Introduction to the Special Issue: Communication Intervention for Individuals with Complex Communication Needs

Complex communication needs refer to situations where a person lacks sufficient speech and language to engage in everyday communicative interactions. People with complex communication needs have considerable difficulty with the production of speech, the understanding of speech and language, and the use of reading and writing skills. The term is generally reserved for cases in which speech and language impairment is significantly impaired; not merely delayed. This term is also not applied to the Deaf, who most often learn to communicate effectively through sign language. Rather, individuals with complex communication needs display a degree of communication impairment that is severe, pervasive, and unlikely to be resolved to any appreciable degree without deliberate, explicit, and often intensive intervention efforts.

Complex communication needs are associated with a number of developmental disorders as well as with many different types of acquired conditions. Beukelman and Mirenda (2012) noted a wide range of conditions concomitant with either extremely limited speech and language development and/or with the loss of previously acquired language skills. These include (a) autism spectrum disorder, (b) intellectual disability, (c) cerebral palsy, (d) developmental apraxia of speech, (e) amyotropic lateral sclerosis, (f) multiple sclerosis, (g) traumatic brain injury, (h) stroke, and (i) spinal cord injury. Among children with autism spectrum disorder, for example, it has been estimated that approximately 30% are “minimally verbal,” meaning they “. . . remain with little expressive spoken language abilities by the time they reach school age” (Tager-Flusberg & Kasari, 2013, p. 468).

The range of etiologies associated with complex communication needs is matched by an equally wide range of communication intervention needs. For example, some individuals require extensive supports and intervention efforts in order to be able to express even their most basic wants and needs. Many such individuals will also require extensive training in order to be able to effectively initiate meaningful social-communicative interactions with others. Meeting this myriad of needs includes finding and teaching viable modes of communication that will enable the person to accomplish a range of communicative functions. In line with the evidence-based practice movement, the overall intervention process should be guided in part by the current best available evidence regarding treatment effectiveness (Dollaghan, 2004).

Along these lines, behavior modification approaches have a long history of demonstrated success in improving the communicative functioning of persons with complex communication needs. Pioneering research in the 1960s and 1970s (e.g., Guess, Sailor, & Baer, 1974; Lovass, 1977; Lovass, Berberich, Perloff, & Schaeffer, 1966) demonstrated successful application of operant conditioning procedures for teaching a range of expressive and receptive language skills to persons who had limited speech due to developmental disability. Later, researchers demonstrated how these same instructional principles could be used to teach non-speech modes of communication (e.g., manual signing and graphic mode communication systems) to individuals with complex communication needs (Carr, Binkoff, Kologinsky, & Eddy, 1978; Duker, 1988; Reichle, Rogers, & Barrett, 1984). Influenced by behavior analytic accounts of language (Skinner, 1957), intervention programs also began to emphasize the acquisition of specific communicative functions (e.g., manding and tacting), rather than focusing on the more structural aspects of language, such as syntax, semantics, and morphology (Sundberg, 1980).

Since these initial successes, researchers operating within a behavior analytic paradigm have continued to make advances in the provision of communication intervention to individuals with complex communication needs. The aim of the present special issue is to showcase contemporary behavior analytic research efforts in the area of communication intervention for individuals with complex communication needs. The papers in this special issue highlight recent trends and advances in communication intervention research conducted within an applied behavior analytic framework.

In the lead article, Reichle, Simacek, Wattanawongwan, and Ganz (2019) provide an overview of the critical components of communication assessment and augmentative and alternative communication (AAC) intervention for individuals with complex communication needs. The authors focus on an increasingly popular AAC option, that is the use of aided AAC systems, such as electronic speech-generating devices (SGDs). The challenges and complexities of supporting this population are made clear as is the need for additional research on configuring aided AAC systems for this population. Overall, the authors provide a tremendous service to the field through this systematic overview of critical decision points and by highlighting a number of priority areas for future research. Their paper provides a context and sets the stage for the four intervention studies that follow.

In the first intervention study of the special issue, Wendt, Hsu, Simon, Dienhart, and Cain (2019) evaluated an intervention that involved using SGDs within the widely used and well-validated Picture Exchange Communication System (PECS) intervention protocol. This integrated approach was provided to three persons (adolescents and adults) with severe autism, all of whom had little to no functional speech. Intervention focused on teaching mands (i.e., requesting behavior) and provided evidence of an effective behavioral intervention for functional use of aided AAC. This demonstration will no doubt stimulate additional research on the utility of combining SGDs with the PECS instructional protocol. The authors do caution, however, that successful acquisition of SGDs for requesting purposes is by itself unlikely to increase natural speech production. The main lesson from this study is perhaps that aided AAC is most properly seen as a viable means of enabling functional communication and its effectiveness should therefore not necessarily be judged by whether or not this type of intervention also facilitates natural speech development.

The next paper by Lancioni et al. (2019) documents effective use of smartphone technology for enabling seven adults with multiple impairments to participate in a very modern type of communication, that is sending and receiving WhatsApp messages. These researchers demonstrated that combining an innovative smartphone configuration with behavior analytic instructional supports, (i.e., verbal and physical prompting), led to an increase in participants’ ability to use this socially meaningful form of message exchange with family members and care staff. Their technology-based program had the added bonus of also promoting increased leisure engagement among the seven participants. Technology-aided programs of this type may enable increased social communication and leisure engagement for people with severe and multiple disabilities.

Roche et al. (2019) adopted a low-tech approach in their efforts to teach multiword spoken requests to two children on the autism spectrum. Interestingly, while both children’s speech repertoire was initially limited to single word utterances, a standardized communication assessment revealed that both of these children showed a relative strength with respect to reading printed words. Capitalizing on this strength, the researchers taught both children to produce multiword utterances by providing printed word prompts and then gradually fading out these textual prompts. By the end of the intervention, the two children were producing three-word (Liam) or four-word (Jacob) spoken requests. The results of this study highlight the value of conducting initial communication assessments to identify areas of relative strength. Once identified, it may be possible to make use of those strengths to advance the person’s communication.

The intervention study by Ferguson, Falcomata, Ramirez-Cristoforo, and Vargas Londono (2019) addresses the important issue of response variability. This is an important issue because many individuals with complex communication needs present with rather inflexible and invariant ways of communicating. Ferguson et al.’s approach involved conceptualizing response variability as a reinforcement problem; a problem that might thus be overcome by modifying the reinforcement contingencies maintaining the person’s communication behavior. In the present case, the modification involved varying the magnitude of reinforcement. The data they collected on four children with autism spectrum disorder clearly showed that larger magnitudes of reinforcement were associated with increased variability in the children’s communication responses. These data suggest that response variability is a modifiable aspect of communication and hence it could be seen as a relevant intervention goal for individuals who present with limited communicative variability.

The final paper by Wolfe, Pound, McCammon, Chezan, and Drasgow (2019) extends the theme of response variability by systematically reviewing intervention studies focused on promoting more varied social-communicative behavior in individuals with autism spectrum disorder. Specifically, Wolfe et al.’s review found moderate to strong evidence to support the use of lag schedules of reinforcement for promoting response variability. The authors provide insightful future directions for research including (a) examining alternative intervention approaches, (b) focusing on increasing novel responses, (c) determining ways to improve maintenance, and (d) teaching individuals to recognize conditional discriminations that indicate when a response should vary in a given context.

Collectively, the articles in this special issue reflect a number of emerging trends and significant advances related to the provision of communication intervention to individuals with complex communication needs. We are grateful to the authors of these papers for contributing new data and syntheses that will no doubt have a lasting impact on the field and ultimately lead to a higher quality of life for individuals with complex communication needs. We are also grateful to the Editor of Behavior Modification, Alan S. Bellack, for giving us the opportunity to serve as Guest Editors for this special issue. Finally, we express our sincere appreciation to the many reviewers who were enlisted to evaluate the merits of each submission. Your constructive feedback on these special issue papers has greatly improved their impact. Thank you.