Beyond “inconsistency” and “abandonment”: a realist-informed study of AAC implementation with adults with intellectual disabilities in social care

Adults with intellectual disabilities often rely on augmentative and alternative communication (AAC) to support participation and autonomy. In the United Kingdom (UK), many receive support through social care services, where AAC is implemented by paid care staff within complex relational and organizational contexts. Previous research has identified barriers and facilitators, but less is known about how AAC implementation is sustained, adapted, narrowed, or paused in practice. This qualitative study used a realist-informed methodology to develop explanatory accounts of AAC implementation in adult social care. Semi-structured interviews were conducted with 16 paid care staff across five UK settings. Interviews explored how AAC was implemented, adapted, and sometimes paused. Analysis followed a framework-informed approach, drawing on the Capability, Opportunity, Motivation-Behavior model and the Theoretical Domains Framework, alongside realist explanatory analysis to identify shared processes and counter-mechanisms shaping AAC implementation across contexts. Findings identified shared processes shaping AAC implementation, including responsiveness to the person's current state, learning through experience, stabilization through routines and organizational structures, perceived functional and relational value of AAC, and values-based commitment to communication. AAC use emerged as a dynamic and adaptive practice shaped by relational, organizational, and contextual conditions rather than fixed strategies.