A Guide to Incorporate Augmentative and Alternative Communication Into Functional Communication Training

Abstract

Children with autism spectrum disorder often display some form of challenging behavior and have complex communication needs. Functional communication training is an evidence-based practice that (a) decreases challenging behavior and (b) increases appropriate communicative behavior. Recent research has demonstrated how using augmentative and alternative communication (i.e., various forms of communication that do not involve vocal speech) can be successfully incorporated into functional communication training interventions. This article introduces a four-step guide on how to incorporate augmentative and alternative communication within functional communication training interventions. Detailed guidelines on how to incorporate augmentative and alternative communication, along with a vignette example, are provided.

Keywords

autism functional communication training augmentative and alternative communication challenging behavior

An estimated 90% of children with autism spectrum disorder (ASD) display some form of challenging behavior (Simó-Pinatella et al., 2019). This is not surprising, as those with ASD often present with complex communication needs, meaning that their vocal speech does not meet their daily needs (American Psychiatric Association, 2013; Beukelman & Light, 2020). Having complex communication needs has been classified as a risk marker for challenging behavior in those with ASD (Dworschak et al., 2016). Until children with ASD are explicitly taught to replace a challenging behavior (e.g., self-injury, tantrums) with a functionally equivalent behavior (e.g., requesting a break), the challenging behavior may serve as the most efficient and effective way to communicate wants and needs. One evidence-based practice to replace challenging behavior with functionally equivalent communication is called functional communication training (FCT; Carr & Durand, 1985; Hume et al., 2021).

Functional communication training has been found to be effective for a wide range of communication modes (e.g., vocal speech, speech-generating devices) and abilities (Heath et al., 2015). Children with ASD and complex communication needs often require systematic and explicit instruction to learn supplemental or alternative forms communication, called augmentative and alternative communication (AAC; Beukelman & Light, 2020). There are many forms of AAC including aided (e.g., speech-generating devices, picture cards) and unaided (e.g., gestures, manual signs) approaches. Recently, FCT with AAC supports has been found to be effective at decreasing challenging behavior and increasing appropriate AAC usage for students with developmental disabilities (Ousley et al., 2020; Walker et al., 2018).

Research-to-practice gaps exist in the implementation of evidence-based practices for children with ASD in real-world settings (Odom et al., 2020). One reason for these gaps is due to practitioners not having the background information or fundamental skills to understand and implement procedures described in research articles within their classroom (Dingfelder & Mandell, 2011). Researchers have developed guidelines on implementing FCT (Tiger et al., 2008; Wu et al., 2021), including those specifically targeting AAC use (McComas et al., 2019; Mitteer et al., 2020) to provide a connection between evidence-based practices and real-world applications. However, currently published guidelines on how to implement FCT with AAC supports use language that may not be easily understood by practitioners who do not have an applied behavior analytic background (e.g., motivating operation, discriminative stimulus). For example, in a book chapter, McComas et al. (2019) provided a robust explanation on how to infuse AAC within FCT by increasing natural contingencies of reinforcement by considering stimuli and motivating operations to increase response strength. In another example, Mitteer et al. (2020) provided suggestions on how to program discriminative stimuli and stimulus deltas within AAC applications systems (e.g., cues on when breaks are available).

It appears that no guide describing how to implement FCT with AAC supports with simple language has been developed for practitioners. Based on a synthesis of the quality and rigor of FCT research that incorporated AAC (Ousley et al., 2020) to assess the components required for successful use of FCT with AAC, this article provides practitioners, such as teachers, speech-language pathologists, and paraprofessionals, with an easy-to-follow guide to assist with replacing challenging behavior with functionally equivalent AAC usage. Four steps will be described and explained through a vignette (see Note 1).

Guidelines for Implementation

Practitioners can quickly teach their students or clients with ASD who display challenging behavior to engage in a functionally equivalent AAC communicative response rather than the challenging behavior. Prior to beginning, it is essential that the practitioner identifies a specific and clearly defined behavior. Behaviors such as “noncompliance” and “tantrums” can vary greatly. For example, noncompliance may involve tearing up homework and throwing it on the floor, but also may be more passive, such as not starting homework when asked. Tantrums can range from dropping to the floor and screaming to forcefully hitting an adult with a closed fist. To be consistent throughout the intervention, practitioners must first develop a clear, complete, and objective definition of the targeted challenging behavior (Baer et al., 1968; Hawkins & Dobes, 1977). Practitioners may find having another colleague review and confirm the definition to be beneficial. Once the definition of the challenging behavior is developed, practitioners can begin using this guide to assist in developing an appropriate program plan for their client or student with complex communication needs who displays challenging behavior. A descriptive vignette explains how the steps can be applied. See Figure 1 for an explanation on how each step connects to one another.

Miss Penny is a first grade teacher and is concerned about a child in her class, Adrian. Adrian has ASD and complex communication needs. He communicates with a speech-generating device. Miss Penny collaborates with a paraprofessional in the classroom, Mrs. Chakra, to clearly define Adrian’s challenging behavior. Together they define Adrian’s challenging behavior of vocal disruption as: a high-pitched vocalization lasting 2 or more seconds at a volume above that of a conversational level. A non-example would be if Adrian is making noises along with the classmates during music class.

Figure 1.

An illustration of the four steps of incorporating augmentative and alternative communication (AAC) supports within functional communication training (FCT) interventions.

Step 1: Determine the Function of the Challenging Behavior

The first step in any FCT intervention is to determine the function of the challenging behavior that is occurring. In other words, “Why is the behavior happening?” Challenging behavior does not occur in a vacuum. It happens in various contexts—usually to get or get out of something (Iwata et al., 1994). Put differently, challenging behavior may occur to gain (a) attention, (b) tangible items or activities, or (c) sensory stimulation. Conversely, challenging behavior may occur to avoid or escape (a) someone’s attention, (b) an unpleasant situation or task, or (f) unpleasant sensory stimulation (Alberto & Troutman, 2013). Sometimes one challenging behavior can serve more than one function and is said to be multiply-maintained. It should also be noted that challenging behavior may arise due to a medical condition (e.g., medication changes, ear infection). Thus, it is important for the practitioner to work closely with the child’s family to rule out these causes first. Table 1 outlines the common functions of challenging behavior and provides corresponding examples.

Table 1.

Functions of Behavior and Examples.

Function	Example
Gain
Attention	During P.E., the class is bowling. A child with ASD likes to knock down the bowling pins when his peers roll the ball. The child then runs around the gym and the paraprofessional chases him. Adult attention is gained.
Tangible	Lunch time is at 1pm. Everyday around 11am, a child with ASD hits his chin with a closed fist. Whenever the child hits his chin, the teacher provides the child with a snack. Access to a tangible food item is gained.
Sensory stimulation	At the conclusion of every speech session, a child with ASD flips tables and clears desks. Following every instance of property destruction, the therapist walks the child to the sensory room to calm down. Sensory stimulation (a calm space with a bubble tower) is gained.
Escape
Attention	A child is on the playground, and another child comes up to get on the same playscape. The child with ASD hits their peer. The other child runs away. Peer attention is removed.
Contexts or tasks	During circle time, all of the children get to choose where they sit. However, a child with ASD has an assigned seat next to the paraprofessional. The child bites the paraprofessional, and he is sent to timeout. The child has escaped the context of circle time.
Sensory stimulation	On Fridays, the whole class walks down to the gym for an all school assembly. It is very loud. The child with ASD now hits his head on Fridays around the time the class walks down to the gym. The paraprofessional walks him back to the room when this happens. The child escapes loud stimulation (aversive noises) by engaging in this behavior.

Note. Before determining the function of the behavior, the practitioner should rule out any medical reasons (e.g., ear infection, urinary tract infection) for the behavior. Behavior may severe more than one function. ASD = autism spectrum disorder.

In some cases, it may be very easy for the practitioner to identify why the child with ASD is engaging in a challenging behavior. For example, a child may scream for a tangible item (e.g., toy) immediately after a peer takes it from them. The function, or purpose, of the behavior is likely to re-access the tangible item, especially given that the child screamed immediately after losing the toy. Unfortunately, the function of challenging behavior is not always so obvious. Furthermore, not all challenging behavior serves the same purpose. For example, in this case the child screamed to gain access to a tangible item. In another scenario, the same child may scream to avoid an undesired task. Despite displaying the same form of challenging behavior, the function of, or reason for, the child’s screaming was different in the two scenarios.

There are many tools to assist practitioners in determining the function of behavior. These assessments are called functional behavior assessments (FBA). Research has demonstrated how educators can quickly learn how to use tools to determine the function of behavior (Machalicek et al., 2010). An FBA may involve (a) indirect methods, such as interviews, questionnaires, and checklists; (b) direct measurement (e.g., data collection, observations); or (c) a combination of these methods. They help practitioners figure out the triggers of the challenging behavior (e.g., certain tasks, times of day) as well as the predictable changes that occur after the challenging behavior (e.g., the child delays work or gets adult attention). What occurred immediately before and after the challenging behavior are important aspects to understand the function of a behavior. See Table 2 for a list of FBA methods.

Table 2.

Types of Functional Behavior Assessments.

Type	Name	Description
Indirect	Behavioral Interview	Questions such as when, where, how, and with whom the behavior occurs are asked to develop clear and objective information to identify the antecedent, behavior, and consequences. Data are analyzed for themes.
Indirect	Behavior Rating Scales	A Likert-like scale (e.g., never, sometimes, often, always) used to estimate the frequency and conditions in which the behavior occurs.
Direct	ABC Recording	An observer documents what happened before (antecedent), during (behavior), and after (consequence) the behavior. Data are collected over time and themes are analyzed.
	Scatterplot Recording	A sheet outlining blocks of time in the day is developed and each occurrence is recorded. Occurrences are then displayed through a scatterplot, demonstrating when the behavior occurs most in the day.

Mrs. Chakra collects ABC Recording data, a direct observational method of data collection, for one school week during math class. After 5 days, Miss Penny and Mrs. Chakra analyze and discuss the data. They note that Adrian engaged in vocal disruption 22 times over the course of the 5 days. The most common consequence was adult attention. Specifically, after each occurrence of the challenging behavior, Mrs. Chakra came over to Adrian’s table to tell him, “You need to have a quiet mouth.” Together, Miss Penny and Mrs. Chakra determine that Adrian is likely engaging in vocal disruption in order to receive attention from Mrs. Chakra.

Step 2: Identify a Functionally Equivalent Replacement

Once the function of the behavior is identified, the practitioner should move to identify a functionally equivalent replacement behavior. In other words, “What behavior will serve the same purpose as the challenging behavior?” The practitioner should identify a more socially appropriate communicative response they wish to teach the child to replace the challenging behavior. This replacement must be functionally equivalent, meaning that it must serve the same purpose as the challenging behavior (Horner & Day, 1991; O’Neill et al., 2014). For example, if a practitioner has identified the reasoning for a child’s challenging behavior is to escape from a difficult task, an appropriate communicative response may involve asking for a 5-min break. Or, in the case of Adrian, Miss Penny and Mrs. Chakra need to determine another way that Adrian can request attention from his teacher.

It is critical that the replacement behavior serves the same function as the challenging behavior. If not, the child may not be as motivated to engage in the replacement behavior, therefore defeating the purpose of the intervention. As an example, a child may engage in tantrums (e.g., screaming, dropping to the floor) serving the function of escaping a task. If the practitioner identifies a replacement behavior such as requesting a break (e.g., asking to get a drink down the hallway, asking for a 5-min break), the function of the replacement behavior is consistent, to escape from a task. This is a functionally equivalent replacement behavior (i.e., leads to the same desired outcome or consequence as the challenging behavior). A nonexample would be if the replacement behavior was requesting a snack (e.g., having a speech-generating device say, “I would like a snack”). Requesting a snack may not serve the same function of escape. Instead, it would serve the function of accessing a tangible item (i.e., snack). The practitioner must ensure the replacement behavior is individualized for the child, as the replacement behavior should be motivating and serve the same purpose as the child’s challenging behavior (Horner & Day, 1991).

Miss Penny and Mrs. Chakra discuss how else Adrian can receive attention. Mrs. Chakra suggests that Adrian could request help on assignments or activities. Miss Penny agreed that it would be an excellent behavior that could serve the same purpose as Adrian’s vocal disruptions, to gain attention.

Step 3: Prepare AAC

The practitioner should choose an appropriate mode of AAC that will allow the child to engage in the replacement behavior. In short, how will the child communicate the replacement communicative response? When selecting an AAC system, practitioners should consider the child and their individual communicative needs (Beukelman & Light, 2020). In doing so, the practitioner encourages the child to communicate a want or need, rather than just engage in a learned behavior. Specifically, the practitioner should ensure (a) the AAC system is accessible and presented at the midline of the child (Light et al., 2019); (b) the concepts selected are familiar and motivating to the child (Beukelman & Light, 2020); and (c) the targeted communication considers the child’s experiences and encourages social interaction (Light, 1997). As an example, if a child does not understand two-dimensional stick figure representations, asking them to pass a picture-symbol may not be the most appropriate form of AAC. Rather, the child may benefit from a photographic exchange using a realistic photo to representing the replacement behavior. If the child is literate, orthographic representations (i.e., the written word) presented on an index card may be appropriate. The key to AAC selection is ensuring it is (a) individualized to the child, (b) engaging for the child, and (c) quick and easy for the child to access.

A further consideration when determining the mode of AAC is the ease of use, or amount of effort needed to engage in the replacement communicative response. Research suggests that teaching replacement behaviors is more successful when the competing replacement behavior requires similar or less effort when compared with the challenging behavior (Horner & Day, 1991; O’Neill et al., 2014). If the replacement behavior is too effortful (e.g., requiring the child to ask for a break with correct grammar), it is extremely likely that the child will revert back to the challenging behavior because it had worked (i.e., gotten them the desired outcome) in the past. For example, if a child screams to seek attention, the replacement behavior should be just as simple and easy to do as screaming. A simple hand-raise or single-switch button that says, “I need help,” requires a similar amount of effort. In this same scenario, a robust three-step speech-generating device (i.e., requiring navigation through multiple pages) to seek help may not be as motivating to child, at least not initially. However, if the child or student has a formal AAC system, this approach may be appropriate. It is imperative that the practitioner chooses an initial replacement communicative response that requires less effort on the child’s part. Doing so will reduce frustration.

Because Adrian is already familiar with using a speech-generating device to request wants and needs, Mrs. Chakra programs a new icon during morning work on his grid-display: Help. The device is placed on Adrian’s desk where Adrian can easily access the device. Adrian immediately notices the new icon and presses it. The AAC system states, “help.” Mrs. Chakra smiles and says, “Yes, Adrian? How can I help you?” Adrian smiles, and Mrs. Chakra helps him with his morning work.

Step 4: Model and Reinforce the Replacement Response

Finally, once the previous steps are complete, the practitioner is ready to implement the fourth and final step, to model and reinforce the replacement communicative response. In other words, teach the replacement communication and give the child what they want. The goal of this step is for the child to seamlessly replace their challenging behavior with the more desired communicative response identified in Step 2. When the environment, AAC system, and child are ready, the practitioner may begin to model the new behavior and reinforce the child for engaging in the replacement behavior.

In the initial stages of teaching the child the replacement communicative response, practitioners may have to provide a model on how to perform the desired communicative response. After modeling the expected behavior, the practitioner may fade to prompt or provide cues for the child to engage in the replacement behavior. Common prompts are verbal (e.g., saying, “Tell me what you want”), gestural (e.g., pointing to the AAC system), partial physical (e.g., guiding the child’s hand from their lap to the table where their AAC system is), and full physical (e.g., controlling the child’s hands with hand-over-hand guidance to sign the word, “more”) guidance (MacDuff et al., 2001). Common cues may be to have a picture of the desired outcome (e.g., tangible item) present for the child to see. As with the previous steps, the prompts and cues that are used should be individualized to the child and their needs. Practitioners may find that the child requires more guidance in the initial stages of the intervention. For example, the first few trials may include a more intrusive prompt (e.g., hand-over-hand guidance) to ensure the child is immediately receiving the reinforcer from the very beginning of the intervention. Over time, the practitioner may then gradually fade out prompt support by moving to a partial physical or gestural prompt. Eventually, the child will learn to engage in the replacement behavior. As previously mentioned, the type of prompt used should be individualized to the child and their needs. The key to prompting is to gradually fade out the support to allow for the child to become independent and not prompt dependent.

At the beginning of independent work time during math, Mrs. Chakra models, or demonstrates, how to use the new icon on his AAC device. “This says, ‘help.’” Mrs. Chakra presses the icon and the device says, “help.” Mrs. Chakra continues, “If you ever need help with something, you can press this symbol, and I will come over to help you. Let’s practice!” Mrs. Chakra prompts Adrian by pointing to the system. Adrian activates his AAC system, and the voice output, “help,” is played. Mrs. Chakra helps Adrian with the first math problem. Afterward, she reminds him to use his AAC system to ask for help whenever he needs it, then she moves on to help another student. The next day, Adrian engages in the challenging behavior during independent math time. Mrs. Chakra ignores the vocalization. Then, Miss Penny walks near the device and points to the icon that says, “help.” Adrian activates the speech-generating device to request attention by asking for help. Mrs. Chakra assists Adrian with one problem, then moves on to helping another student.

As mentioned here, the practitioner should reinforce the child’s communication immediately and frequently after the child engages in the replacement communicative response (Michael, 2004). The key is to reinforce the child’s replacement behavior (i.e., prompted or unprompted) as quickly as possible. The reinforcement for the replacement behavior should be directly linked to the desired outcome for the child (i.e., the function of the behavior). For example, if the replacement behavior is to activate a speech-generating device that says, “eat,” the reinforcement should be immediate access to a desired food item. Over time, the child should replace the challenging behavior with the targeted AAC system. This can be determined by analyzing the data. If the challenging behavior is not replaced with the targeted AAC communicative response, several aspects should be evaluated.

Is the function of the replacement behavior the same as the challenging behavior?

Is the AAC system appropriate for the child?

Is the child’s replacement communicative response being reinforced immediately?

Once these aspects are considered, the practitioner may find that one of the components of the FCT intervention was not appropriate for the child. If so, the practitioner should go back to the corresponding step and adjust as needed.

Once the child has successfully replaced their challenging behavior with the previously identified replacement, the practitioner can begin to delay reinforcement (Hagopian et al., 2011). For example, if a child’s replacement behavior is to hold a card up in the air that states, “break,” the practitioner may tell the child that they can have a break after completing one more task. Over time, the practitioner may expand the number of tasks and/or amount of time between the replacement behavior and reinforcement. This is a balancing act and should be carefully planned and monitored (e.g., if the child starts to engage in the challenging behavior again, the practitioner should reassess). For more detailed information on how to delay or thin reinforcement, see Hagopian et al. (2011).

Finally, practitioners may find it useful to generalize the replacement communicative responses to other communication partners, settings, and activities (Neely et al., 2018). This should occur one aspect at a time and not all at once. Ensuring that the child has access to appropriate AAC systems and is receiving an intensive and individualized intervention may allow the child to have a more robust vocabulary (Kasari et al., 2014), thus preventing future challenging behavior (Machalicek et al., 2007).

After 2 weeks of intervention, Miss Penny and Mrs. Chakra reevaluate the data. Adrian has only engaged in the challenging behavior three times over the last 2 weeks! They then decide to thin the schedule of reinforcement—Mrs. Chakra can only help Adrian three times per independent work time. Mrs. Chakra explains the new rule to Adrian and continues with the intervention.

Conclusion

This guide is based upon decades of research on FCT interventions with AAC supports, developed to help increase the uptake of evidence-based practice in schools and clinics. Given that challenging behavior and communication deficits are common for children with ASD (Machalicek et al., 2016), the use of FCT interventions may assist practitioners in decreasing a child’s challenging behavior, while also increasing desired AAC usage. The simple four-step guide was developed to aid practitioners in implementing the evidence-based practice, FCT, in their classrooms and/or clinics when working with those who require AAC: (a) determine the function of the behavior, (b) identify a functionally equivalent communicative response, (c) prepare AAC, and (d) model and reinforce the replacement communicative response. By incorporating AAC within FCT procedures, practitioners may find the children they work with who have complex communication needs and display challenging behavior will be able to better participate within the classroom, therefore leading to more robust opportunities in the future.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Ciara L. Ousley

Notes

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