to consider predominantly low-technology aids,
with evidence suggesting positive outcomes from use of
the Picture Exchange Communication System (Bondy
and Frost 1998) in particular. Systematic reviews
including high-technology aids (e.g. Schlosser and
Blischak 2001, Schlosser and Wendt 2008, Sigafoos
et al. 2009, Lancioni et al. 2001, Binger and Light
2008) suggest that these devices can be beneficial for
some specific conditions, although highlight that much
available evidence is inconclusive. Authors emphasize
the considerable individual variation in outcomes
following intervention, and the weak evidence regarding
generalization and maintenance of usage (Schlosser
and Lee 2000). In addition, Mirenda et al. (2001)
highlighted that research is needed to investigate
whether high-technology aids offer advantages over less
expensive options.
Objectives
While high-technology AAC technology is a rapidly
growing field, the evidence underpinning intervention
is currently underdeveloped, with diversity in reported
outcomes suggesting a need to explore individual
differences further. If practitioners and potential users
are to make informed recommendations and choices,
having knowledge regarding the process of implemen-
tation and ongoing usage of available technology is
essential. This review was therefore undertaken in order
to investigate the potential barriers and facilitators to
high-technology AAC provision and its ongoing use. As
the aim of the analysis was to explore implementation
factors rather than effectiveness, the review examined
and synthesized data from studies reporting the views
and perceptions of AAC users or staff providing the
devices. These findings were in the form of qualitative
data.
There is growing recognition of the value of
extending systematic review methods to include
evidence from sources other than experimental studies
(Garrett and Thomas 2006). Methods of meta-synthesis
and thematic synthesis are being developed to address
this need to consider wider evidence (Dixon-Woods
et al. 2001). In this article, the methodology that was
used to search for and identify relevant literature is
outlined, together with a description of the process of
data analysis. The second section presents a synthesis of
the results, followed by a discussion of the method, and
implications for service delivery and research.
Methods
Identification of studies
The research question for the review was: What factors
during the process of intervention present barriers;
facilitate uptake or contribute to successful outcomes?
The relevant published literature was identified via

AAC barriers and facilitators review 3
De-duplicated retrieved
citations = 2883
Full paper screened = 299
Rejected at title/abstract level = 2584
Rejected = 272 (discussion/literature review = 102,
language = 2, population = 20, not relevant = 22, low-
tech = 12, not peer reviewed = 4, therapy/intervention
only = 9, not views/perceptions = 101)
Included papers = 27
Unable to source = 3
+ Additional papers identified via reference lists = 3
Figure 1. Flow chart illustrating the inclusion and exclusion process.
searching of the Cinahl, Cochrane Library, Embase,
Medline, Psychinfo, CSA, andWeb of Science electronic
databases. Search terms used related firstly to conditions
(e.g. learning disability, cerebral palsy, Parkinson’s
disease), secondly impairment terms (such as language
disorder, communication impairment), together with
AAC terms (such as speech-generating device, assistive
aids) and in addition, commonly used devices (such
as Cannon Communicator, Minspeak, Touchtalker).
Searches were completed by the third author (an
information specialist) (see tables A1 and A2 in the
appendix for details of the search strategy). In addition
to this electronic database searching, the reference list
of included papers and review papers was scrutinized
for any additional citations of potential relevance and
added to the database.
Inclusion/exclusion criteria
The review considered studies carried out in populations
of people with communication difficulties (excluding
those with hearing loss as the primary condition),
published in peer-reviewed journals between 2000 and
June 2010 that were reported in English. As the review
aimed to be a ‘state-of-the-art’ review (Grant and Booth
2009), rather than a standard effectiveness review, there
were no restrictions in terms of study design or quality.
Papers of any study type that included data describing
uptake or implementation factors were considered.
The review encompassed ‘high-technology’
communication devices only. For the purpose of this
work high-technology devices were defined by exclusion
as those AAC methods or devices which are powered
and cannot be described as low-technology. Thus
signing, gesture, communication books, communica-
tion boards, alphabet boards, writing and drawing,
and pictures/symbols not used with a computer were
outside the remit. Papers that reported both high- and
low-technology were included, with the data relating to
high-technology only extracted. The use of computers
for a treatment tool/therapy only (rather than as an
assistive device) and technology which promotes access
to computers/switches to overcome physical disabilities
was also outside the scope of the review.
Selection of publications for review
Retrieved citations were downloaded to the Reference
Manager database. All the retrieved literature was
screened at title and abstract level for relevance, and
those that met the population and intervention criteria
(above) were taken through to full paper appraisal and
extraction of data. Sifting of the database was carried
out by the first author with inclusions and exclusions
checked by the second author. Figure 1 provides a
summary of the process of inclusion and exclusion,
indicating how papers of relevance to this review were
identified.
Approach to analysis and synthesis
Data of interest to this review related to perceptions of
barriers or facilitators that could potentially be reported
in a range of study designs. Data from the included
papers were extracted by the first author using an
extraction table, and checked by the second author.
The extraction table encompassed details of the authors,
study design, population, themes identified, limitations
identified by authors or reviewers, and any reported
evidence gaps. Following extraction, the data were
analysed using principles of thematic synthesis (Thomas
and Harden 2008) to establish recurring perceptions
across the included papers.
The inclusion of qualitative data in systematic
reviews is a relatively recent development, with
approaches such as meta-ethnography and thematic
synthesis devised to mirror the narrative synthesis and
meta-analysis of systematic reviews examining quantita-
tive data. The approach can include data not only from
qualitative studies, but also from other designs reporting
textual data such as surveys, record analysis, and case

4 Susan Baxter et al.
reports and intervention studies which describe factors
in the implementation process.
In this approach to analysis, the themes from the
included papers form the data to be considered, with
these were compared and contrasted in a process akin
to primary qualitative data analysis (Baxter et al. 2010).
The completed synthesis may simply highlight recurring
findings across the set, or where possible use the data
to create meta-themes which were not present in the
primary papers. For this review an initial charting
method was used to examine the themes identified in
the primary studies, with these listed and compared
(Mason 2002). This was then followed by linking and
categorization of similar ideas to create a synthesis of
themes and subthemes across the papers.
Findings
The searches identified 27 papers which reported AAC
users, families of users or staff perceptions regarding
barriers or facilitators to provision and successful
use of high-technology AAC devices. The publica-
tions reviewed were of descriptive rather than analyti-
cal designs, encompassing qualitative studies, surveys,
record analysis and case studies. Table 1 provides a
summary of the included studies. The largest number
(15) originated from North America, followed by six
from the UK, three from Australia, and one each
from Egypt, Ireland and Israel. The study participants
included thosewith cerebral palsy (nine papers werewith
users or parents of children with CP), multiple disabili-
ties (one paper), autistic spectrum disorder (one paper),
and aphasia following a cerebrovascular accident (two
papers). In addition to users, the papers encompassed
views from family (six papers) speech and language
therapists (four papers) and teachers (two papers). Two
papers included a variety of professionals and four papers
included both family and users.
Study quality
Due to the nature of the research question, a range of
study designs were eligible to be included. Considera-
tion of the quality of the six survey papers using the
Crombie (1996) checklist revealed issues with potential
selection bias (in particular successful users being more
likely to respond) and lack of reported piloting of
survey instruments. The largest survey (of staff views)
encompassed 320 respondents, with surveys of parents
or families of up to 100 participants, and the single
survey of user views totalling 18 respondents. The
critical appraisal of qualitative studies is an area of
considerable debate (Dixon-Woods et al. 2001) with
concerns regarding the appropriateness of applying
predesigned criteria to qualitative work. Using the
Critical Appraisal Skills Programme (2006) checklist as
a broad guide, the included interview and focus group
studies used appropriate methods and had clear aims;
however, there was often limited explanation of the
selection and recruitment of participants and reporting
of role of the researcher. The type of technology used by
participants was also not specified by some studies.
Key themes
Analysis and synthesis of the key themes recurring
across the primary studies indicated a number of factors
impacting on the provision and use of high-technology
AAC devices. These factors were ease of use; reliability;
technical support; the voice and language of the device;
the decision-making process; family perceptions and
support; staff training, the speed of generating amessage,
communication partner responses; and service delivery
issues such as staff training, and access to services.
Ease of use
Eight papers highlighted issues regarding the ease of
learning and using high-technology devices. Bailey et al.
(2006) interviewed relatives of AAC users attending
junior or high schools with multiple disabilities. The
participants described how ease of use and care of the
devices was a significant factor in enhancing the AAC
user’s experiences. The time taken to programme the
system was reportedly an important aspect of ease of
use. Survey data (Angelo 2000) found that 25% of
parents agreed that their child’s device was difficult to
use at home (50% disagreed). Hodge (2007) reported
views of both parents of children using AAC and
adult users. Participants described how devices needed
to be secured to a wheelchair in order to use them
successfully, with physical impairments also making use
slow or inefficient leading to frustration. Rackensperger
et al. (2005) echoed this, reporting how for some users
physically operating a device was a challenge, with
devices difficult to use apart from when seated in a
customized wheelchair.
McCord and Soto (2004) interviewed young people
with cerebral palsy (CP) and their families who had
used AAC for at least one year. The authors reported a
perception amongst the families that the technology was
mysterious and complex. Similarly McNaughton et al.
(2008) described views of parents and a user that a lack
of confidence with technology influenced attitudes to it.
Respondents identified that learning how to programme
a device was amajor challenge. Parents of users described
the benefits of learning from other parents, with the
provision of Help functions in devices described as
being valuable. Marshall and Goldbart (2008) found
that parents expressed concerns that high-technology

AAC barriers and facilitators review 5
T
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ig
ht
(2
00
3)
W
ha
t
ar
e
th
e
ex
pe
ri
en
ce
s
of
te
ac
he
rs
w
it
h
re
ga
rd
to
ch
ild
re
n
us
in
g
A
A
C
in
m
ai
ns
tr
ea
m
cl
as
sr
oo
m
s?
In
te
rv
ie
w
s
N
ot
sp
ec
ifi
ed
E
le
ve
n
te
ac
he
rs
;U
SA
L
as
ke
r
an
d
G
ar
re
tt
(2
00
6)
D
oe
s
a
sc
re
en
in
g
te
st
en
ab
le
op
ti
m
um
de
ci
si
on
-m
ak
in
g
re
ga
rd
in
g
th
e
ch
oi
ce
of
an
A
A
C
de
vi
ce
?
C
as
e
se
ri
es
St
or
ed
m
es
sa
ge
sy
st
em
s
(e
.g
.c
on
te
xt
ua
lm
es
sa
ge
s
on
di
gi
ti
ze
d
vo
ic
e
ou
tp
ut
ai
d,
co
m
m
un
ic
at
io
n
no
te
bo
ok
)
Fo
ur
pa
rt
ic
ip
an
ts
,o
ne
fe
m
al
e,
th
re
e
m
al
e,
ag
ed
54
–6
5.
A
ph
as
ia
du
e
to
ha
em
or
rh
ag
ic
in
fa
rc
t
(o
ne
),
ce
re
br
ov
as
cu
la
r
ac
ci
de
nt
(t
hr
ee
);
U
SA
L
un
d
an
d
L
ig
ht
(2
00
7)
W
ha
t
fa
ct
or
s
m
ay
be
im
po
rt
an
t
in
ou
tc
om
es
fo
r
A
A
C
us
er
s?
In
te
rv
ie
w
s
L
ow
-t
ec
hn
ol
og
y
pl
us
co
m
pu
te
r
so
ft
w
ar
e:
C
o:
W
ri
te
r,
W
ri
te
:O
ut
L
ou
d,
W
iV
ik
W
iV
ox
,
Sp
ea
ki
ng
D
yn
am
ic
al
ly
Pr
o
pl
us
D
ec
T
al
k
sp
ee
ch
sy
nt
he
si
ze
r,
L
ig
ht
w
ri
te
r,
D
yn
av
ox
31
00
Se
ve
n
m
al
e
C
P
ag
ed
19
–2
3,
us
er
s
of
A
A
C
sy
st
em
s
fo
r
at
le
as
t
15
ye
ar
s
pl
us
te
n
fa
m
ily
m
em
be
rs
an
d
13
pr
of
es
si
on
al
s
w
ho
w
or
ke
d
w
it
h
pa
rt
ic
ip
an
ts
;
U
SA

6 Susan Baxter et al.
T
ab
le
1
—
co
n
ti
n
u
ed
R
ef
er
en
ce
R
es
ea
rc
h
qu
es
ti
on
D
es
ig
n
T
ec
hn
ol
og
y
St
ud
y
pa
rt
ic
ip
an
ts
M
ar
sh
al
la
nd
G
ol
db
ar
t
(2
00
8)
W
ha
t
ar
e
th
e
ex
pe
ri
en
ce
s
of
pa
re
nt
s
w
ho
ha
ve
ch
ild
re
n
us
in
g
A
A
C
?
In
te
rv
ie
w
s
L
ow
pl
us
hi
gh
-t
ec
hn
ol
og
y
ai
ds
T
en
m
ot
he
rs
pl
us
on
e
fa
th
er
of
ch
ild
re
n
us
in
g
A
A
C
pl
us
tw
o
lo
ng
-t
er
m
fo
st
er
ca
re
rs
.C
hi
ld
re
n
(1
1)
ag
ed
3–
10
,n
in
e
C
P,
si
x
in
te
lle
ct
ua
ld
is
ab
ili
ti
es
,
tw
o
im
pa
ir
ed
he
ar
in
g,
on
e
ep
ile
ps
y;
U
K
M
at
th
ew
s
(2
00
1)
H
ow
kn
ow
le
dg
ea
bl
e
ar
e
SL
T
s
re
ga
rd
in
g
A
A
C
?
Su
rv
ey
A
ll
32
0
SL
T
s
w
or
ki
ng
in
an
y
fie
ld
;U
K
M
cC
or
d
an
d
So
to
(2
00
4)
W
ha
t
ar
e
th
e
pe
rc
ep
ti
on
s
of
A
A
C
am
on
gs
t
M
ex
ic
an
-A
m
er
ic
an
fa
m
ili
es
?
In
te
rv
ie
w
s
an
d
ob
se
rv
at
io
n
D
el
ta
T
al
ke
r,
D
yn
av
ox
Fo
ur
M
ex
ic
an
-A
m
er
ic
an
s,
th
re
e
C
P,
on
e
po
st
-m
en
in
gi
ti
s
(a
ge
d
7,
20
,1
5
an
d
14
)
w
ho
us
ed
A
A
C
fo
r
at
le
as
t
on
e
ye
ar
an
d
th
ei
r
fa
m
ili
es
;U
SA
M
cM
ill
an
(2
00
8)
C
an
tr
ai
ni
ng
te
ac
he
rs
im
pa
ct
on
st
ud
en
t
us
e
of
SG
D
s
C
as
e
se
ri
es
‘S
G
D
sy
st
em
’w
it
h
sy
m
bo
ls
Fo
ur
m
al
e
(a
ge
d
8–
12
),
au
ti
st
ic
sp
ec
tr
um
di
so
rd
er
s.
Fo
ur
fe
m
al
e
te
ac
he
rs
in
sp
ec
ia
lc
la
ss
ro
om
s
fo
r
st
ud
en
ts
w
it
h
in
te
lle
ct
ua
ld
is
ab
ili
ti
es
,3
–5
7
ye
ar
s’
te
ac
hi
ng
ex
pe
ri
en
ce
in
sp
ec
ia
le
du
ca
ti
on
al
ne
ed
s;
A
us
tr
al
ia
M
cN
au
gh
to
n
et
al
.
(2
00
8)
W
ha
t
ar
e
pa
re
nt
s’
pe
rc
ep
ti
on
s
of
le
ar
ni
ng
A
A
C
te
ch
no
lo
gy
?
In
te
rn
et
fo
cu
s
gr
ou
p
L
ow
pl
us
D
yn
av
ox
,L
ib
er
at
or
w
it
h
U
ni
ty
,
Pa
th
fin
de
r,
A
lp
ha
Sm
ar
t
w
it
h
w
or
d
pr
ed
ic
ti
on
Se
ve
n
pa
re
nt
s
of
us
er
s
ag
e
6–
30
C
P
;U
SA
O
’K
ee
fe
et
al
.(
20
07
)
W
ha
t
ar
e
A
A
C
us
er
vi
ew
s
re
ga
rd
in
g
re
se
ar
ch
pr
io
ri
ti
es
?
Fo
cu
s
gr
ou
ps
C
om
m
un
ic
at
io
n
di
sp
la
y,
L
ig
ht
W
ri
gh
te
r,
te
xt
-t
o-
sp
ee
ch
la
pt
op
,P
at
hfi
nd
er
,L
ib
er
at
or
Fi
ve
m
al
e,
on
e
fe
m
al
e
ag
ed
31
–3
4,
C
P
pl
us
sp
in
al
co
rd
in
ju
ry
,fi
ve
fe
m
al
e,
tw
o
m
al
e
fa
ci
lit
at
or
s
(s
po
us
e,
at
te
nd
an
t,
pa
re
nt
or
w
or
ke
r)
;C
an
ad
a
Pa
re
tt
e
et
al
.(
20
00
)
W
ha
t
ar
e
th
e
vi
ew
s
of
fa
m
ili
es
on
A
A
C
de
vi
ce
de
ci
si
on
-m
ak
in
g?
Fo
cu
s
gr
ou
ps
an
d
in
te
rv
ie
w
s
A
ll
A
A
C
de
vi
ce
s
Fi
ft
y-
ei
gh
t
pa
rt
ic
ip
an
ts
,2
3
fa
m
ily
m
em
be
rs
of
A
A
C
us
er
s,
14
fa
m
ily
m
em
be
rs
of
no
n-
A
A
C
us
er
s,
pl
us
21
‘m
ul
ti
cu
lt
ur
al
’p
ar
ti
ci
pa
nt
s;
U
SA
R
ac
ke
ns
pe
rg
er
et
al
.
(2
00
5)
W
ha
t
ar
e
us
er
vi
ew
s
of
A
A
C
te
ch
no
lo
gi
es
?
In
te
rn
et
fo
cu
s
gr
ou
p
SG
D
de
vi
ce
s:
D
yn
av
ox
31
00
,P
at
hfi
nd
er
,
L
ib
er
at
or
,a
ll
pa
rt
ic
ip
an
ts
ha
d
us
ed
at
le
as
tf
ou
r
lo
w
-
or
hi
gh
-t
ec
hn
ol
og
y
sy
st
em
s
at
so
m
e
po
in
t
Se
ve
n
ad
ul
ts
C
P,
ag
ed
21
–4
1;
U
SA
Sm
it
h
an
d
C
on
no
lly
(2
00
8)
W
ha
t
ar
e
th
e
vi
ew
s
of
ad
ul
t
A
A
C
us
er
s?
Su
rv
ey
co
m
pl
et
ed
on
lin
e/
in
pe
rs
on
D
el
ta
T
al
ke
r,
la
pt
op
co
m
pu
te
r,
L
ig
ht
w
ri
te
r,
D
yn
av
ox
,A
lp
ha
ta
lk
er
,P
at
hfi
nd
er
,B
ig
M
ak
pl
us
co
m
m
un
ic
at
io
n
bo
ar
d
E
ig
ht
ee
n
ad
ul
ts
w
it
h
C
P
ag
ed
19
–4
2;
Ir
el
an
d
Sc
hl
os
se
r
et
al
.
(2
00
0)
D
oe
s
tr
ai
ni
ng
th
e
sc
ho
ol
st
af
f
ha
ve
be
ne
fit
s
fo
r
an
A
A
C
us
er
’s
pa
rt
ic
ip
at
io
n?
M
ix
ed
m
et
ho
d
B
oa
rd
m
ak
er
,O
ve
rl
ay
M
ak
er
fo
r
In
te
lli
ke
ys
,
C
lic
k-
It
sc
re
en
sc
an
ni
ng
so
ft
w
ar
e,
w
or
d
pr
ed
ic
ti
on
pr
og
ra
m
,u
ti
lit
ie
s
fo
r
en
ha
nc
in
g
op
er
at
in
g
sy
st
em
s,
D
is
co
ve
r
Sw
it
ch
T
ea
ch
er
,t
w
o
as
si
st
an
ts
,p
ro
gr
am
m
e
su
pp
or
t
te
ac
he
r,
SL
T
,O
T
,l
ib
ra
ry
re
so
ur
ce
te
ac
he
r,
pa
re
nt
in
vo
lv
ed
w
it
h
a
10
-y
ea
r-
ol
d
m
al
e
w
it
h
C
P
;C
an
ad
a
So
to
et
al
.(
20
01
)
W
ha
t
ar
e
th
e
is
su
es
su
rr
ou
nd
in
g
th
e
in
cl
us
io
n
of
A
A
C
us
er
s
in
m
ai
ns
tr
ea
m
sc
ho
ol
s?
Fo
cu
s
gr
ou
ps
A
ll
(n
ot
sp
ec
ifi
ed
)
T
hi
rt
y
pa
rt
ic
ip
an
ts
,s
ev
en
su
pp
or
t
te
ac
he
rs
,f
ou
r
pa
re
nt
s,
se
ve
n
SL
T
s,
si
x
te
ac
he
rs
,s
ix
te
ac
hi
ng
as
si
st
an
ts
,r
an
ge
of
ex
pe
ri
en
ce
w
it
h
A
A
C
fr
om
3
to
ov
er
11
ye
ar
s;
U
SA
Tr
ue
et
al
.(
20
10
)
W
ha
t
ar
e
th
e
pe
rc
ep
ti
on
s
of
us
er
s
of
Se
nt
en
ce
Sh
ap
er
T
o
G
o?
In
te
rv
ie
w
s
Se
nt
en
ce
Sh
ap
er
T
o
G
o
Se
ve
n
pa
rt
ic
ip
an
ts
w
it
h
ap
ha
si
a
fo
llo
w
in
g
ce
re
br
ov
as
cu
la
r
ac
ci
de
nt
,fi
ve
fe
m
al
e,
tw
o
m
al
e
ag
ed
45
–7
7;
U
SA
W
or
m
na
es
an
d
M
al
ek
(2
00
4)
W
ha
t
ar
e
th
e
pe
rc
ep
ti
on
s
of
SL
T
s
in
E
gy
pt
re
ga
rd
in
g
A
A
C
?
Su
rv
ey
A
ll
T
hi
rt
y
SL
T
s
w
or
ki
ng
w
it
h
in
di
vi
du
al
s
w
it
h
in
te
lle
ct
ua
li
m
pa
ir
m
en
ts
or
co
m
pl
ex
co
m
m
un
ic
at
io
n
ne
ed
s;
E
gy
pt

AAC barriers and facilitators review 7
aids were effortful, and had experience of difficulties
with systems. Adult AAC users with CP in Smith
and Connolly (2008) reported that their own limited
knowledge and skills presented a significant barrier to
usage.
Reliability
Eleven papers described the limited reliability of devices.
Bailey et al. (2006) identified the time taken to repair
AAC systems and described poor reliability as a key
barrier. Participants in Cooper et al. (2009) reported
issues with the battery running out, devices being broken
or not working, or devices not being set up properly. Of
the parents surveyed by Angelo (2000), 11% agreed
that the system needed repair too often, however 60%
disagreed. Opinion voiced by young people using AAC
(Clarke et al. 2001a) was that systems were heavy,
complex and broke down frequently. Dattilo et al.
(2008) also reported frustrations when systems were not
available or not working.
Adult AAC users in O’Keefe et al. (2007) identified
the improved performance of devices as being a research
priority. These experiences of device breakdown and
time taken to repair were also described by teachers in
Kent-Walsh and Light (2003). A survey (Hetzroni 2002)
provided figures of 47% of parents of child AAC users
describing breakdowns as ‘all the time’, 17% ‘usually’,
13% ‘sometimes’, 10% ‘hardly’ and 13% ‘never’. Users
in Rackensperger et al. (2005) described how technology
breakdowns made it difficult for them to make progress
in learning to use devices, and how device breakdowns
were ‘a disaster’. Similarly, Hodge (2007) found that
technical problems were a common cause of frustration,
particularly with the more sophisticated devices.
Availability of technical support
The barrier of limited availability of technical support
was outlined by Bailey et al. (2006), Dattilo et al.
(2008), Hodge (2007), Smith and Connolly (2008),
Rackensperger et al. (2005), Parette et al. (2000), and
Soto et al. (2001). Family members described their
own limitations with regard to technical aspects of
equipment, with support needing to be readily available
(Bailey et al. 2006, Parette et al. 2000). A study in
America (Dattilo et al. 2008) identified a particular
issue with getting devices repaired or maintained via the
Medicare system. Users in Smith and Connolly (2008)
reported that few had assistance for programming
or maintenance when they were provided with their
devices. Of 18 adults with CP in Ireland who completed
this survey, seven reported that they contacted their
speech and language therapist for maintenance, and six
reported that they had no one to contact (no details
of other participant responses). Teachers in Soto et al.
(2001) identified back-up services and support being in
place as essential requirements for successful introduc-
tion and use of AAC. They described technophobia
amongst some staff as a barrier to introduction, together
with a lack of loan devices when systems were broken
and being repaired.
Voice/language of the device
Six papers described limitations of systems in terms of
the quality or appropriateness of the voice orwords being
generated. McCord and Soto (2004) investigated the
perceptions of Mexican-American families and found
that the language of the device was the primary barrier
to use at home. Also, it was reported that the speech
synthesizer was difficult to understand by some family
members who did not speak English as a first language.
Lund and Light (2007) similarly highlighted cultural
issues, with the lack of devices having two languages
available being a limiting factor for some users. Bailey
et al. (2006) reported limited vocabularies as being
an obstacle to effective usage. Also, the frustration
when spelled words were mispronounced by speech-
generating devices. Dattilo et al. (2008) described the
challenge of using devices out of doors when they cannot
be heard above background noise. Clarke et al. (2001a)
reported the perception of some young people that it
was embarrassing when a device did not use their own
voice.
Making decisions
Four papers described views regarding the involvement
of users and user’s families in decisions regarding an
AAC device. McNaughton et al. (2008) reported a
perception of failure to include parents in selection of a
device. Parette et al. (2000) highlighted the importance
of involving families in decision-making. A survey of
family members’ perceptions (Bailey et al. 2006) found
that the role of participants in decision-making varied.
Expectations regarding how much involvement they
should have were also described as varying. In one
paper adult users described how they benefitted from
taking a lead role in decision-making (Rackensperger
et al. 2005).
Time generating a message
Five papers identified negative perceptions regarding the
time that AAC devices take to formulate a message. The
slowness of communication was raised in particular by
those using text-based devices in Hodge (2007). Adult
users in Cooper et al. (2009) and Dattilo et al. (2008)
described how the time taken to formulate amessage was

8 Susan Baxter et al.
a major challenge in using devices. Family members in
McCord and Soto (2004) reported that they often chose
to communicate via other methods due to the inherently
slow response of AAC devices. Lund and Light (2007)
echoed these views, describing the need for technol-
ogy that was faster, and could keep pace with a user’s
thoughts.
Family perceptions and support
Studies highlighted the significance of the family
members of a user in successful implementation of an
AAC system. Three studies (Rackensperger et al. 2005,
Lund and Light 2007, Parette et al. 2000) reported
a need for family support with regard to decision-
making regarding the uptake of a device and use in
functional settings. Speech and language therapists in
Iacono and Cameron (2009) and Johnson et al. (2006)
perceived that family perceptions and attitudes towards
the technology could act as a barrier to implementa-
tion. Marshall and Goldbart (2008) described generally
positive family support amongst 11 parents and two
foster carers of children using high- and low-technology
aids. None of the parents in this study expressed concern
over the introduction of AAC, with some in contrast
reporting that they would have preferred that AAC had
been introduced earlier.One survey paper (Johnson et al.
2006) provided a detailed analysis of factors perceived
by speech and language therapists relating to success or
abandonment of AAC systems. This work developed a
survey tool via focus group input that was returned by
275 members of an AAC special interest group in the
United States. The study outlined a rank order for the
top 20 factors for success and abandonment of AAC
systems and carried out factor analysis to group these
attributes into constructs. The findings of this work
emphasized the perceptions of families, with constructs
for success including: support from family, team and
outside consultants; attitude of realism, ownership and
valuing the system.
Three papers described the role played by parents in
managing the ongoing use of a device. Angelo (2000)
used a survey to explore perceptions of family role
and responsibilities with regard to AAC amongst 100
parents of AAC users. It found that more than half
the families reported that one parent (most often the
mother) had themajority of theAACdevice-related roles
and responsibilities, with this impacting on personal
time availability. Only a small proportion (7%) however
reportedly perceived that the device was a burden.
Parents in Goldbart and Marshall (2004) perceived that
there was a requirement for parents to build up high
levels of specialist or technical information. In a similar
finding regarding the need for technical knowledge,
McNaughton et al. (2008) identified that parents had
a crucial role in teaching usage of a device, and thus
required training and knowledge in order to enable this.
The role of the communication partner
Five studies described how other people’s responses
and attitudes could impact on use of an AAC
device. Marshall and Goldbart (2008) reported
parental perceptions that familiar adults were generally
considered to respond positively and be willing to
interact with an AAC user, however interactions with
other people could be less positive. McNaughton et al.
(2008) suggested that it is important for users to have
skills of asking questions, not just answering them. The
authors recommended that users should have a means of
introducing the system to others; be taught a variety of
means to deal with breakdowns; and that there should
be education for people who may interact with a user.
Rackensperger et al. (2005) described a need for ‘social
and strategic knowledge’ to make use of a device, for
example how to gain attention and how to introduce
the device to unfamiliar people. Smith and Connolly
(2008) identified that the communication partner was
the factor most likely to influence use of an aid. Partici-
pants with aphasia (True et al. 2010) reported that the
audience (along with the content of the message and
their mental and physical state) could make communi-
cation more or less challenging.
Service provision
Lund and Light (2007) outlined a perception of a lack
of availability of local AAC services, and in particu-
lar a lack of services for adult users. Difficulties in
accessing a specialist evaluation were also described by
parents and AAC users in McNaughton et al. (2008).
Nine papers were found that described other aspects of
service provision. Five of these investigated the delivery
of services in a school setting. Clarke et al. (2001b)
reported that provision in theUK in terms of the amount
of therapy, related to educational placement rather
than individual needs. Children in mainstream school
received fewer hours of therapy provision than those in
special schools (p < 0.001). The study also found that
42% of direct therapy took place in classrooms, and in
special schools this was 87% groupwork. This study also
reported that children using speech generating devices
(SGDs) received more therapy (median of 85.8 h) than
those using low-technology aids (median of 38.2 h).
This finding was identified by the authors as probably
due to practice and provision in one particular special
school however, the clinician views data supported that
high-technology aids might require more therapy due to
them being more complicated.

AAC barriers and facilitators review 9
Staff training
The need for staff to have an adequate level of skills
and knowledge was highlighted by six papers. Soto
et al. (2001) carried out focus groups with teachers,
teaching assistants and parents. They reported lack of
training for staff was a significant barrier to successful
implementation of systems. A lack of expertise in schools
was also echoed by Hodge (2007). Lund and Light
(2007) outlined limited expertise of local profession-
als, a lack of collaboration between professionals, and
the need for training for families and teachers. They
also described a negative attitude towards AAC amongst
some professionals. Goldbart and Marshall (2004)
described how parents often reported that profession-
als did not have sufficient experience or expertise in
the area of AAC. Clarke et al. (2001b) analysed school
records and described the amount of official training
of staff by communication specialists as ‘minimal’.
Parette et al. (2000) found that family members appreci-
ated professionals being honest about their level of
knowledge, and wanted clear, accurate and trustwor-
thy information including accurate timelines regarding
the process of acquiring equipment.
Iacono and Cameron (2009) found wide variation
in speech and language therapists’ (SLTs) reported
knowledge and skills in AAC. Wormnaes and Malek
(2004) in Egypt reported that 14 of the 30 SLT
respondents felt that they had no or some knowledge
about AAC, while 13 described themselves as quite
knowledgeable. Four respondents identified that a lack
of AAC knowledge and skills would preclude them from
using AAC with a client. In the UK, Matthews (2001)
surveyed 320 speech and language therapists in various
clinical settings. This study found that 57% reported
experiencing training in AAC as part of pre-qualification
training and 60% had accessed training since qualifica-
tion (mostly on signing). The majority of respondents
categorized their skills in high-technology AAC as none
(31%) or general knowledge/awareness (37%). Forty-
nine per cent identified that it would be useful to
access AAC training, with training aimed at a whole
SLT team in a locality with ongoing support from a
trainer.
Two papers explored whether providing specific
AAC training to school staff was important in provision
of high-technology AAC. Schlosser et al. (2000)
evaluated training for staff involved in supporting a
10-year-old male with CP who had used a dynamic
display VOCA, low-technology symbols and a personal
computer. The authors concluded that there was a
reduction in perceived barriers, and it was described as
useful by participants. McMillan (2008) also evaluated
the impact of a training package. This study carried out
in Australia provided a ‘teacher professional develop-
ment package’ to four staff working with four students
who used SGDs. The author found that by training
teachers in techniques such as time delay that this had
an impact on student use of their AAC devices.
In another paper exploring use in an education
setting, Kent-Walsh and Light (2003) examined the
perceptions of teachers who had AAC users in
their mainstream class. The participants described the
importance of a team approach to inclusion with good
communication, group planning and problem-solving
and a specific need for careful transition planning.
External specialists such as speech and language therapist
and technology consultants were identified as crucial
assistance required. They identified the need for a
positive attitude, the important role of classmates and
realistic curriculum goals. Teacher participants in Soto
et al. (2001) echoed the importance of team collabora-
tion, with AAC training and administrative support also
being prerequisite conditions for successful integration
of AAC users.
Discussion
The purpose of this systematic reviewwas to identify and
describe the current state of knowledge regarding factors
which may impact on the provision and ongoing use of
high-technology AAC devices. Analysis and synthesis
of the literature indicates that the provision and use of
high-technology AAC devices is subject to a wide variety
of factors, which may act as barriers or facilitators to
successful outcomes. These elements are important for
practitioners to consider and address where needed in
the intervention process.
The included papers highlight the need to involve
potential users and the family members of users in
the decision-making process. By full involvement and
detailed discussion, barriers such as the voice of a device,
complexity of operation, and family attitudes may be
overcome. Issues of reliability and lack of availability
of technical support were significant recurring themes,
with the need for early discussion regarding advice and
support, easily accessible technical back-up, and loan
devices to be in place. The need for training in skills
to use the device functionally was also highlighted,
such as learning to ask questions and how to introduce
a communication partner to the device. This may
overcome potential barriers relating to communication
partner negative responses.
The review highlights the complexity which must
be unravelled by researchers endeavouring to evaluate
and compare outcomes from intervention studies. The
range of factors identified by this review may go some
way towards explaining the differences in individual
outcomes reported in the experimental literature. If the

10 Susan Baxter et al.
evidence base regarding potential benefits from AAC
intervention is to be strengthened, there is a need for
high quality studies including the use of controlled
designs. Pring (2006) however discusses the limitations
of many controlled clinical outcome studies due to
poor definition of the therapies being studied, clients
receiving different therapies and amount of therapies,
and poor definition or heterogeneity of the treated
clients. This review further emphasizes the challenge of
conducting high quality effectiveness studies (conducted
under clinical rather than ideal conditions) by outlining
the wide range of elements that may impact on
outcomes. Reviews that explore these often complex
factors are valuable supplements to inform empirical
work.
This work has illustrated how evidence from studies
which are not reporting effectiveness data can be
synthesized using systematic review methods. Increas-
ing recognition of the value of qualitative research has
led the drive for wider evidence to be considered in
systematic reviews, with influential organizations such
as The Cochrane Collaboration investigating ways of
combining different forms of data in reviews. The work
outlined in this article used the method of thematic
synthesis to analyse data in order to identify factors
underpinning the provision of therapy interventions.
We argue that systematic review of this type of evidence
has been able to provide further understanding of
studies investigating clinical effectiveness, and can be
a useful contribution to the exploration of interven-
tion implementation factors supporting evidence based
service development and delivery.
This review was limited by considering only papers
published in English, and while it carried out a
comprehensive electronic database search and citation
checking did not include hand searching of journals or
contact with experts which may have yielded additional
references. Methods of qualitative synthesis endeavour
to combine findings from primary research, however the
richness and detail of much primary qualitative research
presents challenges. The method has been criticized on
the grounds that the removal of context and experiences
of the primary researcher adversely impacts on the
analysis (Dixon-Woods et al. 2001). In common with
primary qualitative research it can also be criticized for
having the potential for bias due to researcher selection
and interpretation of the data.
A reasonable body of evidence was found describing
the views of AAC users, parents, families of users and
staff regarding high-technology devices and their use.
The greatest body of work was found for AAC devices
used by people with cerebral palsy, with limited data
from other client groups. It is also important to note that
much of the work described the views of parents or other
family members. Less than half the papers encompassed
user views. While the perceptions and role of families
was highlighted as a key factor in the review, there seems
a need for further studies to overcome the challenge of
users limited communication to further explore their
experiences,
These data are an important supplement to quantita-
tive outcomes data however would not have been
considered in a traditional systematic review. Writers
(Lund and Light 2006) have highlighted the debate
concerning how AAC intervention outcomes should be
evaluated. Short-term outcomes (such as the number
of communications made using a device pre and post
intervention) offer a temptingly measurable evaluation.
However, ongoing usage for communication in real-life
settings may be the only outcome that is of importance.
This review has indicated the range of factors which
underpin whether a device is functionally useful, such
as how often it is working andwhether it meets the needs
of families for whomEnglish is a second language. These
elements may be a helpful contribution to the consider-
ation of functional usage outcomes.
The review suggests that aspects of high-technology
AAC service delivery may need to be addressed. As
well as the range of ‘device-centric’ concerns which
could potentially be addressed as part of the decision-
making process, concerns were also reported regarding
the availability of specialist provision, and the knowledge
and skill levels of practitioners. There was some evidence
that providing training for school staff, and working
practices such as teamworking could positively influence
functional use of a device. Further work evaluating
the impact of service delivery on the provision of
devices would be helpful. Other aspects of AAC service
delivery that may be worthy of further consideration
are: the need for ongoing advice regarding technical
issues; maintenance and repair; and the influence of
attitudes and responses from those interacting with
AAC users.
Conclusions
The implementation of high-technology AAC interven-
tions may be affected by a range of factors that can be
barriers or facilitators to successful outcomes. Practition-
ers should be aware of these elements when making
recommendations, and consider how barriers, where
present, might be overcome. Aspects of service delivery
such as ongoing technical support and staff training
may also require further consideration. This study
has synthesized evidence describing views of users and
providers regarding the implementation and use of AAC
systems. It is argued that this can provide helpful data
to inform intervention studies and outcome measures,
and that it forms a valuable extension to standard review
methods.

AAC barriers and facilitators review 11
Acknowledgements
This study forms part of a research project commissioned and led
by Communication Matters, the UK charity for augmentative and
alternative communication. The project is funded by the National
Lottery through Big Lottery Fund.
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Appendix
Table A1. Search strategy
1 autism.mp. or Autistic Disorder/ (14974)
2 Dementia/ (29700)
3 Cerebral Palsy/ (12562)
4 stroke.mp. or Stroke/ (127447)
5 motor neuron disease.mp. or Motor Neuron Disease/ (4469)
6 Amyotrophic Lateral Sclerosis/ (9489)
7 Parkinson Disease/ or parkinsons disease.mp. (48577)
8 huntington’s disease.mp. or Huntington Disease/ (9241)
9 multiple sclerosis.mp. or Multiple Sclerosis/ (42249)
10 klinefelter syndrome.mp. or Klinefelter Syndrome/ (3274)
11 down syndrome.mp. or Down Syndrome/ (19829)
12 quadriplegi∗.mp. (7631)
13 Goltz syndrome.mp. or Focal Dermal Hypoplasia/ (326)
14 Rett Syndrome/ (1434)
15 Focal Dermal Hypoplasia/ (178)
16 Cleft Palate/ or incomplete palate.mp. (14653)
17 Woster-Drought syndrome.mp. (0)
18 aphasi∗.mp. (11518)
19 Apraxi∗.mp. (3217)
20 articulation of speech.mp. (63)

AAC barriers and facilitators review 13
Table A1 — continued
21 speech sound disorders.mp. (43)
22 cluttering.mp. (74)
23 tourettes.mp. (1605)
24 dysarthri∗.mp. [mp = title, original title, abstract, name of substance word, subject heading word, unique identifier] (3787)
25 dyspraxi∗.mp. (328)
26 dysprosody.mp. (43)
27 Expressive language disorder.mp. (29)
28 spasmodic dysphonia.mp. (385)
29 nonspeaking.mp. (59)
30 nonvocal.mp. (71)
31 nonverbal.mp. (6356)
32 learning disability.mp. or Learning Disorders/ (11779)
33 learning disorders.mp. or Learning Disorders/ (11246)
34 language based learning disabilities.mp. (15)
35 intellectual impairment.mp. (838)
36 mental retardation.mp. or Mental Retardation/ (52456)
37 mental handicap.mp. (986)
38 cognitive impairment.mp. (16157)
39 cognition disorders.mp. or Cognition Disorders/ (35180)
40 developmental impairment.mp. (130)
41 developmental disabilities.mp. or Developmental Disabilities/ (12491)
42 orafacial myofunctional disorders.mp. [mp = title, original title, abstract, name of substance word, subject heading word, unique
identifier] (0)
43 phonemic disorders.mp. [mp = title, original title, abstract, name of substance word, subject heading word, unique identifier] (0)
44 traumatic brain injury.mp. [mp = title, original title, abstract, name of substance word, subject heading word, unique identifier] (10680)
45 laryngectomies.mp. or Laryngectomy/ (7207)
46 glossectomies.mp. or Glossectomy/ (686)
47 speech disorder.mp. or Speech Disorders/ (9079)
48 speech intelligibility.mp. or Speech Intelligibility/ (2922)
49 speech pathology.mp. or Speech–Language Pathology/ (1939)
50 speech impairment.mp. (257)
51 language disorders.mp. or Language Disorders/ (5488)
52 communication disorders.mp. or Communication Disorders/ (1573)
53 or/1–52 (478852)
54 (augmentative and alternative communication).mp. [mp = title, original title, abstract, name of substance word, subject heading word,
unique identifier] (225)
55 Communication Aids for Disabled/ or communication aids.mp. (1668)
56 voice amplifiers.mp. (2)
57 communicator.mp. (301)
58 synthetic speech.mp. (167)
59 synthesized speech.mp. (72)
60 light writer.mp. (0)
61 talker.mp. (545)
62 assistive aids.mp. (7)
63 speech generation devices.mp. (0)
64 speech-generating devices.mp. (9)
65 voice output devices.mp. (3)
66 voice output communication aid∗.mp. (28)
67 microswitch.mp. (113)
68 taped message.mp. (5)
69 single message.mp. (65)
70 message sequencer.mp. (0)
71 dynamic screen.mp. (2)
72 personal talker.mp. (0)
73 uterance based devices.mp. [mp = title, original title, abstract, name of substance word, subject heading word, unique identifier] (0)
74 augmentative communication.mp. [mp = title, original title, abstract, name of substance word, subject heading word, unique identifier]
(115)
75 computer-aided assistive technologies.mp. (0)
76 graphic system.mp. (38)
77 blissymbols.mp. (24)
78 line drawings.mp. (634)
79 (rebus or widgit literacy symbols).mp. [mp = title, original title, abstract, name of substance word, subject heading word, unique
identifier] (28)

14 Susan Baxter et al.
Table A1 — continued
80 Makaton Vocabulary symbols.mp. (0)
81 minspeak.mp. (2)
82 ((symbol or pictorial or picture communication) and systems).mp. [mp = title, original title, abstract, name of substance word, subject
heading word, unique identifier] (525)
83 picture exchange communication.mp. [mp = title, original title, abstract, name of substance word, subject heading word, unique
identifier] (27)
84 visual timetable∗.mp. [mp = title, original title, abstract, name of substance word, subject heading word, unique identifier] (0)
85 Picture exchange communication.mp. [mp = title, original title, abstract, name of substance word, subject heading word, unique
identifier] (27)
86 e-tran frames.mp. [mp = title, original title, abstract, name of substance word, subject heading word, unique identifier] (0)
87 talking mats.mp. (4)
88 semiotics.mp. (270)
89 eye gaze.mp. (307)
90 ((trasparent or translucent) and icon∗).mp. [mp = title, original title, abstract, name of substance word, subject heading word, unique
identifier] (2)
91 eye pointing chart.mp. (0)
92 tangible symbols.mp. [mp = title, original title, abstract, name of substance word, subject heading word, unique identifier] (0)
93 objects of reference?.mp. [mp = title, original title, abstract, name of substance word, subject heading word, unique identifier] (13)
94 talking mat∗.mp. [mp = title, original title, abstract, name of substance word, subject heading word, unique identifier] (5)
95 pictalk.mp. [mp = title, original title, abstract, name of substance word, subject heading word, unique identifier] (0)
96 Votrax.mp. (5)
97 Canon communicator M.mp. (0)
98 Alea Intelligaze.mp. (0)
99 Tellus Mobi.mp. (0)
100 Vantage lite.mp. (0)
101 partner four plus.mp. (0)
102 go talk 9+.mp. (0)
103 tech?speak 32.mp. (0)
104 Echo 11.mp. (55)
105 SmoothTalker.mp. (1)
106 KeyTalk.mp. (0)
107 little mac.mp. (0)
108 AbleNet.mp. (1)
109 Attainment Company.mp. (0)
110 Auxilia.mp. (0)
111 DagligData.mp. (0)
112 Dynavox.mp. (1)
113 Easy Labs.mp. (0)
114 Falck Igel As.mp. (0)
115 Fondation Suisse Pour Les Teletheses.mp. (0)
116 Gewa-QuoVadis Nederland BV.mp. (0)
117 Handicom.mp. (0)
118 Hearing Products International Ltd.mp. (0)
119 JABBLA Bvba.mp. (0)
120 Klein & Melgert Developments.mp. (0)
121 Liberator.mp. (215)
122 Prentke Romich Company.mp. (0)
123 SuperVoca.mp. (0)
124 TouchTalker.mp. (0)
125 Tobii Technology AB.mp. (0)
126 Toby Churchill.mp. (0)
127 Widgit Software.mp. (0)
128 Words+ Inc.mp. (0)
129 (communication adj (book∗ or chart∗ or card∗ or board∗ or passport∗)).mp. [mp = title, original title, abstract, name of substance word,
subject heading word, unique identifier] (45)
130 or/54–129 (4993)
131 53 and 130 (1188)
132 communication.mp. [mp = title, original title, abstract, name of substance word, subject heading word, unique identifier] (173426)
133 131 and 132 (864)
134 from 133 keep 1–864 (864)
135 131 not 134 (324)
136 limit 134 to yr = ‘2000 -Current’ (456)
137 from 136 keep 1–456 (456)

AAC barriers and facilitators review 15
Table A2. Search results
Database Number of results Comments
Cinahl 594 Did not include manufacturers’ names
Cochrane Library 10 Did not include manufacturers’ names
Embase 298
Medline 456
Psychinfo 518
CSA 2485 ASSIA, Biological Sciences, ERIC, Linguistics and Language
Behaviour Abstracts, MLA International Biography, CSA
Social Services Abstracts, CSA Sociological Abstracts
Web of Science 574
Total 4935 De-duplicated = 2883