Reciprocal Innovation to Optimize Low-Tech Augmentative and Alternative Communication (AAC) for Individuals (AAC)

Reciprocal Innovation to Optimize Low-Tech Augmentative and Alternative Communication (AAC) for Individuals With Complex Communication Needs and Their Caregivers

Many people with autism and other developmental conditions have difficulty speaking or do not use speech and need other ways to communicate. Augmentative and alternative communication (AAC) includes tools such as picture boards, communication books, and gestures that support communication. In low-resource settings and underserved rural areas in the United States, high-tech AAC devices are often too expensive or difficult to access, and trained specialists are limited.

Low-tech AAC options are more affordable but are often not used successfully because tools may not match the individual's abilities or daily environment, caregivers and providers may lack training, and stigma or low awareness may discourage use. These challenges can lead to AAC abandonment and social isolation.

Rural Virginia and western Kenya face similar barriers, including limited AAC expertise, inconsistent assessment, and insufficient training for families, educators, and community providers. This project uses a shared learning approach that combines western Kenya's experience implementing low-tech AAC in new settings with rural Virginia's expertise in individualized assessment, training, and scalable service delivery. The goal is to better match individuals to appropriate low-tech AAC systems and support communication partners to use them effectively.

Study Overview

• Status: Not yet recruiting
• Conditions: Autism; Neurodevelopment
• Intervention / Treatment: Behavioral: Automated AAC Assessment and Low-Tech AAC Implementation Support; Behavioral: Standard AAC Support

Detailed Description

Many people with autism and related developmental conditions have difficulty speaking or do not use speech at all. These individuals often benefit from augmentative and alternative communication (AAC), which includes tools such as picture boards, communication books, object symbols, and structured communication routines. AAC helps people express needs, make choices, and engage socially.

In low-resource countries and underserved rural areas of the United States, high-tech AAC devices are often not available. These systems can be expensive, require reliable electricity or internet access, and depend on trained specialists who may not be available locally. As a result, families and providers frequently rely on low-tech AAC options, which are more affordable and practical in these settings.

However, low-tech AAC is often not used effectively. Common barriers include stigma around disability, limited awareness of AAC, lack of access to appropriate materials, and poor matching between the communication system, the individual's abilities, and their everyday communication environment. Inconsistent assessment practices and limited training for caregivers, teachers, and other communication partners further reduce successful use. These challenges often lead to AAC being abandoned, leaving individuals socially isolated and unable to communicate effectively.

Rural Virginia and western Kenya face many of the same challenges. In both locations, access to AAC specialists is limited, individualized assessments are inconsistent, and communication partners often receive little or no formal training. Addressing these gaps requires approaches that are scalable, affordable, and culturally responsive. Effective solutions must systematically assess individual abilities and environments, guide selection of appropriate low-tech AAC systems, and support communication partners in using these systems consistently and correctly.

This project uses a reciprocal innovation approach, in which both regions contribute expertise. Western Kenya offers experience in implementing low-tech communication systems in communities that are new to AAC, while rural Virginia contributes experience with individualized assessment, provider training, and scalable technology-based tools. By combining strengths from both settings, the project aims to create solutions that work across diverse contexts.

The overall goal of this study is to develop, validate, and test an automated AAC assessment and implementation system for minimally verbal or non-speaking individuals. This system is designed to improve how well AAC tools match users' abilities and environments and to improve everyday communication outcomes. The project is based on the idea that combining an adaptive computer-based assessment with culturally appropriate low-tech AAC materials and automated training for communication partners will lead to better AAC selection, more consistent use, and lasting improvements in functional communication and participation.

Aim 1 focuses on developing and validating an open-access, computer-based AAC assessment. This assessment will adapt to the individual being assessed and gather information about motor, sensory, cognitive, language, and environmental factors that affect communication. Based on these responses, the tool will generate personalized recommendations for low-tech AAC systems. The study will examine whether the assessment is reliable, valid, works similarly across cultures, and produces recommendations that align with expert clinician judgments in both western Kenya and rural Virginia.

Aim 2 focuses on adapting and standardizing low-tech AAC materials for use across cultures. Using information from the assessment, the research team will develop and adapt AAC tools such as picture boards, object-based symbols, and structured communication routines to ensure they fit local languages, cultures, and daily environments. These materials will be tested and refined with individuals who use AAC and their communication partners to ensure they are easy to use, acceptable, and meaningful in both settings.

Aim 3 consists of a multi-site, parallel-group randomized controlled trial conducted in western Kenya and rural Virginia. Communication partners, including caregivers, teachers, community health workers, and aides, will be randomized to receive either an automated AAC training toolkit or standard AAC support available in their community. The primary outcomes assess implementation outcomes, including communication partner competence, compliance, and fidelity in the use of AAC strategies. Secondary outcomes assess child functional communication, caregiver-child interaction quality, and quality of life. Sustainability of AAC implementation and AAC system retention will be assessed at six-month follow-up.

Overall, this project will produce a tested, open-access AAC assessment and implementation system that reduces reliance on scarce specialists, improves matching between individuals and communication systems, and strengthens communication outcomes. By combining automated assessment, culturally adapted low-tech AAC materials, and scalable training within a reciprocal innovation framework, this research will support more equitable access to effective AAC in both global low-resource settings and underserved rural communities in the United States.

• Study Type: Interventional
• Enrollment (Estimated): 500
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Ananda Ombitsa; Phone Number: +254 718 748 223; Email: rananda@ampath.or.ke
• Study Contact Backup: Name: Kristen Cunningham, MPH; Phone Number: 317-278-5675; Email: kricunn@iu.edu

Study Locations

• Kenya
  • Eldoret, Kenya
    • Moi Teaching and Referral Hospital
    • Contact: Ananda Ombista; Phone Number: +254 718 748 223
    • Principal Investigator: Eren Oyungu, MBChB
• United States
  • Virginia
    • Charlottesville, Virginia, United States, 22903
      • University of Virginia
      • Contact: Kristen Cunningham, MPH; Phone Number: 317-278-5675; Email: kricunn@iu.edu
      • Principal Investigator: Mandy Rispoli, PhD
      • Principal Investigator: Jim Soland, PhD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Communication partners (e.g., caregivers, parents, teachers, community health workers, or aides) aged 18 years or older
• Primary communication partner of a child aged 3 to 14 years
• Child has a documented diagnosis of autism spectrum disorder or a related neurodevelopmental condition
• Child is minimally verbal or non-verbal
• Able to communicate in English (U.S. sites) or English or Swahili (Kenya sites)
• Able and willing to provide informed consent

Exclusion Criteria:

• Communication partners younger than 18 years of age
• Communication partners of children younger than 3 years or older than 14 years
• Communication partners of children who use fluent spoken language
• Inability to communicate in the required study languages
• Inability or unwillingness to provide informed consent

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Sequential Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Automated AAC Training; Communication partners receive access to an automated AAC system-matching assessment and an automated training toolkit designed to support implementation of personalized low-tech AAC strategies in daily routines.	Behavioral: Automated AAC Assessment and Low-Tech AAC Implementation Support; This intervention includes a computer-based assessment that identifies individual communication needs and generates personalized recommendations for low-tech augmentative and alternative communication (AAC) strategies. Recommended AAC materials, such as picture-based boards, object symbols, and communication routines, are culturally adapted for use in western Kenya and rural Virginia. Communication partners use these recommendations to support consistent and appropriate AAC use in daily activities.
Active Comparator: Standard AAC Support; Communication partners receive standard of care, defined as usual AAC referral pathways and locally available AAC training resources.	Behavioral: Standard AAC Support; Communication partners receive standard of care, defined as usual AAC referral pathways and locally available AAC training and support resources.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Functional Communication	Change in child functional communication, measured by the Communication Matrix total score. The Communication Matrix assesses intentional communication behaviors across communication functions and modalities.	Baseline, 6 months, and 12 months
AAC Implementation Fidelity	Fidelity of augmentative and alternative communication (AAC) implementation by communication partners, measured using a standardized AAC fidelity checklist based on recommended system use and communication strategies.	Baseline to end of intervention (approximately 12 weeks)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Provider Competence	Communication partner knowledge and skills related to AAC implementation, measured using a structured competency assessment.	Baseline to end of intervention (approximately 12 weeks)
Provider Compliance	Adherence to recommended AAC strategies during daily routines, measured as the proportion of recommended AAC strategies implemented, based on caregiver-reported use across daily activities.	Baseline to end of intervention (approximately 12 weeks)
Observed Communication Behaviors	Change in observed child communication behaviors, measured using video-recorded communication samples coded with the Communication Complexity Scale (CCS) for a randomly selected subset of participants	Baseline, 6 months, and 12 months
Caregiver-Child Interaction Quality	Quality of interactions between communication partners and children, measured using structured observational ratings derived from video-recorded interaction samples.	Baseline to end of intervention (approximately 12 weeks)
Adaptive Communication Skills	Change in adaptive communication skills, measured using the Communication domain of the Vineland Adaptive Behavior Scales.	Baseline, 6 months, and 12 months
Child Quality of Life	Caregiver-reported child quality of life and participation, measured using a standardized caregiver questionnaire.	Baseline, 6 months, and 12 months

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
AAC System Retention	Proportion of children continuing to use the recommended AAC system, as reported by communication partners.	6 months after intervention completion
Sustainability of AAC Implementation	Continued use of recommended AAC strategies by communication partners, assessed by caregiver report at follow-up.	6 months after intervention completion
AAC Use and Dosage	Frequency of AAC use, caregiver implementation dosage, and availability of AAC systems during daily routines, measured using ecological momentary assessment (EMA) delivered via smartphone application.	Twice weekly during the 12-week intervention period

Collaborators and Investigators

• Sponsor: Indiana University
• Collaborators: University of Virginia; Moi Univeristy
• Investigators: Principal Investigator: Eren Oyungu, MBChB, Moi University; Principal Investigator: Megan S. McHenry, MD, Indiana University; Principal Investigator: Mandy Rispoli, PhD, University of Virginia; Principal Investigator: Jim Solan, PhD, University of Virginia

Study record dates

Study Major Dates

• Study Start (Estimated): June 1, 2027
• Primary Completion (Estimated): June 1, 2030
• Study Completion (Estimated): June 1, 2032

Study Registration Dates

• First Submitted: April 28, 2026
• First Submitted That Met QC Criteria: May 6, 2026
• First Posted (Actual): May 12, 2026

Study Record Updates

• Last Update Posted (Actual): May 12, 2026
• Last Update Submitted That Met QC Criteria: May 6, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Keywords: Minimally Verbal; Communication Needs; Neurodevelopmental Conditions; Non-Verbal Communication
• Additional Relevant MeSH Terms: Autism Spectrum Disorder; Mental Disorders; Neurodevelopmental Disorders; Child Development Disorders, Pervasive; Behavior; Communication; Autistic Disorder; Nonverbal Communication
• Other Study ID Numbers: AAC

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No