Literacy instruction has an important role in augmentative and alternative communication (AAC) because spelling and writing support precise communication. Unfortunately, few students with extensive support needs and complex communication needs (ESN/CCN) develop literacy skills at or above the first grade reading-level. Given that learning to read and write begins with extensive emergent literacy learning opportunities, limited skills may result from insufficient opportunity to learn (OTL) emergent literacy skills. This study examined the instruction provided in early U.S. childhood classrooms to students with ESN/CCN to understand OTL during this critical period. This study used a concurrent embedded mixed methods design integrating a survey of teachers of students with ESN/CCN (n = 26) with a qualitative multiple case study (n = 2). Results suggest the time teachers are devoting to instruction is not translating into increased OTL for individual students. Solutions that may increase learning opportunities and implications for future research are discussed.