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5766 Evidence-Based Decision Making for Individuals with ASD Who Need AAC [ASHA Session]

Thursday, July 7, 2011: 10:45 AM-12:00 PM
Sun 1-2 (Gaylord Palms Resort and Convention Center)
How do teams document that decisions regarding improving the communication competence of children and adults with ASD are evidence-based? Applying the principles of evidence-based practice is even more critical when decisions about augmentative and alternative communication (AAC) are being considered. Following four (4) steps for using evidence to guide decision-making provides a framework supported with tools and resources to monitor performance and outcomes. This presentation provides examples of each step based on cases and clinical records from ICAN™ Talk Clinics. For many professionals working with individuals with autism spectrum disorder (ASD), applying the principles of evidence-based practice (EBP) and/or evidence-based education (EBE) will require gaining new knowledge and skills.  Parents also will be required to gain new skills in participating on educational and health care teams applying EBP/EBE.   Many individuals with ASD have severe communication disorders and would benefit from using augmentative and alternative communication (AAC).   Teams considering AAC as an intervention to build language and communication competence soon realize that EBP/EBE is not doing the same thing, but simply calling it a different name.  Making conscienteous and judious evidence-based decisions requires applying scientific and principled approached that have not been part of the authority-based procedures or models of the past. 

As with evidence-based medicine, EBP and EBE starts with the person and ends with the person as practitioners, educators and health care providers hold the interests (values and expectations) of the individual who relies on AAC paramount. EBP has been defined as “placing the individual’s benefits first, practitioners adopt a process of life-long learning that involves continually posing specific questions of direct practical importance to individuals, searching objectively and efficiently for the current best evidence relative to each question, and taking appropriate action guided by evidence” (Gibbs, 2003).  Since the essence of EBP involves implementing principles and methods that have not been routine for many team members, starting to incorporate EBP into decision-making appears to be more time and labor intensive, especially with large caseloads and paperwork requirements. However, as practitioners and educators become more comfortable and efficient with the skills for putting these basic principles into practice, the initial perceptions of increased time and effort fade.  In addition, achieving improved performance and outcomes translates into decreased cost and time effectiveness and not having to redo work.

Another factor that may discourage some teams from moving through the processes involved with AAC evidence-based decisions is the perception of the emphasis on the research literature and having to search and appraise volumes of research studies.  Team members do not have to become researchers or statisticians to make evidence-based decisions.  Evidence-based practice happens at the level of the practitioner and the person and is a synergy among the three components of 1) clinical or educational evidence, 2) external evidence, and 3) personal evidence.  An EBP/EBP model teaches a process of life-long learning, while an authority-based model follows traditions and guidelines which allow professionals to become out-of-date (Gibbs, 2003). 

Regardless of experience with EBP, team members from various educational and health care professions working with individuals with ASD and providing AAC services can follow a systems model of EBP and apply 4 basic steps to achieve better outcomes (Hill & Romich, 2002).

Step 1:  Asking meaningful, value-based questions

Before teams can formulate the best questions, they have to thoroughly characterize the person with ASD and identify and prioritize the values and expectations of the individual and family.  A well-built question has 4 basic features in which the question components come from the obtained information (Sackett, et. al., 2000).  In addition, formulating meaningful questions related to AAC decisions requires thorough background information.  The question features include, the person/problem; intervention; comparison intervention; and desired performance/outcome.  Example questions related to individuals with ASD across the lifespan who may benefit from AAC are used to illustrate this step.

Step 2:  Locating and reviewing the external (research) evidence

Formulating well-built questions with key words provides the most effective approach to searching and finding the best evidence to answer the question. Teams need to commit to searching fairly and thoroughly for evidence and reviewing evidence that may confirm as well as refute their original opinions especially as this related to ASD and AAC.  Teams should be able to answer openly the questions that family members are asking about the strength and quality of the evidence related to ASD and AAC.  Teams have to be honest and truthful with what type and/or level of evidence was used to make a decision about an AAC intervention.  

Step 3:  Collecting and reviewing the clinical and personal evidence

When external evidence is of a low level or may not be available, clinical/educational and personal evidence can be used to support decisions. Frequently individuals with ASD have not had comprehensive evaluations to identify their communication strengths and language skills and potential.   Collecting language samples provides the most reliable and valid evidence to monitor AAC performance and outcomes.  LAM (Language Activity Monitoring) tools which are the automated recording of communication events using an AAC technology make data collection easy and efficient (Hill & Romich, 2001).  Involving the individual and family is critical to collect the most useful personal evidence.  Case study examples of clinical and personal evidence from individuals with ASD using AAC interventions will be discussed.

Step 4:  Using the evidence for assessment and intervention

In order to achieve the most effective communication possible for individuals with ASD, teams need to build skills based on the dynamics of the complex nature of interactive communication (Hill, 2004).  The most effective AAC teams evaluate services based on the routine use of performance measurement to monitor results and make decisions about the effectiveness of intervention.  A growing pool of performance data on individuals with ASD across the lifespan is available that documents outcomes and provides for comparison of AAC intervention approaches. 

A performance-based understanding of the communication competence of children and adults with ASD who rely on AAC has long been a basic aim for AAC intervention.  AAC teams (including families) applying the four steps of EBP see the results in documented performance. Measuring language performance is paramount in order to achieve the goal of AAC, the most effective communication possible. 


American Speech-Language-Hearing Association (ASHA). (2001). Scope of Practice. Rockville, MD.

Gibbs, L. B. (2003). Evidence-based practice for the helping professions: A practical guide with integrated multimedia. Pacific Grove, CA:  Thompson Brooks/Cole.

Hill, K. (2004). AAC evidence-based practice and language activity monitoring. Topics in Language Disorders: Language and Augmented Communication, 24, 18-30.

Hill, K., & Romich, B. (2001).  A Language Activity Monitor to support AAC evidence-based practice.  Assistive Technology, 13, 12-22.

Hill, K., & Romich, B.  (2002). AAC evidence-based clinical practice: A model for success.  Edinboro, PA: AAC Institute Press2(1), 1-6.

Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W. M., & Haynes, R. B. (2000).  Evidence-based medicine: How to practice and teach EBM.  Edinburgh:  Churchill Livingstone.

Learning Objectives:

  • Identify the four steps of EBP for working with individuals who have an ASD.
  • Identify the three types of evidence that can be used to guide clinical decision making.
  • Explain the importance of using evidence to support assessment and intervention.

Content Area: Communication


Katya Hill, CCC-SLP
Executive Director, Speech Language Pathologist
ICan Talk Clincs of the AAC Institute

Katya Hill is an Associate Professor at the University of Pittsburgh. Clincally she has over thirty years of experience working with individuals with ASD who use AAC. She is Executive Director of ICAN™ Talk Clinics, a non-profit organization dedicated to maximizing the potential of individuals with severe communication impairments.

Rachel Harkawik, CF-SLP
Speech Language Pathologist
ICan Talk Clincs of the AAC Institute

Rachel Harkawik is a speech-language pathologist at ICan™ Talk Clinics and a University of Pittsburgh doctoral student. She provided AAC services for a wide range of clinical populations for several years. Currently she provides language-based AAC assessment and intervention services for children with autism at a specialized school.

Juliet Nellis, CF-SLP
Speech Language Pathologist
ICan Talk Clincs of the AAC Institute

Juliet Nellis is a clinical fellow at ICan™ Talk Clinics. Juliet works at a partial hospital program for children with autism ranging from 3 to 14 years of age. She provides service to both verbal and non-verbal children with an emphasis on increasing their expressive language abilities.