Speech Generating Devices

Number: 0437

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses speech generating devices.

1. Medical Necessity

   1. Aetna considers speech generating devices (SGDs) as medically necessary durable medical equipment (DME) when the following criteria are met:

      1. Prior to the delivery of the SGD, the member has had a formal evaluation of their cognitive and language abilities by a speech-language pathologist (SLP). The formal, written evaluation must include, at a minimum, all of the following elements:

         1. A description of the functional communication goals expected to be achieved and treatment options; and
         2. A treatment plan that includes a training schedule for the selected device; and
         3. An assessment of whether the individual's daily communication needs could be met using other natural modes of communication; and
         4. Demonstration that the member possesses the cognitive and physical abilities to effectively use the selected device and any accessories to communicate; and
         5. Evaluation of current communication impairment, including the type, severity, language skills, cognitive ability, and anticipated course of the impairment; and
         6. For a subsequent upgrade to a previously issued SGD, information regarding the functional benefit to the member of the upgrade compared to the initially provided SGD; and
         7. Rationale for selection of a specific device and accessories; and
      2. A copy of the SLP's written evaluation and recommendation have been forwarded to the member's treating physician prior to ordering the device; and
      3. Other forms of treatment have been considered and ruled out; and
      4. The member’s medical condition is one resulting in a permanent severe expressive speech disability, including, but not limited to, anarthria, aphasia, aphonia, apraxia or dysarthria; and
      5. The member's speaking needs can not be met using natural communication methods; and
      6. The member's speech disability will benefit from the device ordered; and
      7. The SLP performing the evaluation of the member may not be an employee or have a financial relationship with the supplier of the SGD.  
         
         
   2. Accessories and upgrades for the SGD are considered medically necessary if the basic medical necessity criteria are met and the medical necessity for each accessory is clearly documented in the formal evaluation by the SLP.
   3. A variety of access devices (ocular tracking devices (e.g., Tobii Dynavox), head control mouse, pointers, mouth sticks, key guards) may be medically necessary to enable persons with neurologic conditions to use an SGD. Other medically necessary features of the device include the capability to generate email, text, or phone messages to allow the member to “speak” or communicate remotely, as well as the capability to download updates to the covered features of the device from the manufacturer or supplier of the device. A speech generating device with multiple interfaces is generally considered not medically necessary; the need for multiple interfaces must be clearly documented in the medical record.
   4. Only 1 SGD or speech generating software program at a time is considered medically necessary per member.
   5. Multi-lingual modules for SGDs are considered not medically necessary.

2. Experimental and Investigational

   Aetna considers SGDs experimental and investigational when criteria are not met.

3. Policy Limitations and Exclusions

   1. As long as the speech-generating device is limited to use by a person with a severe speech impairment and is primarily used for the purpose of generating speech, it is not necessary for a speech-generating device to be dedicated only to speech generation to be considered DME.  Desktop computers, laptop computers, pagers, personal digital assistants (PDAs), portable multi-media players (e.g., iPod), smart phones, and tablet devices (e.g., Galaxy, iPads, Kindle), or other devices that are not dedicated SGDs are not covered because they do not meet the definition of DME because they are useful in the absence of illness and injury. Please check benefit plan descriptions for details.
      
      Software that enables a laptop computer, desktop computer, or PDA to function as a SGD is considered an SGD; however, installation of the program or technical support is not separately reimbursable.
      
      There should be no separate billing of any software, interfaces, cables, adapters, interconnects, and switches necessary for the accessory to interface with the SGD.
      
      Internet or phone services or any modification to a member’s home to allow use of the speech generating device are not covered because such services or modifications could be used for non-medical equipment such as standard phones or personal computers. In addition, specific features of a speech generating device that are not used by the individual who has a severe speech impairment to meet his or her functional speaking needs are not considered medically necessary. This would include any computing hardware or software not necessary to allow for generation of audible/verbal speech, email, text or phone messages, such as hardware or software used to create documents and spreadsheets or play games or music, and any other function a computer can perform that is not directly related to meeting the functional speaking communication needs of the patient, including video communications or conferencing.
      

   2. SGDs, as described above, are considered medically necessary regardless of whether the plan has an exclusion for "communication aids."  Communication aids that are not SGDs are not covered under plans that exclude communication aids.  Please check benefit plan descriptions for details. 

   3. This CPB does not apply to electronic speech aids that are used by laryngectomized persons and persons with a permanently inoperative larynx.  These are considered prosthetics.  There are 2 types of electronic speech aids.  One operates by placing a vibrating head against the throat.  The other amplifies sound waves through a tube which is inserted into the user's mouth.  A person who has had radical neck surgery and/or extensive radiation to the anterior part of the neck would generally be able to use only the "oral tube" model or one of the sensitive and more expensive "throat contact" devices.

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
CPT codes covered if selection criteria are met:
92521	Evaluation of speech fluency (eg, stuttering, cluttering)
92522	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)
92523	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)
92524	Behavioral and qualitative analysis of voice and resonance
92607	Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour
+ 92608	each additional 30 minutes (List separately in addition to code for primary procedure)
92609	Therapeutic services for the use of speech-generating device, including programming and modification
HCPCS codes covered if selection criteria are met:
E2500	Speech generating device, digitized speech, using pre-recorded messages, less than or equal to 8 minutes recording time
E2502	Speech generating device, digitized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time
E2504	Speech generating device, digitized speech, using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time
E2506	Speech generating device, digitized speech, using pre-recorded messages, greater than 40 minutes recording time
E2508	Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device
E2510	Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access
E2511	Speech generating software program, for personal computer or personal digital assistant
E2512	Accessory for speech generating device, mounting system
E2599	Accessory for speech generating device, not otherwise classified [not covered if used as a modification to home internet or phone services.]
G0153	Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes
V5336	Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)
V5362	Speech screening
V5363	Language screening
HCPCS codes not covered for indications listed in the CPB:
Speech generating device with multiple interfaces –no specific code
E1902	Communication board, nonelectronic augmentative or alternative communication device
Other HCPCS codes related to the CPB:
L8500	Artificial larynx, any type
L8505	Artificial larynx replacement battery/accessory, any type
ICD-10 codes covered if selection criteria are met:
F80.0 - F80.9	Specific developmental disorders of speech and language
I69.020 - I69.028 I69.120 - I69.128 I69.220 - I69.228 I69.320 - I69.328 I69.820 - I69.828 I69.920 - I69.928	Speech and language deficits following cerebrovascular disease
R47.01 - R47.9	Speech disturbances, not elsewhere classified

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Background

This policy is based on Medicare DME MAC criteria for speech generating devices (SGDs). Speech generating devices (SGDs), also known as augmentative or alternative communication devices, are utilized to help individuals who have severe speech impairments such as aphasia, apraxia or dysarthria, to be able to meet their functional speaking needs. The individuals may also have impairments that interfere with writing.  

SGDs may utilize either digitized or synthesized speech. Digitized SGDs are those that deliver "whole message" speech output. These devices deliver words or phrases that have been prerecorded by an individual other than the user of the speech generating device, who can play it back on demand.

Synthesized SGDs are those that translate the user’s input into device-generated speech using algorithms representing linguistic rules. Users are not limited to prerecorded messages but can create messages independently according to their communication needs. These devices may also be called text to speech systems. 

Speech generating devices are defined as durable medical equipment that provides an individual who has a severe speech impairment with the ability to meet his or her functional, speaking needs. Speech generating devices are speech aids consisting of devices or software that generate speech and are used solely by the individual who has a severe speech impairment. The speech is generated using one of the following methods:

• Digitized audible/verbal speech output, using prerecorded messages;
• Synthesized audible/verbal speech output which requires message formulation by spelling and device access by physical contact with the device-direct selection techniques;
• Synthesized audible/verbal speech output which permits multiple methods of message formulation and multiple methods of device access; or
• Software that allows a computer or other electronic device to generate audible/verbal speech.

Other covered features of the device include the capability to generate email, text, or phone messages to allow the patient to "speak" or communicate remotely, as well as the capability to download updates to the covered features of the device from the manufacturer or supplier of the device.

As long as the speech-generating device is limited to use by a patient with a severe speech impairment and is primarily used for the purpose of generating speech, it is not necessary for a speech-generating device to be dedicated only to speech generation to be considered DME. Computers and tablets in general are not considered DME because they are useful in the absence of an illness or injury.

Internet or phone services or any modification to a patient’s home to allow use of the speech generating device are not covered because such services or modifications could be used for non-medical equipment such as standard phones or personal computers. In addition, specific features of a speech generating device that are not used by the individual who has a severe speech impairment to meet his or her functional speaking needs are not covered. This would include any computing hardware or software not necessary to allow for generation of audible/verbal speech, email, text or phone messages, such as hardware or software used to create documents and spreadsheets or play games or music, and any other function a computer can perform that is not directly related to meeting the functional speaking communication needs of the patient, including video communications or conferencing.

Synthesized speech, unlike pre-recorded messages of digitized speech, is a technology that translates a user's input into device-generated speech using algorithms representing linguistic rules.  Users of synthesized speech SGDs are not limited to pre-recorded messages but rather can independently create messages as their communication needs dictate.  Some SGDs require message formulation by spelling and access by physical contact with a keyboard, touch screen, or other display containing letters.  Speech generating software programs enable a laptop computer, desktop computer or personal digital assistant (PDA) to function as an SGD.  Within this policy, the term SGD also describes these speech generating software programs.  Speech generating devices may permit multiple methods of message formulation and multiple methods of device access.  For purposes of this policy, a SGD with multiple methods of message formulation should include message selection by 2 or more of the following methods: letters, words, pictures, and symbols.  A SGD with multiple methods of access should include the capability to access the device by 2 or more of the following: direct physical contact with a keyboard or touch screen, indirect selection techniques and a specialized access device such as a joystick, head mouse, optical head pointer, light pointer, infrared pointer, scanning device, or Morse code.

Upgrades of a SGD are subsequent versions of a SGD's software program or memory modules that may include enhanced features or other improvements.  Mounting switches are devices necessary to place the SGD, switches, and other access devices within the reach of the patient.

Accessories for SGDs include, but are not limited to, access devices that enable selection of letters, words, or symbols via direct or indirect selection techniques.  Examples of access devices include, but are not limited to, optical head pointers, joysticks, and SGD scanning devices.  The assessment of need for an SGD should be performed by a qualified speech-language pathologist (SLP).  For purposes of this policy, SLPs are licensed health professionals trained in the diagnosis and treatment of speech and language disorders.  The SLP should hold a Certificate of Clinical Competence from the American Speech and Hearing Association.

Communication aids that do not generate speech or writing are not covered under most Aetna benefit plans, as most plans have a specific contractual exclusion of communication aids.  Please check benefit plan descriptions for details.  In addition, communication aids that are not SGDs are not considered prosthetics for speech, as they do not replace internal or external body parts lost or impaired by disease or injury.  Picture books and flashcards are examples of non-covered communication aids.

In addition, these communication aids that are not SGDs do not meet the definition of covered durable medical or surgical equipment under Aetna's benefit plans.  Aetna's DME benefit covers medical or surgical equipment for treatment of disease or injury; or for the purpose of improving body function lost or impaired by disease or injury; or to enable the patient to perform essential activities of daily living related to the patient's health and hygiene, within or outside the home, with minimal or no assistance from others.  Aetna does not consider communication to be a bodily function.  Although communication may be considered an activity of daily living, it is an activity that is not related to the patient's health and hygiene.  Examples of functions and essential activities of daily living for which Aetna covers DME include bathing; feeding; toileting; walking; and transferring from bed to chair, wheelchair or walker.  Aetna does not consider communication to be an activity of this type.  Furthermore, patients requiring a communication aid are usually unable to perform any of these functions without assistance from others, with or without a communication aid.

The literature for some communication aids emphasize their value in expanding vocabulary skills, for use in business and for report preparation, and their ability to be connected to a personal computer.  This goes beyond what is considered to be an essential medical device.  For similar reasons, Aetna does not cover visual alert systems for the deaf or special controls on cars for people who need them to drive.

Speech may gradually improve after head trauma or stroke.  For these acquired disorders, SGDs are used as a last option.  Therefore, use of an SGD is not usually initated less than 4 to 6 months after trauma or stroke.

Medicare classifies SGDs as DME.  To be eligible for an SGD, Medicare requires that the beneficiary is enrolled in Medicare Part B; the beneficiary lives in his/her family home, or an assisted living facility (but not in a hospital, skilled nursing facility, or hospice); the beneficiary is determined, following an assessment by a SLP, to require an SGD to meet daily functional communication needs; and the beneficiary's physician prescribes the SGD.

Autism Spectrum Disorder

Lorah et al (2015) stated that powerful, portable, off-the-shelf handheld devices, such as tablet-based computers (i.e., iPad; Galaxy) or portable multi-media players (i.e., iPod), can be adapted to function as SGDs for individuals with autism spectrum disorders or related developmental disabilities.  These investigators reviewed the research in this new and rapidly growing area and delineated an agenda for future investigations.  In general, participants using these devices acquired verbal repertoires quickly.  Studies comparing these devices to picture exchange or manual sign language found that acquisition was often quicker when using a tablet computer and that the vast majority of participants preferred using the device to picture exchange or manual sign language.  The authors concluded that future research in interface design, user experience, and extended verbal repertoires is recommended.

Gevarter et al (2016) taught individuals with autism spectrum disorder (ASD) and limited vocal speech to emit target vocalizations while using a SGD. Of the 4 participants, 3 began emitting vocal word approximations with SGD responses after vocal instructional methods (delays, differential reinforcement, prompting) were introduced; 2 participants met mastery criterion with a reinforcer delay and differential reinforcement, and 1 met criterion after fading an echoic model and prompt delay.  For these participants, vocalizations initiated before speech outputs were shown to increase, and vocalizations generalized to a context in which the SGD was absent.  The fourth participant showed high vocalization rates only when prompted.  The authors concluded that these results suggested that adding vocal instruction to an SGD-based intervention can increase vocalizations emitted along with SGD responses for some individuals with ASD.  These preliminary findings need to be validated by well-designed studies.

Almirall et al (2016) noted that there are limited data on the effects of adaptive social communication interventions with a SGD in autism. These researchers compared growth in communications outcomes among 3 adaptive interventions in school-age children with ASD who are minimally verbal.  A total of 61 children, aged 5 to 8 years, participated in a sequential, multiple-assignment randomized trial (SMART).  All children received a developmental behavioral communication intervention: joint attention, symbolic play, engagement and regulation (JASP) with enhanced milieu teaching (EMT).  The SMART included 3 2-stage, 24-week adaptive interventions with different provisions of a SGD in the context of JASP+EMT.  The first adaptive intervention, with no SGD, initially assigned JASP+EMT alone, then intensified JASP+EMT for slow responders.  In the second adaptive intervention, slow responders to JASP+EMT were assigned JASP+EMT+SGD.  The third adaptive intervention initially assigned JASP+EMT+SGD; then intensified JASP+EMT+SGD for slow responders.  Analyses examined between-group differences in change in outcomes from baseline to week 36.  Verbal outcomes included spontaneous communicative utterances and novel words.  Non-linguistic communication outcomes included initiating joint attention and behavior regulation, and play.  The adaptive intervention beginning with JASP+EMT+SGD was estimated as superior.  There were significant (p < 0.05) between-group differences in change in spontaneous communicative utterances and initiating joint attention.  The author concluded that school-age children with ASD who are minimally verbal made significant gains in communication outcomes with an adaptive intervention beginning with JASP+EMT+SGD.  They stated that future research should explore mediators and moderators of the adaptive intervention effects and second-stage intervention options that further capitalize on early gains in treatment.  These findings were also confounded by the use of multiple modalities.

Gevarter and colleagues (2017) reported the findings of 5 children with ASD who were taught to request preferred items using four different augmentative and alternative communication (AAC) displays on an iPad-based SGD.  Acquisition was compared using multi-element designs.  Displays included a symbol-based grid, a photo image with embedded hotspots, a hybrid (photo image with embedded hotspots and symbols), and a pop-up symbol grid.  Three participants mastered requesting items from a field of 4 with at least 3 displays, and 1 mastered requesting items in a field of 2.  The fifth participant did not acquire requests in a field of preferred items.  Individualized display effects were present, and the photo image appeared to have provided the most consistent advantages for 3 participants.  Some errors were more or less common with specific displays and/or participants.  The authors concluded that the results have important implications for AAC assessment and implementation protocols.

Thiemann-Bourque et al (2017) examined the effects of a peer-mediated intervention that provided training on the use of a SGD for preschoolers with severe ASD and peer partners.  Effects were examined using a multiple probe design across 3 children with ASD and limited to no verbal skills; 3 peers without disabilities were taught to Stay, Play, and Talk using a GoTalk 4+ (Attainment Company) and were then paired-up with a classmate with ASD in classroom social activities.  Measures included rates of communication acts, communication mode and function, reciprocity, and engagement with peers.  Following peer training, intervention effects were replicated across 3 peers, who all demonstrated an increased level and upward trend in communication acts to their classmates with ASD.  Outcomes also revealed moderate intervention effects and increased levels of peer-directed communication for 3 children with ASD in classroom centers.  Additional analyses revealed higher rates of communication in the added context of preferred toys and snack.  The children with ASD also demonstrated improved communication reciprocity and peer engagement.  The authors concluded that these findings provided preliminary evidence on the benefits of combining peer-mediated and SGD interventions to improve children's communication.  Furthermore, it appeared that preferred contexts were likely to facilitate greater communication and social engagement with peers.

Furthermore, an UpToDate review on "Autism spectrum disorder in children and adolescents: Overview of management" (Weissman and Bridgemohan, 2018) does not mention SGDs as management tools.

In a community-based, randomized controlled, pilot study, Gilroy and colleagues (2018) compared the effects of the Picture Exchange Communication System (PECS) to a teaching sequence using a high-tech SGD to teach social communication behaviors.  The 2 approaches were compared to evaluate the effectiveness of the newer, more high-tech intervention using technology to improve social and communicative behavior of children diagnosed with ASD.  A total of 35 school-age children were randomized to either a high-tech (SGD device) or low-tech (PECS cards) form of AAC.  Subjects received 4 months of communication training delivered in their classrooms, and the primary outcome measures of the trial were several functional communication skills emphasized in the PECS teaching sequence.  Results indicated that both high-tech and low-tech AAC approaches resulted in significant improvements in communication, and that these improvements did not differ significantly between the 2 approaches.  These findings supported the use of high-tech AAC, and highlighted the need for evidence-based guidelines for its use as well as evaluation with individuals with various impairments and disabilities.  The authors concluded that these findings indicated that both "high-tech" and "low-tech" interventions were effective for improving behavior and that there was not a significant difference between the 2 approaches.

Thiemann-Bourque and associates (2018) examined the effects of incorporating a peer-mediated approach into a SGD intervention on communication of 45 non-verbal and minimally verbal preschoolers with ASD and 95 peers without disabilities.  The SGD was an iPad 2 (Apple) with voice output app.  Effects were evaluated using a multi-variate RCT design with repeated measures for 4 cohorts across baseline, intervention, generalization, and maintenance phases.  Children were randomly assigned to an experimental treatment that trained peers on use of the SGD or a business-as-usual comparison condition with untrained peers.  Communication outcomes were measured for both children with ASD and peers.  Children receiving the treatment demonstrated significant increases in rates of communication and more balanced responses and initiations (a measure of reciprocity) than children in the comparison group.  They were able to generalize improvements and maintain communication gains.  Treatment fidelity was high for school staff and peer implementation.  The authors concluded that the findings of this study supported positive effects on communication of teaching young children with ASD and peers without disabilities to use the same SGD system in typical preschool activities.  These researchers stated that SGD interventions that utilize peer-mediated approaches may improve core deficits in communication and reciprocity and allow for greater classroom social participation and interactions with peers.  They stated that much more research is needed that focuses on support and training for early education service providers working with this population in inclusive settings; and given the recent advances in the use of iPads as SGDs in classrooms and in clinical practice without evidence of effectiveness, it will be essential for future research to incorporate what is already known as effective SGD and peer-mediated instructional strategies to support staff using this technology.

The authors stated that although this was the largest study to-date of treatment effects on children and peers communication following an SGD intervention that utilized peer-mediated approaches, a few drawback of the study need to be addressed.  First, subjects with ASD varied in skill level for symbol selection at the start of each year.  Some children could select between 2 enlarged pictures, whereas some children were selecting from 15 to 20 symbols per page and scrolling pages.  These differences were attributed to varied experiences with SGDs and the rapid surge in the use of iPads over the course of the study.  However, all subjects with ASD were non-verbal or minimally verbal at the start (i.e., no speech or were using less than 20 words).  A second drawback was related to collecting data for the comparison group once-weekly and for the treatment group 2 to 3 times per week.  These investigators recognized this as a potential confound, in that the treatment group had more exposure to typically developing children and familiarity with the social activities, which could have impacted the outcomes.  However, repeated weekly observations of communication rates remained low and relatively stable for the comparison group; thus, there were enough repeated observations that these researchers believed the threat to internal validity was small.  Also, one could argue that additional observations may have been punitive for children who did not receive training and often sat silently, unsure what to do.  A third drawback of the study was the sample size.  Although this number could be considered large for an intervention study of this intensity with a low incidence population, outcomes could be generalized to a wider number of preschoolers with ASD and complex communication needs with more participants.  Furthermore, the sample size likely limited the statistical power to detect significant differences between groups on the parent and teacher report social validity measures.  Fourth, researchers who administered the post-intervention standardized language measures were not blind to group assignment at the end of the year.  A second research staff scored each standardized test protocol separately for 25 % of all children.  Item-by-item reliability across sub-tests on the 2 assessments was consistently above 80 % for all secondary scorings, limiting the possibility of experimental bias by assessors.  Another drawback related to procedures for coding communication acts.  Due to the timing criterion for coding initiations (INs) and responses (RSs), if a child initiated using speech ("my ball") then 2 seconds later pushed the SGD to request "ball" and a peer responded, then only the last communication act prior to the peer RS was coded (SGD not speech in this example).  Further, if a child pushed multiple buttons in a sequential manner, only one communication act was coded (e.g., pushed symbols for "I want + puzzle piece + Sarah" all coded as one IN using SGD).  The authors also coded child vocal imitations and SGD imitations of peer acts as RSs.  Not coding imitative acts would have strengthened the findings in relation to the importance of measuring and reporting changes in spontaneous communication and contextual responding.  Finally, the authors did not code the appropriateness of the communication act in matching the child's actual communicative intent.  On occasions when this occurred, the peer responded accordingly to the perceived intent (e.g., "you already have that color, what other one do you want?").  This type of peer feedback is important for children to learn new communication skills.  These examples showed how the coding system could be improved in future research to better understand outcomes on a number of important child-peer communication variables.

Wendt and colleagues (2019) employed a multiple baseline, single-subject research design to examine the efficacy of an iPad-based SGD.  The iPad was equipped with the SPEAKall! application to function as a SGD.  SGDs are a form of aided AAC allowing a user to communicate using digitized and/or synthesized speech.  Instruction followed a modified version of the intervention phases from the Picture Exchange Communication System (PECS).  This modified PECS protocol was implemented with 2 adolescents and 1 young adult between the ages of 14 and 23.  All 3 subjects were diagnosed with severe autism spectrum disorder (ASD) and little to no functional speech.  Dependent measures included the ability to request for edible and tangible items as the primary measure, and the ability to engage in natural speech production as an ancillary measure to determine simultaneous, additive effects on speech acquisition.  Results indicated increases in requesting behaviors for all 3 subjects across intervention and maintenance phases.  Once subjects mastered requesting of edible items, they were able to generalize the skill to tangible items.  However, mixed results were found when targeting natural speech production.  Based on the current findings, the infusion of an iPad-based SGD into PECS instruction may be effective in increasing initial requesting skills; however, a facilitative effect on increasing speech acquisition cannot necessarily be expected for every subject.  Moreover, these investigators stated that future research may also wish to pay attention to assessing and reporting what cognitive, speech, and language skills the subjects bring to the task.  A precise and systematic assessment and documentation of individual characteristics can enhance the ability to identify potential predictors of communication and speech production outcomes.

The authors stated that this study had several drawbacks.  First, subjects were 1 young adult and 2 adolescents with ASD.  The findings may limit to certain cohorts and may not able to generalize to different age groups or individuals with different characteristics.  Subjects in this study were taught to discriminate graphic symbols; however, 2 of them still had difficulty with discrimination under systematic instruction.  Second, the PCS stimuli used in this study were selected based on the assumptions that PCS represented a highly iconic symbol set, and were commonly used as part of visual supports within the subjects’ natural environments.  However, there was no symbol assessment process to identify symbol preferences a priori to the investigation.  A detailed symbol assessment can help to choose types of symbols that fit with current communication needs and abilities as well as future needs.  Third, generalization was tested after the completion of intervention; generalization of each PECS phase by itself was not evaluated.  Although the results indicated the subjects were able to apply the taught skill for requesting for different categories of items, more research is needed to evaluate if subjects are able to apply the skill and transfer it from a clinical setting to a natural setting.

Bourque and Goldstein (2019) reported a secondary analysis of the nature of communicative functions and modalities used in initiations and responses of minimally verbal preschoolers with severe ASD from a previously published study.  This analysis focused on the final cohort (n = 6) from a group design study (n = 45) that examined a peer mediation and SGD intervention compared to an SGD-only condition.  After teaching peers to use an iPad as an SGD within a modified stay-play-talk approach, school staff implemented SGD instruction in child-peer dyads during typical preschool activities.  To examine individual differences among children who demonstrated increased communication acts in the peer + SGD condition, changes in reciprocity, modalities used, and communicative functions were examined using a multiple-baseline design across children.  Fidelity of implementation and social validity data were also collected.  A total of 6 children with ASD and their peers demonstrated more balanced reciprocity, with individual differences in how and why children communicated during exchanges.  That is, all children with ASD increased in SGD use as their primary communication mode; 3 children used different modalities including more speech, and 3 children used primarily gestures and SGD.  The most frequent function expressed was requests for objects.  More modest increases were observed in comments and requests for actions, with negligible changes in gaining attention.  Social validity reports by naive judges reflected clear improvements in communication interactions.  The authors concluded that the findings of this study were promising for a preschool SGD intervention that could expand children's modalities and communicative functions to engage in balanced exchanges with peer partners.  Moreover, these researchers stated that future research is needed to document outcomes of peer-mediated and AAC interventions on these early skills as well as the long-term effects on children's relationships and social participation in elementary school.

The authors stated that this study had several drawbacks.  Within single-case experimental designs, external validity is enhanced by replicating intervention effects across different individuals, with the goal of providing strong experimental evidence of treatment efficacy and generality to similar children.  One design limitation in this study was collecting 4 baseline sessions for 2 children as well as collecting 3 follow-up sessions; the recommended minimum is 5 per phase.  Performing this type of study in school settings puts limits on the amount of data that could possibly be collected in 1 school year.  These findings from 6 children indicated individual variations in the response to this intervention.  One could expand upon the generalizability of effects via systematic replications with refined procedures or with participants with different characteristics.  Determining the broad applicability to the larger population of minimally verbal children with ASD can be accomplished via RCTs.  These researchers stated that large samples are needed to identify the myriad of factors that may moderate treatment effects.

Frampton and colleagues (2020) noted that direct instruction (DI) is an evidence-based approach to education that has been demonstrated to be effective across various student populations.  Growing evidence suggests that DI may be an effective strategy for individuals with ASD.  These investigators examined the feasibility of using DI with students with ASD who utilize SGDs.  In this study, a total of 3 students with ASD whose primary mode of communication was an SGD were exposed to the Language for Learning Curriculum, Lessons 1 to 10.  Student performance on pre- and post-tests was measured, as well as student performance on exercises within each lesson.  The average time to complete an exercise, number of repetitions, number of terminated sessions, and student affect were also evaluated.  Results indicated that all 3 students could participate and complete exercises with some modifications to support SGD use.  The students demonstrated improved performance, positive affect, and overall timely completion of exercises.  The authors concluded that these findings suggested that DI may be feasible for some students with ASD who use SGDs.  These researchers stated that this study offered preliminary support for the feasibility and effectiveness of the DI-LL for children with ASD who utilize SGDs. The intervention was effective for all participants, producing increased performance from baseline, though only one participant met the criteria for mastery. This participant, Brian, also had the strongest overall scores on the EVT and PPVT. More research is needed to determine what types of prerequisite skills are predictive of success with the DI Language for Learning (DI-LL) for children with ASD.  They stated that future studies should consider using preference assessment procedures to examine if participants would choose the DI-LL intervention over traditional forms of language instruction.  These researchers hoped that the findings of this study offered an avenue of investigation for clinicians wishing to use this technology with their learners.

The authors stated that this study had several drawbacks.  The clinician leading the sessions was an SLP with many years’ experience using and programming SGDs for students with ASD.  Although it was not necessary for every session, the SLP frequently needed to add vocabulary to the students’ devices so they could complete the exercises.  This task was necessary for completion of the study.  Furthermore, these 3 students were selected for participation in the study based on the SLP’s familiarity with them as well as their educational needs.  Whether these results can be obtained with broader recruitment and randomized assignments to treatment remains to be determined.

Children with Developmental and Language Delays

Barton-Hulsey and colleagues (2017) reported the findings of 3 children aged 3 years and 6 months to 5 years and 3 months with developmental and language delays who were provided experience with a traditional grid-based display and a contextually organized visual scene display on a SGD to illustrate considerations for practice and future research in AAC assessment and intervention.  Twelve symbols were taught in a grid display and visual scene display using aided input during dramatic play routines.  Teaching sessions were 30 minutes a day, 5 days a week for 3 weeks.  Symbol comprehension and use was assessed pre- and post-3 weeks of experience.  Comprehension of symbol vocabulary on both displays increased after 3 weeks of experience.  Subjects 1 and 2 used both displays largely for initiation; subject 3 had limited expressive use of either display.  The authors concluded that the methods used in this study demonstrated one way to inform individual differences in learning and preference for SGD displays when making clinical decisions regarding AAC supports for a child and their family.  They stated that future research should systematically examine the role of extant comprehension, symbol experience, functional communication needs, and the role of vocabulary type in the learning and use of grid displays versus visual scene displays.

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References