Augmentative and alternative communication (AAC) is an umbrella term that encompasses methods of communication for those with impairments or restrictions on the production or comprehension of spoken or written language.[1] AAC systems are extremely diverse and depend on the capabilities of the user. They may be as basic as pictures on a board that the are used to request food, drink, or other care; or they can be advanced speech generating devices, based on speech synthesis, that are capable of storing hundreds of phrases and words.[2]
Modern use of AAC began in the 1950s with systems for users who had lost the use of speech following surgical procedures.[3] During the 1960s the use of manual sign language grew greatly, but it was not until the 1980s that AAC began to emerge as an area in its own right.[3] AAC is now used for a wide variety of speech impairments. Studies show that AAC use does not impede the development of speech, and may even result in a modest increase in speech production.[4]
A great diversity of diagnoses, including cerebral palsy, intellectual impairment, autism, and many others, cover varying degrees of communication impairment. AAC interventions are highly individualized, taking into account specific abilities of language comprehension, social-relational characteristics, learning strengths and weaknesses, and developmental patterns for specific types of intellectual disabilities.[5] AAC can be used to aid both spoken and written language, and can supplement or replace speech and writing as necessary. AAC can be a permanent addition to a person's communication or a temporary aid.[1] The systems used in AAC include gestures, hand signals, photographs, pictures, line drawings, words and letters,[6] which can be used alone or in combination to communicate.[7]
Aided AAC makes great use of symbols, particularly for non-literate users,[6] as well as a large variety of input methods. The specific access method will depend on the skills and abilities of the user. Body parts, pointers, adapted mice, joysticks, or eye tracking[8] could be used, whereas switch access scanning is often used for indirect selection.[9][10] In many cases, rate enhancements methods may be used to speed up the generation of messages.[6] Clearly, an evaluation of a user's abilities and requirements is necessary to match a user with the most appropriate AAC method, input approach, and vocabulary. This evaluation requires the input of family, particularly for early intervention. Respecting ethnicity and family beliefs are key to a family-centered and ethnically competent approach.[11] Adult AAC users generally have satisfying relationships with family and friends and engage in pleasurable and interesting life activities.[12]
History of AAC
Although AAC can trace its roots back to the days of Ancient Greece, with the first recorded use of augmentative strategies with the deaf,[13] its modern inception began in the 1950s. At this time, AAC devices were mainly implemented for those whose oral and laryngeal anatomy was damaged by surgical procedures such as laryngectomies and glossectomies.[3] During the 1960s in the United States, the Civil Rights Movement, as well as the deaf community's pursuit of the right to be educated using American Sign Language (ASL), helped increase public and governmental awareness of issues related to AAC.[3]
During the late 1960s, manual sign languages were used both with individuals who had hearing impairments and those who had cognitive impairments. AAC devices were also used with individuals where intelligible speech would likely never be possible, including those with severe dysarthrias, cerebral palsy and amyotrophic lateral sclerosis. However, in most cases AAC strategies were only employed after traditional speech therapy had failed, as many felt hesitant to provide non-speech intervention to those who might be able to learn to communicate verbally.[3][14]
This view continued to dominate the field until the 1970s, when legislation began requiring that all children received educational services. As a result, many children with disabilities entered the school system, compelling classroom teachers to find ways in which to assist communicative exchanges.[3][14]
During the beginning of the 1980s, AAC became an area of professional specialization. Articles, newsletters, and textbooks on the matter were published as well as the first international conferences. The American Speech-Language-Hearing Association published a position paper regarding AAC as a field of practice for speech-language pathologists in 1981, and in 1983, the International Society for Alternative and Augmentative Communication (ISAAC) was founded.[3] In 1992, the Communication Bill of Rights, set forth by the National Joint Committee for the Communication Needs of Persons with Severe Disabilities, stated that all individuals with severe communication disabilities have a right to use AAC devices at all times as well as a right to information and the opportunity to have and make choices.[3][14]
Prior to the mid 1980s, individuals with Intellectual impairment were often not provided with AAC devices because it was believed that they did not demonstrate prerequisite skills for AAC, or because of the notion that AAC would interfere with speech development,[15] although both these notions have since been disabused.[16] Since the 1990s, users have increasingly been educated in the mainstream school system, as opposed to placing users in special schools or in one-to-one education. This has led professionals to seek ways for children with disabilities to participate more comprehensively and successfully in classroom activities. This inclusion model promotes the enrichment of functional skills taught within a natural context.[3][14]
Unaided AAC
Unaided AAC systems are those that do not require any external device for their use, and include facial expression, vocalizations, gestures, and signed languages and systems.[6][17] Informal vocalizations and gestures such as body movements, facial expressions, and body postures are part of natural communication, and such signals may be used by those with profound disabilities.[18] More formalized gestural codes exist that lack a base in a naturally occurring language. For example, the Amer-Ind code is based on Plains Indian Sign Language, and has been used with children with severe-profound disabilities, and adults with a variety of diagnoses including dementia, aphasia and dysarthria.[19] The benefits of such gestures and pantomime are that they are always available to the user, usually understood by the educated listener, and are efficient means of communicating.[20]
Manual signs include both manually coded language (such as Signing Exact English) and signed languages (such as American Sign Language). These are used, alone or in conjunction with speech, as forms of AAC.[21] Formal gesture and sign systems require adequate memory and fine motor skills to be able to remember and physically make the signs and gestures, as well as for communication partners to understand the symbols made.[22] Manual signs in particular are less transparent in meaning than gestural codes and require more fine-motor coordination to execute.[23] In sign systems, the symbols are hand signals which may at times resemble the word they represent, or may sometimes be more abstract.[20] With signs, communication partners need to understand the signs for successful communication. The user's ability to control gross and fine motor movements needs to be considered as well with these approaches.[20]
Aided AAC
An AAC aid is any "device, either electronic or non-electronic, that is used to transmit or receive messages".[24][1] This can include many diverse tools such as communication books or voice output devices using symbols such as photographs, line drawings, words or letters.[6] Since the skills, areas of difficulty and communication requirements of AAC users vary greatly, an equally diverse range of communication aids and devices exists to meet these demands.
Low-tech
Low-tech communication aids are defined as those that do not need batteries, electricity or electronics to meet the user's communication needs. These are often very simple aids created by placing letters, words, phrases, pictures, or symbols on a board or in a book, which may be accessed by the user.[25]
Depending on physical abilities and limitations, users might indicate the appropriate message with a body part, light pointer, eye-gaze direction, or a head or mouth stick. Alternatively, they might indicate yes or no as a listener scans through possible options.[26]
High-tech
High-tech AAC aids permit the storage and retrieval of electronic messages, with most allowing the user to communicate using speech output.[10] Such devices can also be referred to as Voice Output Communication Aids.[27] High-tech systems may be dedicated devices developed solely for AAC, or they may be non-dedicated devices, such as computers that run additional software to allow them to function as AAC devices.[10][9] On static display devices, all the symbols are constantly displayed on the device. On dynamic AAC devices, the user may naviagate between many sets of symbols that are arranged into pages.[28]
High-tech devices vary in size, weight, and the amount of information they can store.[3] Access methods depend on the abilities of the user, and may include the use of direct selection of a screen or keyboard with a body part, pointer, adapted mice or joysticks, or indirect selection using switches and scanning.[3][9] Because electronic devices can breakdown or run out of batteries, many experts recommend that users also have access to a low-tech communication alternative.[25][9]
Symbols
There are a variety of different symbol systems available to users. It is important to consider the individual user's preference, visual acuity, and visual processing of information when establishing which type of pictures are appropriate for their communication system.[20]
Picture-based symbol sets are available which do not require the ability to read. Some picture systems, such as Blissymbols, have linguistic characteristics, while others such as the Picture Communication System (PCS) do not.[29] Symbols can be realistic pictures or simple line drawings, and can be in color or black and white. Some users understand the line drawings better than detailed colorful pictures, while others prefer the reverse.[20] Symbols can be strictly visual when located on boards or screen displays or they can be tactile such as with the Picture Exchange Communication System (PECS).[20] With this system, the pictures are on cards for the user to move around to form a message. Tangible items can also be part of symbol systems, such as miniature objects representing their real counterpart, or small items as abstract representations.[30]
The user's visual acuity and visual-perceptual discrimination skills will affect the presentation of the symbol system on the AAC device (e.g. determining the size of the graphic symbols or the background-figure contrast).[31] For literate users, both low and high tech devices may use alphabet-based symbols including individual letters, whole words, or parts thereof.[30] In low-tech devices, the communication partner must interpret the symbols chosen whereas, with a high tech device such as a Voice Output Communication Aid, the device can read the created message aloud.[30]
Organization of symbols
Vocabulary organization refers to the way pictures, words, phrases, and sentences are displayed.[32] In an AAC system, symbols must be organized to facilitate efficient and effective communication. This is especially important when the individual has a large number of symbols in an AAC system.[33]
On static systems, symbols are placed in certain fixed positions; the number of symbols that can be included in a fixed display is limited, and in order to compensate the device may be set up on multiple levels, or an encoding strategy used, in which a person can express multiple messages by combining one or more symbols on a fixed display.[34] On a "dynamic display", a computer screen can display linking symbols that, when activated, automatically change the selection set on the screen to a new set of symbols.[35]
Individual pages of a communication book or device may presented into several ways. In grid displays, individual symbols, words, phrases, or pictures are combined in a grid format.[36] The grids may be organized in a variety of ways, including by spoken word order or frequency of usage. The Fitzgerald Key organization, for example, places symbols from left to right into categories labelled "who", "doing", "what", "where", and "when", with frequently used phrases and letters clustered along the top or bottom of the display.[37][38] The use of these displays has been shown to facilitate language and literacy skills in children.[39] Core vocabulary, the words and messages that are communicated most frequently, appears on a "main page". A user's fringe vocabulary, including words and messages that are specific to an individual, appear on other pages.[40] Research has shown that both children and adults use a small core vocabulary and a large fringe vocabulary.[41][42]
Large symbols vocabularies may also be organized by category, by grouping people, places, feelings, foods, drinks, and action words together.[43] Research conducted with typically developing children found that this type of organizational strategy is not useful until they reach at least the age of six or seven.[44]
Another form of grid organization groups vocabulary according to specific activities.[45] These can include items that are related to an activity (i.e. going grocery shopping) or routines within that activity (i.e. making a list, paying for items at the cash register).[46] Each display contains symbols for the people, places, objects, feelings, actions, and other relevant vocabulary items for a specific activity or routine.
Visual scene displays represent a different method of organizing and presenting symbols. These are depictions of events, people, objects, and related actions in a picture, photograph, or virtual environment representing a situation, place, or specific experience.[47][48] They are similar to activity displays, as they contain vocabulary that is associated with specific activities or routines. For example, a photo of a child's room could be included in the child's AAC system. Objects and events within the photograph could then be used as symbols for communication. For example, the symbol for "play" could be accessed by selecting the toy box, whereas selecting an individual toy would access the name of the toy.[46] Research suggests that visual scene displays are easier than grid displays for young or developing children to learn and use.[49][44][50] Symbols can also be presented in a hybrid display, in which both the grid and visual scene displays appear together.[47]
Access and selection methods
There is a complex relationship between the AAC technology, the users's physical abilities, and the interaction abilities of the user and their communication partner.[50] Technological development in direct selection and scanning have dramatically increased access to AAC technologies for individuals with a wide range of communications needs.[50]
In "direct Selection", a selection is made by pointing to the desired symbol using a finger or an alternative pointing technique. To accommodate motor control difficulties some users use alternative activation strategies; for example in "timed activation" must maintain contact with the aid for a predetermined period of time for the selection to be recognized by the system. With the "release activation", the selection of the item is only made when the person releases contact from the display.[51] Direct access is generally the first choice for AAC users as it is cognitively easier and faster to use.[52]
AAC users may also take advantage of an indirect selection technique called "scanning", whereby items displayed for selection are scanned visually by an indicator (such as small lights, highlighting, or contrasting borders) or auditorily by the communication partner or by the device. When the desired message is reached, the AAC user indicates his or her choice by using an alternative selection technique (i.e. switch access, head nodding) to confirm the choice.[53] Several different patterns for switch access scanning are available: in "Circular scanning", the least complex pattern, the items are displayed in a circle and then scanned them one at a time, until the user selects a desired item. As it the easiest to understand, it is often introduced first to children or beginning AAC users. In "Linear scanning", items are organized in rows and are scanned one at a time until a choice is made. Although more demanding than circular scanning, it is still easy to learn. Finally, in "group-item scanning" first a group of items is selected; this group is then scanned, eliminating options until a final selection is made. One of the most common group-item strategies is row-column scanning in which rows of items are first scanned and selected, and the items in the resulting row scanned one at a time until a choice is made.[53]
There are three main selection control techniques in scanning. In "Automatic scanning", the scan proceeds at a pre-determined speed and pattern; when the desired item or group is reached the individual makes the choice using a control interface such as switch. In inverse scanning, the switch is held down to advance the scan, and released to choose the desired item. In "step scanning", the AAC user activates one switch to move the indicator through the items, and another switch to select the item.[53]
At a design level, AAC systems may require modification to make them accessible to AAC users who have visual impairments. Modifications in the size, layout and colours of AAC systems can benefit AAC users with some residual vision.[54] Tactile/tangible symbols are textured objects, real objects or parts of real objects that may be included on an AAC device for individuals with visual impairment.[55] Braille is further an example of a tactile/tangible reading and writing system.[56] Tactile/tangible symbols can be used on low or high tech displays and switches.
In some high-tech devices, symbols produce a meaningful sound when activated are thus useful for AAC users who have vision impairments. Morse Code is an example of an auditory symbol system, where long and short tones represent letters, words, and phrases.[57] Some AAC devices can convert Morse code into text or speech.[58] Speech is another example of an auditory symbol that can be integrated with assistive technology for the blind and visually impaired.[55] Auditory scanning is an access method that utilizes speech with an AAC device. It presents options to the user by pronouncing them out loud and allows the users to select the desired option upon hearing it.[59]
Rate enhancement strategies
Augmentative and alternative communication is generally slower than speech.[60] Rate enhancement strategies increase the user's rate of output, and as a result enhance the efficiency of communication. There are two main options for increasing the rate of communication for AAC devices: encoding and prediction.[60] Encoding is a technique permitting an AAC user to produce an entire word, sentence or phrase using only one or two activations of their AAC system.[60] In iconic encoding strategies such Semantic compaction, a sequences of icons (picture symbols) are combined to produce words or phrases.[61] In numeric, alpha-numeric, and letter encoding (also known as Abbreviation-Expansion), words and sentences are coded as sequences of letters and numbers. For example, typing "HH" or "G1" (for Greeting 1) may retrieve "Hello, how are you?".[61]
Prediction is a rate enhancement strategy in which the AAC device attempt to predict the letter, word or phrase being written by the user. The user can then select the correct prediction without needing to write the entire word. Word prediction software may determine the choices to be offered based on their frequency in language, association with other words, past choices of the user, or grammatical suitability.[60][61][62]
User assessments and training
An evaluation of a user's abilities and requirements is necessary to implement appropriate intervention and match the user with the most appropriate AAC device. In the United States, AAC evaluations are conducted by specialized multidisciplinary teams which may consist of a speech-language pathologist, occupational therapist, physiotherapist, social worker and a physician.[63][64] The assessment team conducts interviews with the user, family members, caregivers and/or teachers to obtain additional information about the user's behaviour and skills in different settings. The team also assesses the user's motor abilities, communication skills, cognition and vision.[64]
During the process, the occupational therapist assists with the positioning and seating adaptations so that the individual can have the best access to the AAC system. For example, an individual with spastic arm movements might need a key guard on top of a keyboard or touch screen to minimize the chance of selecting a wrong button. The physiotherapist works on motor development training. The speech-language pathologist's role is to teach the user and their communication partners how to use the AAC device, encouraging the use of natural speech when possible. In selecting and adapting the AAC device for the user's individual needs, the speech-language pathologist's goal is to ensure that the AAC device can be used in different contexts and with different communication partners.[63]
The speech-language pathologist's teaching attempts to also deal with an additional communication challenge in which family members and peers tend to direct and control conversations. Consequently, children may not use their AAC aids as often. This has the potential to lead to delays or failure to develop the full range of communication skills such as initiating or taking the lead in conversation, using complex syntax, asking questions, making commands, or adding new information.[65][66] Training of communication partners may prevent the development of learned helplessness in children using AAC that can result from being passive communicators.[67] Additional training can help the user communicate effectively with others, to control their environment through communication, and using their AAC system to make choices, decisions and mistakes.[68]
Multicultural aspects
Cross cultural differences should be taken into account when assessing and planning for AAC intervention.[69] Ethnic awareness helps professionals determine which AAC system is best suited for their client.[70][71] Providing AAC services requires the input of family, particularly for early intervention. Respecting ethnicity and family beliefs are key to a family-centered and ethnically competent approach.[11] Respect and understanding of cultural diversity can help prevent family alienation,[72] contribute to the selection of the right AAC system for the user,[73][74][75] and to the family wanting to continue collaborating with the AAC team.[76]
Professionals must consider the "visibility" of the device.[77] Members of some cultures may not want the AAC to attract attention to the user, or they may not want to attend training sessions, considering AAC usage a private matter. These priorities may differ considerably from the AAC team's views, but they require consideration to promote cultural respect.[78]
Culturally diverse child rearing practices influence AAC intervention.[74] Accepting a communication aid and being labeled with a disability may be easier for some cultures which promote accessibility. Other cultures may place greater value on hierarchical family structures, politeness, indirect communication, and respect toward authority figures. Disability may also be viewed with a stigma; thus, folk, spiritual, and natural interventions may be preferred over modern technology.[74] Other cultures may expect an AAC device will immediately reduce the visibility of the disability, while other cultures may prefer not to have an AAC device at all in order to reduce stigma.[79]
When attempting to match the AAC system to the user, professionals consider several factors, including the need for the communication device to help promote self-determination, i.e., the ability to make one's own decisions and choices about one's life.[80][81] Some cultural groups consider a child's independence as a rebellion, and do not believe children should be allowed to have greater control of their own lives.[82] Thus, an AAC device may not be considered necessary if the goal is to increase the user's independence and promote individualism.
Cultural sensitivity may require avoiding stereotyping color and symbols, such as using black to denote "wrong" or "bad" and using culturally specific symbols and colors.[11]
Development
Effect on speech
In contrast to fears expressed by family members and clinicians, a 2008 systematic review found that AAC use does not impede the development of speech, and may result in increased speech production, with modest gains observed.[4] A 2009 descriptive review that looked specifically at Picture Exchange Communication System (PECS). intervention studies, and found inconsistent and unclear data on whether PECS led to increased speech; several studies reported an increase in speech, often during later phases, while one noted little or no effect.[83]
Some researchers hypothesize that using an AAC device relieves the pressure of having to speak, allowing the individual to focus on communication, and that the reduction in psychological stress making speech production easier.[84] Others speculate that, in the case of speech generating devices, a model of spoken output is provided which may lead to an increase in speech production.[85]
Language and literacy
Children whose disabilities require AAC often experience developmental delays in vocabulary knowledge, length of sentences, syntax, and impaired pragmatic skills.[86] Many of those whose disabilities require AAC have difficulties learning to read and write due to a variety of impairments that can affect emergent literacy. Most children in this category do not achieve literacy skills beyond a second grade level.[87] These cognitive, language and learning delays contribute to difficulty with literacy development, since these children may fall behind their typically developing peers in regular classrooms that assume a certain level of language mastery.[86]
The most literate AAC users often report having access to abundant reading and writing material at home as well as in school during childhood.[88] Engaging in rich language and literacy experiences before entering school fosters vocabulary development, discourse skills, and phonological awareness, all of which supports successful literacy learning.[86] However, many do not have these advantages. In addition, reduced expectations of teachers and parents mean that AAC users are often given fewer opportunities to engage in reading and writing activities in and outside of the classroom, which limits the amount of time, range, and quality of experience.[89][90][91] Language and literacy delay have far reaching effects as they facilitate self-expression and social interaction in face-to-face conversation and provide opportunities to participate in home, work, school, and social settings.[92] The limited experience/exposure to print, also leads to weaker knowledge about the world and vocabulary.[93] However, current research suggests that with explicit reading instruction, AAC users can better develop good literacy skills.[94][95] Furthermore, literacy fosters independence by providing access to educational and vocational opportunities.[89]
Outcomes
Employment
Physical disability may reduce the ability to work, and individuals with severe physical disabilities are often forced to discontinue their employment. According to U.S. Census Bureau (1997), among severely disabled individuals, less than 10% were employed. Despite the various barriers to employment, it is possible for AAC users to achieve success in educational endeavors and employment.[12] Although they are frequently limited to low wage jobs,[96] some AAC users also maintain higher-skilled jobs. Some individuals using AAC who have a severe disability, such as ALS, may continue working.[97] Access to AAC, determination, and a positive attitude help individuals to participate in society and have a good quality of life in their working environments.[97] Personality factors that have been found to be related to employment are a strong work ethic and access to AAC technology. The support of family and friends, education, and work skills are also related to positive employment outcomes.[98]
Quality of life
Adult AAC users generally have satisfying relationships with family and friends and engage in pleasurable and interesting life activities, remaining optimistic even when unemployed.[12] Some adults, however, may have more negative post-school quality of life outcomes, especially when post-secondary education or employment are not pursued. The negative outcomes are related to dissatisfaction with the service delivery and AAC supports, which results in communication barriers for AAC users. These issues reflect issues with policy barriers, lack of resources, and dissatisfaction with communication devices that exist for AAC users.[12]
Specific groups of AAC users
Cerebral palsy
Cerebral palsy is an umbrella term encompassing several developmental neuromotor disorders with a common upper motor neuron lesion origin.[99] Many people with CP would not benefit from AAC, but those with dysarthria may require AAC support for communication. Gross and fine motor challenges may be of particular concern in accessing the AAC device.[100]
Intellectual impairment
Studies have shown that appropriate use of AAC devices can modify classroom, home, and social environments for children and adults with intellectual impairments to increase participation,[15] make choices,[101] enhance communication skills,[102][103][104] and even influence the perceptions and stereotypes of communication partners.[15]
While most individuals with intellectual disabilities do not have concomitant behavioural problems, it is known that behavioural problems are typically more prevalent in this population than others.[105] In the past, strategies to "manage" behavioural problems included incarceration, medication and aversive behaviour modification techniques.[106] Since the mid 1980s, greater emphasis has been placed on teaching functional communication skills to individuals as an alternative to "acting out" for the purpose of exerting independence, taking control, or informing preferences. This paradigm shift in the management of behavioural problems for this population has placed new emphasis on AAC because many of these individuals do not have functional speech for communication.[107]
Individuals with intellectual impairments face challenges in developing communication skills, including problems with generalization (the transfer of learned skills into daily activities). They also often lack naturally occurring communication opportunities and responsive communicators with whom they can interact in the home, school and community environments. AAC intervention for this population emphasizes partner training as well as opportunities for integrated, natural communication.[107]
Autism
Autism is a disorder distinguished by qualitative impairments in communication and social interactions and typically have more difficulty acquiring expressive skills.[108][109] Children with autism have been found to have strong visual-processing skills, making them good candidates for an AAC device.[110]
AAC intervention in this population is directed towards the linguistic and social abilities of the child,[111] including providing the child with a concrete means of communication, as well as facilitating the development of interaction skills.[108] Existing functional communication skills, such as joint attention, predict better use of AAC.[110][112]
AAC systems for this population will generally begin with communication boards as well as with object or picture exchanges such as the Picture Exchange Communication System.[108] A 2009 descriptive review provides preliminary evidence that PECS is easily learned by most individuals and provides communication to individuals with little or no functional speech, and some limited positive impact on social communication and challenging behaviours.[83] However, a study that compared the use of a voice-output communication aid to a picture-exchange system found that each were plausible options for children with autism, as the ease and speed of acquisition of both systems was similar among all participants.[113]
Developmental dyspraxia
Developmental dyspraxia (or apraxia of speech) is a childhood motor speech disorder involving impairments in the motor control of speech production, typically causing impairments in motor programming and execution.[114] The speech of a child with developmental dyspraxia may be unintelligible to the point that daily communication needs cannot be met and that the child experiences great amounts of frustration. AAC can be a strategy to support communication, alongside more traditional speech therapy to improve natural speech production.[115]
A wide variety of AAC systems have been used with children with developmental dyspraxia.[116] Manual signs or gestures are the most frequent unaided AAC system introduced to these children, and can include signing unintelligible target phonemes (using fingerspelling) alongside speech. Manual signs have been shown to decrease articulation errors and speech sequencing errors.[115]
Aided systems used with children with developmental dyspraxia typically include communication boards (books using graphic symbols) and voice output devices.[116] While these are portable and tailored to child's communicative needs, they limit the user's ability to communicate to the topics on the board.[117] Voice output devices provide the user with a much greater vocabulary, access to a wider range of topics, and the ability to generate grammatical sentences.[115]
A multimodal approach is often chosen, such that more than one AAC option is introduced to the child. This way, the child is not only given the opportunity to experiment with various aided and unaided AAC systems, but can also take advantage of certain systems that may be better than others in certain contexts.[115]
Aphasia
Aphasia is the result of an impairment to the brain's language centers affecting production, comprehension, or both, and can cause severe, chronic language impairment.[118] Individuals with aphasia can use AAC to communicate using a variety of means, including a combination of speech, gesture, or other devices, which may change over time as needs and skills change.[119]
Those with aphasia may use low-tech AAC interventions such as communication and remnant books, drawing, photography, written words and messages, and written choices. In addition, high-tech AAC devices such as voice output communication aids, keyboards, or pictographic grid displays may be used for communication.[118] Visual scene displays have been used with adults who have chronic, severe aphasia, in which photos of events or people that are meaningful to the individual are used to give context to communicative interactions.[118] Approaches such as "Supported Conversation for Adults with Aphasia" train the communication partners to use resources such as writing key words, providing written choices, drawing, and using items such as photographs and maps to help the individual with aphasia produce and comprehend conversation.[120][121]
Brainstem stroke
Strokes that occur in the brainstem may cause profound deficits, including locked-in syndrome,[122] in which cognitive, emotional and linguistic abilities remain intact but all or almost all voluntary motor abilities is lost.[123] Most people affected by this type of stroke will need to rely on AAC strategies to communicate, since few recover intelligible speech or functional voice.[124] The AAC strategy used varies depending on the time post-stroke, the residual motor capabilities and individual preference. Eye blinks are frequently used for communication, as vertical or horizontal eye movements may be preserved.[123] Low-tech alphabet boards are often introduced immediately to provide the individual with basic communication. Listener-assisted scanning may be used, in which the alphabet is read out by the communication partner, and AAC user signals the desired letter is reached. When vertical and horizontal eye movements are functional, a transparent alphabet board may be used in which the AAC user looks at the desired letter and this is acknowledged by the communication partner.[123] These methods can be very slow and require intense concentration, patience and good memory on the part of the communication partner.
The use of a high-tech AAC device with individuals with locked-in syndrome may be difficult due to the problems with voluntary muscle activity, visual focusing, memory, alertness and linguistic ability.[123] A voluntary, reliable and easily controlled muscle movement is necessary to access such as a device, such as the movement of a finger, wrist or chin, a frowning of the forehead, or biting.[123] If the patient has good head control, a head mouse may activate the computer.[123] Those who do not have stable head movement require extensive practice to control the AAC device accurately. Laser pointers paired with laser-sensing surfaces have been shown to increase the accuracy and consistency of head movements.[124] Examples of assistive hardware and software used with this population include word prediction programs which reduce the effort required to write; speech synthesizer programs which convert written text into speech; or the replacement of a regular keyboard with an on-screen keyboard layout activated by a switch or head-mouse.[123]
Amyotrophic lateral sclerosis
Amyotrophic Lateral Sclerosis (ALS) or Motor Neurone Disease (MND) is a progressive condition in which the motor neurones required for movement break down, leading to weakness and eventual paralysis. Approximately 75% of people with ALS are unable to speak by the time of their death.[125] Generally, AAC is necessary when speech intelligibility becomes inconsistent, especially in adverse listening conditions such as a noisy restaurant.[125] In most cases, this happens when speaking rate drops to 100 words per minute.[126] In the early stages of ALS, AAC may only be necessary to augment natural speech with unfamiliar partners (e.g. using an alphabet board to cue the listener to the first letter of the word being spoken). In the later stages of ALS, AAC often becomes the main communicative method, although familiar conversation partners may still understand specific spoken words.[127] Since ALS is degenerative in nature, the choice of device has to take into account both present and future needs.[125] Some high-tech AAC aids allow a user to record his or her own voice while the person is still able to do so, for use once speech ability has begun to deteriorate.[128]
The chosen AAC system will depend on severity of speech impairment, functional status, and communication needs in particular environments. These include issues of portability, durability and powered mobility.[129] As cognition and vision are unaffected in ALS, writing and typing systems tend to be the most recommended and preferred devices because they allow unlimited expression.[127] The access to the device depends on the type and severity of the disease. In the spinal form of ALS, the limbs are affected from the onset of the disease. In these cases a high-tech device using a head mouse or eye tracking access may be used.[8] Low-tech systems, such as eye gazing or partner assisted scanning, may be used in situations when electronic devices are unavailable (e.g., during bathing).[130] In a different form of ALS, called the bulbar form, speech is affected before the limbs. As a result, handwriting is often the first course of AAC in these cases. As the disease progresses and starts affecting hand movement, writing or typing on high-tech AAC devices may be optimal, as these require less manual dexterity, while still offering full freedom of expression. In the final stages of the disease, eye gaze and partner assisted scanning are preferred as they carry the added benefit of promoting social closeness.[130]
Parkinson's disease
Parkinson's disease is a progressive neurological condition in which initially no speech disorder may be present.[131] However, hypokinetic dysarthria may develop later in the disease progression,[126] and some individuals eventually lose all functional speech.[132] Factors affecting AAC use in Parkinson's disease include motor deficits and cognitive changes, including lack of insight into the extent of their communication difficulties.[131][133] Since most individuals with Parkinson's disease are able to communicate using natural speech, AAC devices are generally used to supplement speech.[132] A portable amplifier, for example, increases the volume of a person's voice and thus intelligibility. In addition, the person may be taught to point to the first letter of each word on an alphabet board supplementation; this results in a reduced speech rate and visual information for the listener to compensate for impaired articulation. Entire words can be spelled out if necessary.[132] Since Parkinson's disease is associated with reduced range and speed of movement, a small-sized board may be preferred. High-tech AAC keyboard speech-generating devices are also used; keyguards may be required to prevent accidental keystrokes caused by tremors.[132]
Multiple sclerosis
Dysarthria is the most common communication problem in individuals with multiple sclerosis (MS); significant difficulties with speech and intelligibility are uncommon.[134][135] Individuals with MS vary widely in their motor control capacity and the presence of intention tremor, and methods of access to AAC technology are adapted accordingly. Visual impairments are common in MS, and 35% of people with MS experience optic neuritis as the first symptom. AAC users with visual impairments may require devices that allow auditory scanning systems, large-print text, or synthetic speech feedback that plays back words and letters as they are typed.[136]
Dementia
Dementia is an acquired, chronic, cognitive impairment characterized by deficits in memory and in at least one additional cognitive domain, such as language, visuospatial function, apraxia (movement), judgment or executive functions.[118][137] Its most common form is Alzheimer's disease.[138] Communication impairments are partly attributed to memory deficits.[137] AAC intervention can be used here to compensate for deficits and to capitalize on the person's strengths, focussing on recognition rather than recall.[139] Low tech devices are generally preferred, such as memory books that include autobiographical information, daily schedules, small wallets with photographs, and reminders or labels,[139] and several studies have shown positive outcomes in the amount of on-topic conversation and the length of interaction with their use.[140][141][142] In addition, training designed to teach individuals with dementia to use such memory aids was maintained four months after intervention.[142] High-tech devices with voice output have been found to be less effective: in one study such devices resulted in limited topic elaboration/initiation, reduced output and heightened distraction.[137] AAC is also used to enhance the comprehension of those with dementia. The use of augmented listening strategies, such as identifying topics of conversation with pictures, improves the conversational skills of individuals with dementia.[139]
Traumatic brain injury
Traumatic brain injury results in severe motor speech disorders—particularly dysarthria—in roughly a third of cases.[143] Depending on the stage of recovery, AAC intervention may involve the establishment of consistent responses, the facilitation of reliable yes/no responses, and the ability to express basic needs and answer questions. If necessary, longer term approaches may be used. Individuals who do not recover natural speech to a degree sufficient to meet their communication needs typically suffer from severe impairments related to cognition.[144] Memory impairments and difficulties with new learning may influence AAC choices; overlearned techniques such as spelling may be more effective than AAC systems that require navigation through multiple pages to access information.[144]
Notes
- ^ a b c ASHA (2005).
- ^ Gilliam & Marquardt, pp. 356–359.
- ^ a b c d e f g h i j k Glennen & DeCoste.
- ^ a b Schlosser & Wendt.
- ^ Beukelman & Mirenda.
- ^ a b c d e Mirenda.
- ^ Beukelman & Mirenda, pp. 246-249.
- ^ a b Mathy Cite error: The named reference "MathyALS" was defined multiple times with different content (see the help page).
- ^ a b c d Jans & Clark.
- ^ a b c Glennen & DeCoste, pp. 62-63.
- ^ a b c Perette et al. (2000).
- ^ a b c d Hamm & Mirenda.
- ^ Ladd, p. 90.
- ^ a b c d Hourcade.
- ^ a b c Wilkinson & Hennig.
- ^ Millar et al.
- ^ Beukelman & Mirenda, p. 36.
- ^ Beukelman & Mirenda, pp. 38–42, 283-4.
- ^ Beukelman & Mirenda, pp. 42–3.
- ^ a b c d e f Reichert Hoge & Newsome.
- ^ Beukelman & Mirenda, pp. 43–51.
- ^ Beukelman & Mirenda, pp. 108–109.
- ^ Daniloff.
- ^ Beukelman & Mirenda, p. 4.
- ^ a b Millar & Scott.
- ^ Scott.
- ^ Schlosser (2003), p. 472.
- ^ Hochstein.
- ^ Huer (2000).
- ^ a b c Hazel (2001).
- ^ Beukelman & Mirenda, pp. 51-52.
- ^ Blackstone (1993).
- ^ Beukelman & Mirenda, pp. 107-110.
- ^ Beukelman & Mirenda, p. 84.
- ^ Beukelman & Mirenda, p. 85.
- ^ Beukelman & Mirenda, pp. 335-339.
- ^ McDonald & Schultz.
- ^ Brandenberg & Vanderheiden, pp. 84–135.
- ^ Beukelman & Mirenda, pp. 344-350.
- ^ Beukelman & Mirenda, pp. 30-32.
- ^ Beukelman (1989).
- ^ Marvin et al. (1994).
- ^ Beukelman & Mirenda, p. 336.
- ^ a b Fallon, Light, & Achenbach.
- ^ Beukelman & Mirenda, pp. 336-338.
- ^ a b Drager, Light & Speltz.
- ^ a b Beukelman & Mirenda, pp. 338-339.
- ^ Blackstone (2004).
- ^ Drager et al. (2004).
- ^ a b c Higginbotham et al.
- ^ Beukelman & Mirenda, pp. 96-97.
- ^ Beukelman & Mirenda, pp. 102-103.
- ^ a b c Beukelman & Mirenda, pp. 97-101.
- ^ Carroll-Few & Cockerill, p. 77.
- ^ a b Beukelman & Mirenda, pp. 51-53.
- ^ Boser.
- ^ Burns.
- ^ Fleming et al.
- ^ Church & Glennen.
- ^ a b c d University of Washington, Augmentative and Alternative Communication.
- ^ a b c Venkatagiri.
- ^ Augmentative Communication.
- ^ a b Beukelman & Mirenda, pp. 118-125.
- ^ a b Mineo.
- ^ Pennington & McConachie.
- ^ Clarke & Wilkinson.
- ^ Beukelman & Mirenda, p. 187.
- ^ Beukelman & Mirenda, pp. 227-231.
- ^ Parette et al. (1996).
- ^ Hetzroni & Harris.
- ^ Huer (1997).
- ^ Kalyanpur & Harry, pp. 246-249.
- ^ Angelo.
- ^ a b c Beukelman & Mirenda, pp. 152-154.
- ^ Parette & Angelo.
- ^ Crais (1991).
- ^ Parette and McMahan.
- ^ Dinnebeil.
- ^ Parette & Brotherson.
- ^ Turnbull.
- ^ Wehmeyer (1992).
- ^ Wehmeyer & Palmer.
- ^ a b Preston (2009).
- ^ Schlosser & Lloyd.
- ^ Cress & Marvin.
- ^ a b c Sturm & Clendon.
- ^ Sturm et al. (2006).
- ^ Koppenhaver et al. (1991a).
- ^ a b Light & McNaughton.
- ^ Erickson & Koppenhaver.
- ^ Kopperhaver & Yoder.
- ^ Koppenhaver et al. (1991b).
- ^ Hetzroni (2004).
- ^ Fallon et al. (2004).
- ^ Blischak.
- ^ Mank et al.
- ^ a b McNaughton & Light.
- ^ McNaughton et al.
- ^ Beukelman & Mirenda, pp. 235-237.
- ^ Beukelman & Mirenda, pp. 237-239.
- ^ Cosbey & Johnston.
- ^ Wilkinson & McIlvane, pp. 273-322.
- ^ Romski & Sevcik.
- ^ Cheslock et al.
- ^ Batshaw, pp. 287–305.
- ^ Beukelman & Mirenda, pp. 239-241.
- ^ a b Beukelman & Mirenda, pp. 241-243.
- ^ a b c Paul.
- ^ Chiang & Lin.
- ^ a b Cafiero.
- ^ Beukelman & Mirenda, pp. 246-248.
- ^ Ogletree & Harn.
- ^ Son et al.
- ^ Bornman et al.
- ^ a b c d Beukelman & Mirenda, pp. 250-254.
- ^ a b Weitz et al., pp. 395–405.
- ^ Cumley & Swanson.
- ^ a b c d Beukelman et al. (2007).
- ^ Fox & Fried-Oken.
- ^ Garret & Lasker.
- ^ Kagan et al.
- ^ Teasel et al.
- ^ a b c d e f g Soderholm et al.
- ^ a b Fager et al.
- ^ a b c Doyle & Phillips.
- ^ a b Duffy.
- ^ a b Beukelman & Mirenda, pp. 445-447.
- ^ Anderson.
- ^ Beukelman & Mirenda, p. 441.
- ^ a b Beukelman & Mirenda, pp. 444-445.
- ^ a b Armstrong (2000).
- ^ a b c d Beukelman & Mirenda, pp. 455-460.
- ^ Tjaden.
- ^ Beukelman & Mirenda, pp. 448-449.
- ^ Beukelman (1985).
- ^ Beukelman & Mirenda, pp. 449-454.
- ^ a b c Fried-Oken (2009).
- ^ Beukelman & Mirenda, p. 508.
- ^ a b c Beukelman & Mirenda, pp. 508-515.
- ^ Andrews-Salvia.
- ^ Bourgeois (1993).
- ^ a b Bourgeois (2001).
- ^ Sarno.
- ^ a b Fager (2007).
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|doi=10.1080/07434610500395493
instead. - Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 15513730, please use {{cite journal}} with
|pmid=15513730
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|pmid=17701743
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|doi=10.1177/10883576040190040501
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suggested) (help) (full text) - Koppenhaver, D. (1993). "Classroom literacy instruction for children with severe speech and physical impairments (SSPI): What is and what might be". Topics in Language Disorders. 13 (2): 143–153. PsychINFO 1994-35341-001.
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- Light, Janice (1993). "Literacy and augmentative and alternative communication (AAC): The expectations and priorities of parents and teachers". Topics in Language Disorders. 13 (2): 33–46. doi:10.1097/00011363-199302000-00005. ISSN 0271-8294.
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|doi=10.1080/07434619412331276930
instead. - Mathy (2000). "Augmentative Communication for Individuals with Amyotrophic Lateral Sclerosis". In Beukelman, D.; Yorkston, K.; Reichle, J. (ed.). Augmentative and Alternative Communication Disorders for Adults with Acquired Neurologic Disorders. Baltimore: P.H. Brookes Pub. ISBN 978-1557664730.
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suggested) (help)CS1 maint: multiple names: editors list (link) - McDonald, E.; Schultz, A. (1973). "Communication boards for cerebral palsied children". Journal of Speech and Hearing Disorders. 38: 73–88.
- McNaughton, D.; Light, J.; Groszyk, Linda (2001). ""Don't Give Up": Employment Experiences of Individuals with Amyotrophic Lateral Sclerosis Who Use Augmentative and Alternative Communication". Augmentative and Alternative Communication. 17 (3): 179–195. doi:10.1080/aac.17.3.179.195.
- Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1080/07434610212331281171, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with
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instead. - Millar, D.C. (2006). "The impact of augmentative and alternative communication intervention on the speech production of individuals with developmental disabilities: A research review". Journal of Speech, Language, and Hearing Research. 49 (2): 248–264. doi:10.1044/1092-4388(2006/021).
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ignored (|author=
suggested) (help) - Millar, Sally V.; Scott, J., Sue (1998). "What is Augmentative and Alternative communication?". In Wilson, Allan (ed.). Augmentative Communication in Practice: An Introduction. University of Edinburgh CALL Centre. ISBN 978-1898042150.
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- Mineo, Beth (1990). "Augmentative and alternative communication: Tech Use guide. Using computer technology". United States Department of Education.
{{cite journal}}
: Cite journal requires|journal=
(help) - Mirenda, Pat (2003). "Toward Functional Augmentative and Alternative Communication for Students With Autism: Manual Signs, Graphic Symbols, and Voice Output Communication Aids". Language, Speech, & Hearing Services in Schools. 34 (3): 203–216. doi:10.1044/0161-1461(2003/017).
- Ogletree, B.T. (2001). "Augmentative and alternative communication for persons with autism: History, Issues, and Unanswered Questions" (PDF). Focus on Autism and Other Developmental Disabilities. 16 (3): 138–140.
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ignored (|author=
suggested) (help) - Parette, H.P. (1996). "Augmentative and alternative communication impact on families: Trends and future directions". The Journal of Special Education. 30 (2): 77–98. doi:10.1177/002246699603000105.
{{cite journal}}
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ignored (|author=
suggested) (help) - Parette, H.P. (1996). "Family participation in assistive technology assessment for young children with disabilities". Education and Training in Mental Retardation and Developmental Disabilities. 31: 29–43.
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ignored (|author=
suggested) (help) - Parette, H.P. (1996, December). "Family-centered augmentative and alternative communication issues: Implications across cultures". Paper presented to the International Early Childhood Conference on Children with Special Needs, Phoenix, AZ.
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ignored (|author=
suggested) (help) - Parette, H.P. (2000). "Giving families a voice in augmentative and alternative communication decision-making". Education and Training in Mental Retardation and Developmental Disabilities. 35: 177–190.
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ignored (|author=
suggested) (help) - Parette, P. (2002). "Team sensitivity to family goals for and expectations of assistive technology". Teaching Exceptional Children. 35: 56–61.
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ignored (|author=
suggested) (help) - Paul, R. (2007). Language Disorders from Infancy Through Adolescence: Assessment and Intervention (3rd ed.). St. Louis: Mosby, Inc. ISBN 0801679273.
- Pennington, Lindsay (2001). "Predicting patterns of Interaction between Children with Cerebral Palsy and their Mothers". Developmental Medicine & Child Neurology. 43 (02): 83–90. doi:10.1017/S0012162201000147.
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ignored (|author=
suggested) (help) - Preston D, Carter M (2009). "A review of the efficacy of the Picture Exchange Communication System intervention". J Autism Dev Disord. 39 (10): 1471–86. doi:10.1007/s10803-009-0763-y. PMID 19495952.
- Reichert Hoge, Debra (2002). The Source for Augmentative Alternative Communication. East Moline, Illinois, USA: LinguiSystems Inc. ISBN 0760604630.
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suggested) (help) - Romski, M.A. (1996). Breaking the speech barrier: Language development through augmented means. Baltimore: Brookes. ISBN 1557662525.
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suggested) (help) - Sarno M, Buonaguvro A, Levita E (1986). Characteristics of verbal impairment in closed head injured patients. Archives of Physical Medicine and Rehabilitation, 67, 400-405
- Schlosser, Ralf W., Blischak, Dorothy M., Koul, Rajinder K. (2003). Ralf W. Schlosser (ed.). The efficacy of augmentative and alternative communication: towards evidence-based practice. San Diego: Academic. ISBN 0-12-625667-5.
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: CS1 maint: multiple names: authors list (link) - Schlosser, R.W.; Lloyd, L.L. (2003). "Chapter, 16: Effects of AAC on Natural Speech Development". In Schlosser, R.W. (ed.). The Efficacy of Augmentative and Alternative Communication: Toward Evidence-Based Practice. USA: Emerald Group Publishing. ISBN 978-0126256673.
- Schlosser RW, Wendt O (2008). "Effects of augmentative and alternative communication intervention on speech production in children with autism: a systematic review". Am J Speech Lang Pathol. 17 (3): 212–30. doi:10.1044/1058-0360(2008/021). PMID 18663107.
- Scott, Janet, Low Tech methods of Augmentative Communication, In Augmentative Communication in Practice: an Introduction (ISBN 1-898042-15-2), ed. Allan Wilson; CALL Centre, Univ of Edinburgh, 1998
- Soderholm, Sinikka (2001). "Augmentative and alternative communication methods in locked-in syndrome". Journal of Rehabilitation Medicine. 33 (5): 235–239. doi:10.1080/165019701750419644. PMID 11585156.
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suggested) (help) - Son,S., Sigafoos, J., O'Reilly, M., & Lancioni, G.E. (2006). Comparing two types of augmentative and alternative communication systems for children with autism. Pediatric Rehabilitation, 9, 389-395.
- Sturm, J.M. (2006). "What happens to reading between first and third grade? Implications for students who use AAC". Augmentative and Alternative Communciation. 22 (1): 21–36. doi:10.1080/07434610500243826. PMID 17114156.
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ignored (|author=
suggested) (help) - Sturm, J.M. (2004). "Augmentative and alternative communication, language, and literacy: Fostering the relationship". Topics in Language Disorders. 24 (1): 76–91. doi:10.1097/00011363-200401000-00008.
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ignored (|author=
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ignored (|author=
suggested) (help) - Tjaden, Kris (2008). "Speech and swallowing disorders in Parkinson's disease". Topics in Geriatric Rehabilitation. 24 (2): 115–126. doi:10.1097/01.TGR.0000318899.87690.44. PMC 2784698. PMID 19946386.
- Turnbull, A.P. (2001). "Self-determination for individuals with significant cognitive disabilities and their families". The Journal of the Association for Persons with Severe Handicaps. 26: 56–62. doi:10.2511/rpsd.26.1.56.
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ignored (|author=
suggested) (help) - Rate Enhancement. Augmentative and Alternative Communication at the University of Washington, Seattle. Retrieved on March 19, 2009.
- Venkatagiri, H. (1995). "Techniques for Enhancing Communication Productivity in AAC: A Review of Research". American Journal of Speech-Language Pathology, 4:36-45
- Wehmeyer, M.L. (1992). "Self-determination for individuals with significant cognitive disabilities and their families". Education and Training in Mental Retardation. 27: 302–314.
- Weymeyer, M.L. (2000). "Promoting the acquisition and development of self-determination in young children with disabilities". Early Education and Development. 11: 456–481.
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suggested) (help) - Weitz, Cynthia. The Handbook of Augmentative and Alternative Communication.
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ignored (|author=
suggested) (help) - Wilkinson, K.M. (2007). "The state of research and practice in augmentative and alternative communication for children with developmental/intellectual disabilities". Mental Retardation and Developmental Disabilities Research Reviews. 13 (1): 58–69. doi:10.1002/mrdd.20133. PMID 17326111.
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ignored (|author=
suggested) (help) - Wilkinson, K.M. (2002). Reichle, J., Beukelman, D., Light, J. (ed.). Implementing an augmentative communication systems: Exemplary strategies for beginning communicators. Baltimore: Brookes.
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External links
- ISAAC - International Society for Augmentative and Alternative Communication
- AAC-RERC - Augmentative and Alternative Communication Rehabilitation Engineering Research Centers
- USSAAC - United States Society for Augmentative and Alternative Communication
- Communication Matters
- AAC Institute
- ASHA AAC Information
- Rehabilitation Engineering and Assistive Technology Society of North America