Augmentative and Alternative Communication, 2015; 31(2): 124–136 © 2015 International Society for Augmentative and Alternative Communication ISSN 0743-4618 print/ISSN 1477-3848 online DOI: 10.3109/07434618.2015.1035798

RESEARCH ARTICLE

Building Evidence-based Practice in AAC Display Design for Young Children: Current Practices and Future Directions JENNIFER J. THISTLE & KRISTA M. WILKINSON Department of Communication Sciences and Disorders, The Pennsylvania State University, University Park, PA, USA

Abstract Each time a practitioner creates or modifies an augmentative and alternative communication (AAC) display for a client, that practitioner must make a series of decisions about which vocabulary concepts to include, as well as physical and organizational features of the display. Yet, little is known about what factors influence the actual decisions and their outcomes. This research examined the design factors identified as priorities by speech-language pathologists (SLPs) when creating AAC displays for young children (age 10 years and under), and their rationale for the selection of these priorities. An online survey gathered ratings and comments from 112 SLPs with experience in AAC concerning the importance of a variety of factors related to designing an aided AAC display. Results indicated that some decisions were supported by existing research evidence, such as choosing vocabulary, collaborating with key stakeholders, and supporting partner modeling. Other decisions highlight areas for future research, including use of visual scene display layouts, symbol background color, and supports for motor planning.

Keywords: Clinical practices; Display design; Survey; Augmentative and alternative communication

Introduction

of an individual, and using these characteristics of the individual to drive the selection and design of the system (Light & McNaughton, 2013a). For example, depending on the individual’s visual or motor access abilities, the size of the symbols may or may not be an important feature to manipulate (Kovach & Kenyon, 2003). A 2006 survey examined SLPs’ perceptions on what contributes to success and abandonment of AAC technology (Johnson, Inglebret, Jones, & Ray, 2006). SLPs reported that an appropriate match between the individual and the system is one factor that promotes greater success with the device. Intrinsic abilities such as motor, cognitive/linguistic, literacy skills, and sensory perceptual skills must be assessed and compared to external features of systems to determine the best match. With the great variety of aided AAC technologies available, matching external features to intrinsic abilities is no small task. Ideally, practitioners are combining their practical knowledge and experiences with available evidence to inform a trial-based, feature-matching approach. However, such an approach may increase the time it takes an individual to reach competence with a system. Rather, if there are design decisions that follow specific patterns, these could potentially reduce the number of trials needed to identify the best fit for

Individuals with complex communication needs often rely on augmentative and alternative communication (AAC) to participate in communication interactions. An AAC system encompasses a variety of methods to support communication, such as gestures, sign language, communication boards, and speech generating devices (Beukelman & Mirenda, 2013). Techniques that utilize tools outside of the body, such as a communication board with graphic symbols or a computer programmed with voice output, are called aided AAC. Substantial evidence suggests the use of AAC interventions increases language development with individuals with a variety of communication disabilities (e.g., Binger & Light, 2007; Drager et al., 2006; Romski & Sevcik, 1996). Once a system is selected, AAC intervention requires more than taking the device out of the box and handing it over to the individual. One of the challenges facing practitioners such as speech-language pathologists (SLPs), special education teachers, and occupational therapists is creating an aided AAC system that maintains an appropriate balance between the benefits of the communication afforded by the system, and the costs of learning how to use it (Beukelman, 1991). Achieving this balance requires determining the needs and abilities

Correspondence: Jennifer Thistle, Department of Communication Sciences and Disorders, HSS 112, University of Wisconsin-Eau Claire, Eau Claire, WI 54702, USA. Tel: ⫹ 1 715 836 6015. E-mail: [email protected] (Received 28 March 2014; revised 23 March 2015; accepted 24 March 2015)

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AAC Display Design Decisions the individual. The first step in identifying decision processes that are more likely to result in positive outcomes is to better understand the factors considered by practitioners in designing AAC displays. There has been limited research specifically exploring the kinds of decisions SLPs and other practitioners make related to display design. One of the only studies to date that examined this topic was a preliminary and qualitative study using a hypothetical case study format. Specifically, McFadd and Wilkinson (2010) provided six clinicians who specialize in the field of AAC with a partial list of vocabulary to include on an aided AAC display. Clinicians selected additional vocabulary and created a low-tech communication board for a hypothetical student to use during snack time. Clinicians were asked to narrate their thought processes while making decisions regarding the selection and arrangement of vocabulary on the display. The clinicians in McFadd and Wilkinson (2010) applied research-based recommendations by incorporating vocabulary that supported a variety of communicative functions (Adamson, Romski, Deffebach, & Sevcik, 1992; Light & Drager, 2005). For example, five of the clinicians included verbs and social terms to support a variety of interactions. Another clinician only included object labels, but described her rationale that those labels would support social communication by allowing the child and peers to talk about the foods they were eating. Five of the six clinicians used Boardmaker Picture Communication Symbols (PCS; Mayer-Johnson, 1992) to represent the content, based on the instruction from the researchers; the sixth pulled similar types of images from the Internet because her school did not have access to the Boardmaker program. Choices related to arrangement of the symbols were less consistent across clinicians. All clinicians organized the vocabulary in some fashion, and those that included different types of words (e.g., object, verbs, socialregulatory) created subsets based on those types. However, the placement of the subsets varied. For instance, some clinicians placed social-regulatory symbols along the top row while others placed the same symbols along the left-hand column. Still another clinician used spacing within the page to separate types of words. Finally, some clinicians used background color to distinguish different symbol word classes while another placed the symbols on a colored page to support navigation across multiple pages. One challenge when examining clinical practices lies in the heterogeneity of individuals who can benefit from AAC systems. Children with developmental disorders, for example, may have very different needs and abilities compared to adults with acquired disorders. The current study focused on practitioners, specifically SLPs, working with young children (aged 10 years and under) in an attempt to constrain some of the variability seen in AAC decision-making. Even when limited to elementary school children, however, the caseloads of SLPs will influence the experiences upon which they draw when © 2015 International Society for Augmentative and Alternative Communication

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designing AAC displays. In the 2014 American SpeechLanguage-Hearing Association (ASHA) Schools Survey (ASHA, 2014), the 55% of SLPs who regularly provided AAC-related services reported serving an average of five students. This represents 10% of an elementary school SLPs’ average monthly caseload, and 20% of a residential/special day school SLPs’ average monthly caseload (ASHA, 2014). Furthermore SLPs who work in residential/special day schools reported that 71% of their caseloads consisted of students with severe communication impairments. It is likely, then, that SLPs will have had different experiences designing AAC displays. Professional preparation in AAC also may influence SLPs’ comfort level with providing AAC services, thereby affecting the decisions they make when designing AAC displays. In a survey of 71 SLPs, 72% rated their competence in providing AAC services as fair to poor (Marvin, Montano, Fusco, & Gould, 2003). Similar results emerged in surveys conducted in Egypt (Wormnaes & Abdel Malek, 2004) and New Zealand (Sutherland, Gillon, & Yoder, 2005). Such low levels of competence may be precipitated by education and training provided by SLP programs. In a survey of SLP training programs, 33% of respondents felt that the majority of their students were prepared to work with individuals who use AAC (Ratcliff, Koul, & Lloyd, 2008). Just under half (47%) of the respondents reported that only up to one quarter of their students receive clinical practice in AAC. In a review of research conducted from 1985–2009, Costigan and Light (2010) examined surveys of pre-service AAC training programs in the US, and reported that the majority of SLPs received minimal to no pre-service training in AAC. Thus, it is possible that the variability noted between SLPs in McFadd and Wilkinson’s (2010) study reflected the SLPs’ educational background and experiences with individualizing displays for the wide variety of children who use AAC. If there are some practices that professionals have found to be more successful than other practices, it is important to identify the successful approaches in order to reduce the number of trials of different features that an individual who uses AAC must go through. Research Questions This research addressed the following question: What design factors do SLPs identify as priorities when they create aided AAC displays for young school-aged children, and what are their rationales for the selection of these factors as priorities? Through an online survey, participants answered questions related to the decisions they make regarding vocabulary selection, symbol types and arrangement, and manipulation of a variety of visual features (e.g., size, color, etc.) of aided AAC displays. The responses were analyzed not only to gain a broad view of the general clinical practices but also to understand the factors that might influence the decision-making process.

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Method Survey Development Survey questions were developed and refined through initial pilot testing and reviews by experts in survey design. Initial questions were developed to target decisions related to vocabulary selection, symbol types and arrangement, and manipulation of a variety of visual features of aided AAC displays. The initial pilot survey from which the final version was developed was completed by three SLPs, with an average of 8 years (range: 7–10 years) experience providing AAC services to children. Feedback from the pilot participants ensured that the focus of the questions centered on the goals of the study. The university’s Survey Research Center then reviewed the survey for structure and adherence to survey design principles. As a result, demographic questions were moved from the beginning to the end of the survey, based on the rationale that it may be perceived as less intrusive to answer personal demographic questions at the end of the survey (Groves et al., 2009). The final version of the survey consisted of 42 questions intended to solicit information about two aspects of display design: the principles guiding aided AAC display design in general, and child-specific decisions driven by a given case study. Participants advanced through the survey sequentially (answering the general questions first, then the child-specific questions) and received an error message if they attempted to advance without completing a question. Therefore, as the survey progressed, no questions could be skipped. Because the survey could be abandoned prior to completion, a greater number of responses were provided to questions asked earlier in the survey than those that were asked later. The current study reports on responses related to the first section because the goal was to outline general principles guiding aided AAC display design decisions. Appendix A (to be found online at http://informahealthcare.com/doi/abs/10.3109/07434618.2015.1035798) presents these survey questions. The results of the answers related to the specific case will be reported in a separate study. Participants Target participants were practicing SLPs who (a) maintained a current certificate of clinical competence from ASHA, (b) had at least 1 year of experience supporting individuals who use AAC, and (c) provided AAC services to school-age children aged 10 and under. The online survey was available for 12 weeks and participants were recruited through multiple contact points to allow for adequate opportunity for responding and to increase sample size (Dillman, Smyth, & Christian, 2009). Qualtrics1 online survey software hosted the web-based survey. Participants completed the survey at a computer of their choosing and were able to take the survey over multiple sessions if they chose to do so.

The University’s Office for Research Protections provided human subjects approval for this research project. An implied consent form was embedded as the first page of the online survey and participants were advised that continuing the survey indicated consent. Participants had the option of downloading the implied consent form if desired. Survey Distribution Members of two list serves were contacted at three time points. The list serves were the ASHA Special Interest Group 12-Augmentative and Alternative Communication (SIG-12) and Quality Indicators for Assistive Technology (QIAT). A general recruitment notice describing the study and soliciting participation was posted to each list serve at the initial time point, 3 weeks later, and again 7 weeks from the initial posting. Throughout this data collection period, in-person recruitment also occurred during the ISAAC biennial convention. Finally, appeals to personal contacts and postings on social media websites provided additional advertising regarding availability of the survey. Data Analysis The survey consisted of a mix of open-ended and closed-ended questions. Descriptive methods of data analysis were utilized due to the exploratory nature of the questions and the goal of the survey to identify trends to inform future research directions. Descriptive data in the form of frequency tables were used to examine the closed-ended questions. The open-ended questions were coded for common themes using scrutiny techniques (Ryan & Bernard, 2003). Like Ryan and Bernard, three research assistants and the first author initially identified themes and subthemes by reading each response and listing commonly repeated terms and identifying similarities and differences in responses. Refinement of the themes and subthemes occurred during a cycle of consensus coding. The research team formally defined the codes in a codebook that contained the definition as well as examples and non-examples. A summary page of the codes is presented in Appendix B (to be found online at http://informahealthcare.com/doi/abs/10.3109/ 07434618.2015.1035798). Two of the primary codes were each further refined into five secondary codes, resulting in 16 possible codes. The primary codes were used to identify responses that (a) were unclear to the coder, (b) noted features the participant did not think were important, (c) related to the child’s skills and abilities, (d) related to the communication demands, (e) related to the AAC device, and (f) related to key stakeholders (e.g., clinicians, teachers, communication partners). The secondary codes provided detail related to the child’s abilities (e.g., vision abilities) and the communication demands (e.g., functional vocabulary for the setting). The first author divided the responses into individual thought units consisting of the smallest meaningful piece Augmentative and Alternative Communication

AAC Display Design Decisions of information contained in the response (Fraenkel, 2006). Typically, the thought units corresponded with a participant’s sentence. However, when the participant included a variety of ideas in one sentence, the resulting thought units were individual words or phrases. Research assistants then assigned one code per thought unit. Inter-observer agreement was assessed on the final coding of the thought units. Two research assistants each independently coded thought units. After a period of training, the coders reached a minimum Kappa coefficient of .7 (Fleiss, Levin, & Paik, 2003). Coders then individually coded all questions and subsequent reliability was recalculated on 25% of the responses. Agreement on each question was on average .76 (range .71–.78). Kappa values of .4–.75 are considered good and values of .75 or greater signify excellent agreement (Fleiss et al., 2003).

Results Responses In total, 192 individuals accessed the survey. Of those, 24 dropped out during the initial screening section, 17 were excluded because they did not meet the selection criteria, and two reported living outside the United States, in Canada and South Africa. Due to the small number of international participants, these responses were excluded from the final analysis. Of the 149 eligible participants, 112 completed the broad design questions2 but provided only some demographic data, 77 completed the entire survey (including all demographic data), and 37 did not complete the primary questions. The presentation of the results follows the sequence of the survey, although demographics and initial design decisions for the 77 participants who provided that information will be described first. A discussion of the clinical implications and future directions follow the survey results. Demographics Of the 77 participants who provided complete demographic data, 60 (78%) were members of ASHA SIG-12, and nearly half (48%) reported living in the Northeast. Table I presents a summary of the demographic information, including distribution by geographical region, participant gender, and race/ethnicity. One of the screening questions asked participants’ years of experience supporting children who use AAC. Thus, although only 77 participants completed the demographics section of the survey, all 112 participants provided years of experience. Table II presents the proportion of participants who completed the broad design questions but did not complete the demographic questions and those who completed both sections by their level of experience. The following results address similarities and differences observed in responses across the different levels of experience. © 2015 International Society for Augmentative and Alternative Communication

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Table I. Percentage of Participants by Geographical Region, Gender, and Race/Ethnicity.

Characteristic

Participants (%)

Geographic region Northeast Southeast North Central South Central West/Mountain Gender Female Male Race/ethnicity White/Caucasian African American Hispanic Asian

n

%

37 12 7 6 15

48.0 7.8 15.6 9.1 19.5

75 2

97.4 2.6

72 1 3 1

93.5 1.3 3.9 1.3

Initial Design Decisions One of the first decisions a clinician must make when creating a new display for young children is whether to modify the page set provided by the manufacturer. Of the 77 participants answering this question, 60 (78%) reported often or always making changes to the page set provided by the AAC manufacturer, and 8 (10%) reported rarely or never making changes to the page set provided by the manufacturer. An examination of the responses by level of experience did not reveal a distinctive pattern related to experience level. Across most experience levels, only 9% (5 out of 53) of the participants reported rarely or never making changes. However, 21% (3 out of 14) of the participants with 13–20 years of experience reported rarely or never making changes. This difference in responding by participants with this level of experience recurs throughout the survey and will be explored in the Discussion section. Decisions Related to Vocabulary Selection SLPs often play a key role in choosing the display content, including what concepts and communication functions the content supports. Several themes emerged in terms of decisions made by SLPs with regard to the importance of child preferences, other stakeholders, the role of core vocabulary, and the range of word classes to include. Table II. Number and Percentage of Participants Completing the Broad Design and the Demographic Questions Sections.

Years of experience 1–3 4–7 8–12 13–20 21 or more

Completed demographic questions (n ⫽ 77) n % 8 23 13 14 19

10.4 29.9 16.9 18.2 24.6

Completed only broad design questions (n ⫽ 35) n % 3 7 5 11 9

8.6 20.0 14.3 31.4 25.7

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Child Preferences. The child’s preferences were noted to be extremely or fairly important in vocabulary selection by 87% (97 out of 112) of respondents. Figure 1 illustrates the level of importance participants placed upon the child’s preferences in their vocabulary selection process, for each level of clinician experience. All of the participants with 1–3 years of experience felt the child’s preferences were extremely or fairly important. On the other hand, 28% (7 of 25) of respondents with 13–20 years of experience indicated that the child’s preferences were only somewhat or not very important. This accounted for half of the 13% (15 out of 112) of all participants who felt that child’s preferences were somewhat or not very important. Additional Priorities. An open-ended question provided some insight into what additional priorities respondents felt were important when choosing vocabulary. Figure 2 illustrates the main categories of priorities identified by participants by years of experience. Key Stakeholders. As a whole, 46 of 112 (41%) participants mentioned collaborating with key stakeholders. Once again, however, there was a somewhat unusual pattern in the group with 13–20 years’ experience, as only 20% (5 out of 25) mentioned key stakeholders compared to 41% (41) of the remaining 87 participants. Some participants mentioned specific instances that would influence vocabulary selection. One wrote, “I add vocabulary based on family preferences too – parents often like some of the politeness terms, for instance.” Other participants were more general in their description and rationale of including key stakeholders: “I take into account what the family and classroom find important.” Role of Core Vocabulary. Clinicians with more than 13 years of experience reported choosing core vocabulary based on frequency of words more often (15%, 8 out of 53) than those with less than 13 years of experience (8%, 5 out of 59). Some respondents prioritized core vocabulary above the child’s or key stakeholders’ preferences. For instance, one participant stated, “I would ONLY consider the child’s vocabulary preferences

Figure 2. Percentage of participants mentioning additional vocabulary selection considerations beyond a child’s preferences, by years of experience.

when I am including personal words that are part of the child’s extended vocabulary set. These personal extended vocabulary words are second on my list after CORE vocabulary” (emphasis provided by participant). This quote also illustrates the challenge inherent in design decision – many decisions influence other decisions, and trade-offs must be made. In this case, it seems the participant was making a choice between providing core vocabulary or personalized vocabulary. Range of Word Classes. Most participants indicated that they frequently used a variety of word forms in support of language acquisition and use. Specifically, participants incorporated subjects (82%, 92 of 112), actions (97%, 109 of 112), objects (83%, 93 of 112), and emotion words (84%, 94 of 112) most or all of the time. Figure 3 shows the frequency with which participants incorporate each of these types of words by their level of experience. In all, 93% (26 out of 28) of participants with the most experience reported incorporating emotion words most or all of the time, whereas on average 81% (68 out of 84) of the clinicians with other levels of experience incorporated emotion words most or all of the time. Decisions Related to Symbol Type Following identification of appropriate content, SLPs consider options regarding how best to represent that content. The type of symbol representation was rated as fairly or extremely important by 100% of participants with 1–3 years’ experience (n ⫽ 11), but only 76% (77 out of 101) of all other participants. When asked what factors influence their choice of symbol type, 90% (10 out of 11) of the participants with 1–3 years of experiences cited the child’s cognitive abilities as an important consideration. Across all other experience levels, just under half (45%, 45 out of 101) reported that the child’s cognitive level should be considered. Decisions Related to Visual Features of the Display

Figure 1. Percentage of participants who rated child’s preference in vocabulary selection as either fairly/extremely important or not very/ somewhat important, by years of experience.

The visual nature of an aided AAC display allows for manipulation of such features as symbol arrangement Augmentative and Alternative Communication

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Figure 3. Percent of participants indicating the frequency with which they include subjects, action words, descriptors, and emotion words in displays, by years of experience.

and display layout, symbol size, and use of color. Three themes that emerged from this survey concerned choices related to (a) the type of display layout, (b) the use of black and white versus colored symbols, and (c) the use of background color cuing. Type of Display Layout. When asked to estimate the percentage of hybrid or visual scene displays (VSDs) participants design, 83% (64 out of 77) reported using these displays less than 25% of the time, suggesting grid-based displays were used most of the time. Only 3% (2 out of 77) of participants reported using VSD/hybrid displays more than 50% of the time. Use of Symbol Internal Color. Of the 112 participants, 94 (84%) reported utilizing symbols that have internal color most or all of the time; only one participant indicated very rarely using color symbols, but did not provide a reason in the following open-ended question. Despite the widespread use of symbol color, 78 (69%) reported using black and white symbols some of the time. Participants reported that black and white symbols were used to highlight new symbols, when color would not contribute to the meaning (e.g., prepositional words), or when team members did not have access to color printers. Use of Background Color. Color can also be featured in the background of symbols. All participants reported using symbol background color at least sometimes, and 49 (43%) reported that they used it most of the time, a trend that was consistent across all experience levels. The top two reasons provided regarding use of background color were (a) to support development of grammatical skills through color coding parts of speech, and © 2015 International Society for Augmentative and Alternative Communication

(b) to draw attention to specific symbols. Using background color as a cue to word class category reflects a common clinical recommendation (Goossens’, Crain, & Elder, 1999; Kent-Walsh & Binger, 2009); however, to date there has been no research that specifically examines if the dimension of color aids in learning appropriate sentence structure. Additional Decisions When given the opportunity to discuss any additional general factors not previously mentioned, 32% (36 out of 112) of participants supported the use of consistency in display design to support motor planning and automaticity. In this approach, the location of previously learned symbols on the display does not change as new symbols are added to the display. Finally, an additional feature participants consider was mentioned in response to several different, unrelated, open-ended questions: designing the display in a way that supports partner modeling.

Discussion The goal of AAC intervention for a child is to provide support for participation and language development across all environments, facilitating early communication (Light & Drager, 2005; Romski & Sevcik, 1996), advancing linguistic growth and functional communication (Binger & Light, 2007; Drager et al., 2006; Johnston, McDonnell, Nelson, & Magnavito, 2003), and providing early literacy experiences (Koppenhaver & Erickson, 2003; Light & McNaughton, 2013b). Designing an appropriate AAC display is one part of AAC intervention that may contribute to this goal. There are

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many factors to consider when designing an AAC display, including but not limited to appeal of the display (Light, Drager, & Nemser, 2004; Light, Page, Curran, & Pitkin, 2007), ease of use (Drager, Light, Speltz, Fallon & Jeffries, 2003; Drager et al., 2004; Fallon, Light, & Achenbach, 2003), and communicative functions supported by the display (Adamson et al., 1992; Romski & Sevcik, 1996). Furthermore, these considerations must be weighed against the needs and abilities of the child who will be using the display (Light & McNaughton, 2013a). Certainly, as a field, we are at times successful as we strive toward this goal; at other times, however, we do not succeed (Johnson et al., 2006; Snell et al., 2010). In this study, SLPs reported considering a number of factors in the development of AAC displays, suggesting at least some awareness of the need for AAC systems to be responsive to the needs of the child and team. This is in line with the multifaceted nature of AAC intervention that supports long-term success (Johnson et al., 2006). The reported decisions regarding vocabulary selection suggest that many clinicians prioritize the child’s preference while also considering input from others. The Participation Model presented by Beukelman and Mirenda (2013) highlights the importance of considering the interests and abilities of the child during the assessment process and subsequent intervention. Along these lines, in a survey of SLPs’ perspective of AAC success and abandonment, two of the top five factors associated with long-term success were the degree to which the device (a) matched the individual’s physical capabilities, and (b) was valued as a means of communication (Johnson et al., 2006). Research also illustrates the importance of involving a range of key stakeholders (e.g., the child, family, teachers, specialists, etc.) at all stages of intervention (Beukelman & Mirenda, 2013; Ogletree, 2012). Practicing a family-centered approach may reduce device abandonment through the provision of supports that result in a good fit between device and family members (Angelo, 2000; Jones, Angelo, & Kokoska, 1999). The collaboration of various stakeholders, including SLPs, teachers, and paraprofessionals, has been shown to increase communication initiation and engagement and decrease classroom assistance needed by students who use AAC (Hunt, Soto, Maier, Müller, & Goetz, 2002). Decisions regarding vocabulary selection highlighted the inclusion of core vocabulary. While there is a breadth of research describing typical vocabulary development and listing commonly used words by age (Ball, Marvin, Beukelman, Lasker, & Rupp, 1999; Banajee, Dicarlo, & Stricklin, 2003; Beukelman, Jones, & Rowan 1989), the effect of providing core vocabulary on language development in children who use AAC has not yet been directly studied. Furthermore, the provision of core vocabulary to the exclusion of personalized vocabulary runs counter to both recommended practices for people who use AAC (Williams, Krezman, & McNaughton, 2008) and factors contributing to device success (Johnson et al., 2006; Murphy, Markova, Collins, & Moodie, 1996).

Evidence suggests that providing children with a range of vocabulary increases the frequency of using AAC (Beukelman, McGinnis, & Morrow, 1991; Yorkston, Honsinger, Dowden, & Marriner, 1989). Additionally, research has illustrated that when provided with a range of symbols across word classes, children who use AAC learn and use those symbols for more complex and varied communicative functions beyond requesting (Adamson et al., 1992; Light & Drager, 2005). Thus, although the decision process for the provision of vocabulary relies heavily on clinical experience and stakeholder input, available evidence suggests that it is critical to include a variety of word classes and vocabulary specific to the child. When making decisions about the type of symbol to use, nearly half (49%) of the clinicians said they consider the child’s cognitive abilities. They may have been relying in part on the literature base regarding iconicity to inform their decisions (e.g., Fuller & Lloyd, 1991; Mizuko & Reichle, 1989). Within this literature there is strong evidence supporting the hypothesis that more iconic symbols (i.e., symbols that have a high degree of resemblance to the referent) are more easily learned than those that are less iconic (for a complete review, see Schlosser & Sigafoos, 2002). Clinicians also reported other considerations (e.g., planning for the future, device software, symbol availability) when choosing the symbol type. Such extrinsic issues (e.g., team member familiarity with specific symbol sets) are often a consideration when developing an AAC system; however, too great a focus on designing a display in response to others runs the risk of neglecting the child’s needs and abilities, which could ultimately undercut the goal of AAC. Once the vocabulary and type of symbol is chosen, decisions related to the visual appearance of the display, such as the layout type, use of color, and number or size of the symbols, are made. There are numerous factors to consider, which is likely to result in heterogeneous decisions. However, the results of the survey highlighted three factors that illustrate some consistency across respondents: display layout, internal symbol color, and background color. Overall, grid-based designs were reportedly used more often than VSDs. Historically, the layout of symbols has been in a grid format, with individual concepts represented by isolated symbols arranged in rows and columns (Zangari, Lloyd, & Vicker, 1994). More recently, a visual scene display layout, where concepts are embedded within the context in which they naturally occur, has been proposed (Light & Drager, 2007; Shane, 2006; Wilkinson & Light, 2011). The research with young children without disabilities suggests VSDs may be an appropriate layout for beginning communicators (Drager et al., 2003, 2004; Light & Drager, 2007; Olin, Reichle, Johnson, & Monn, 2010). Although the clinicians in the current study worked with young children, no further caseload information was collected. It is possible that low VSD usage rates were a reflection of either caseloads that do not include Augmentative and Alternative Communication

AAC Display Design Decisions many beginning communicators or a lack of awareness of VSDs, which were first introduced in the early 2000s. If the latter is the case, it highlights the need for pre-service training that is thorough and evidence based, and for in-service training that provides information on current research and newly emerging evidence. A majority (84%) of SLPs reported using symbols with internal color most of the time, suggesting a consistency across clinicians with respect to this factor. Research from the field of visual cognitive science suggests color plays a role in a variety of basic perceptual processes, including drawing attention to objects, distinguishing between similar objects, and contributing to object recognition (Gegenfurtner & Rieger, 2000; Wurm, Legge, Isenberg, & Luebker, 1993; Xu, 2002). More closely linked to AAC research, Wilkinson and colleagues have examined the effect of arranging symbols based on their internal color (Wilkinson, Carlin, & Jagaroo, 2006; Wilkinson, Carlin, & Thistle, 2008; Wilkinson, O’Neill, & McIlvane, 2014). Children with and without disabilities have consistently demonstrated benefits of grouping like-colored symbols, as measured by faster reaction times locating a target symbol within an array. However, in one study with children with autism, identification and generalization for the learning of color symbols was compared to the learning of grey-scale symbols (Hetzroni & Ne’eman, 2013). In an alternating treatment design study, all four children successfully learned and maintained recognition of the new vocabulary, regardless of the level of color included in the symbols. Further research is necessary, but the results reported by Hetzroni and Ne’eman provide evidence that, although pervasive and easily incorporated, symbols may not need to have color to be learned and used. Another consistent response was in relation to the use of color in the background of symbols. Although clinicians reported multiple reasons for using background color, to date, research related to the use of background color has been limited to its use as a cue for organizing vocabulary on the display. Thistle and Wilkinson (2009) compared the response time of children with typical development in locating symbols across several conditions, including variations of background color. The purpose of the background color was to add a secondary cue that the symbols with similar background color were within the same group (e.g., orange background behind green vegetables, pink background behind yellow fruits and vegetables). Wilkinson and Snell (2011) used background color as a cue to the meaning of the symbol by having PCS emotion symbols of similar category (e.g., happy, sad, angry) share background color. In both studies, the presence of background color detracted from performance of participants under the age of 4 years. One hypothesis is that the background color attracts too much attention and distracted participants from the critical information: the symbol content. These results suggest that caution is warranted when deciding on the use of background color for a specific individual. © 2015 International Society for Augmentative and Alternative Communication

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One third of the respondents independently mentioned consistency as an important principle to follow when designing a display. Specifically, they suggested that organizing the symbols on the display in a consistent manner may support motor planning. The effect of motor learning can be observed in daily activities such as typing on a keyboard or playing an instrument. With practice, the effort involved becomes more automatic. Motor learning theory posits that practice leads to changes in motor patterns that in turn result in changes in the cognitive resources required to complete the motor movement (Fitts & Posner, 1967; Rosenbaum, 2009). However sound the theory, evidence specific within AAC has so far been limited to case studies and vendor-developed strategies targeted toward individuals with autism spectrum disorders (Cafiero & Delsack, 2007; Stuart & Ritthaler, 2008). Suggestions for future research are offered in an upcoming section. Finally, although the survey did not specifically ask about partner modeling, some participants mentioned the importance of this technique. Research supports the use of partner language modeling as a method of supporting comprehension of input (Cafiero, 2001; Drager et al., 2006; Goossens’ et al., 1999; Romski & Sevcik, 1996). Romski and Sevcik (1996; 2003) also argued that by providing augmented input, partners not only provide a visual scaffold for the verbal input but also demonstrate both how to use the display and the acceptability of using aided AAC as a mode of communication. The survey responses suggest that participants recognize the potential value of partner modeling and seek to facilitate its practice. Factors Contributing to Differences in Decision Making The current survey suggests differences in clinical decision making that may be a reflection of a variety of factors, such as years of experience, characteristics of caseloads, or availability of relevant pre-service and in-service training. Future research is necessary to determine if these differences are replicated in future studies, and if so, what factors may be contributing to the replication. One possible explanation may be differences in training experiences. As the field evolves, so too does training and education, such that today’s students enrolled in SLP training programs, taught under the current ASHA scope of practice (ASHA, 2007), may learn different content than the SLP educated 15 or 20 years ago (Koul & Lloyd, 1994; Ratcliff et al., 2008). For instance, the results of the current study revealed that the proportion of SLPs who rated the child’s preferences as highly important was much larger in the group with 1–3 years of experience compared to SLPs with 13–20 years of experience. In 2004, the ASHA scope of practice guidelines underwent a substantial revision that involved significant shifts in emphasis with respect to family/child-centered practices and the inclusion of AAC as a service area (ASHA, 2007). In the current study, if the majority of clinicians with fewer years of

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experience in AAC service provision received their training after 2004, a shift in pre-professional experiences might be reflected in their decision-making. Alternatively, regardless of training, differences in perspectives might emerge depending on number of years of experience with a variety of children. Consider, for example, the responses related to the importance of the type of symbol: Given that the range of available symbol sets has proliferated over just the last few years, training may account for the differences between those clinicians with the greatest and the least number of years of experience, but only if the less experienced clinicians were trained in the last few years and only if their training included an introduction to the range of technologies/symbols. These clinicians may rate symbol type as a high priority, based on the knowledge of a variety of symbol types. A plausible alternative explanation is that longer experience imbues clinicians with insights about the additional factors that may also influence decisions about symbol type. For instance, perhaps these clinicians feel that the specific representation is less important than other features of the display, such as the organization or flexibility of layouts. Decisions are likely influenced by the outcomes of previous experiences, allowing the clinician to weigh factors that colleagues with less experience may not consider. However, it is also quite possible that previous experiences may unduly influence current decision-making, ultimately undermining the best course for the current case. Future Research Directions The results of this study highlight that a great deal remains unknown about how to support SLPs in contributing to the development of effective AAC displays. What are best practices? What education, tools, and training experiences support developing these best practices? How does experience and caseload influence decision-making? The following are suggested areas for future research that may help to answer these questions. Identifying Best Practices. This survey sought to determine current practices, as a first step toward identifying display design decisions that were and were not common across clinicians. Additionally, the decisions were examined within the context of available evidence. Decisions regarding the type of layout, use of background color, and support for the development of motor planning are three areas in which future research is needed. Type of Layout. The great majority of the SLPs in this study reported that they typically make use of a traditional grid display. Although research with young children without disabilities suggests VSDs may be an appropriate layout for beginning communicators (Drager et al., 2003, 2004; Light & Drager, 2007; Olin et al., 2010), this type of display was not considered to be a first choice by clinicians in this sample. Grid-based layouts have been available for far longer,

thus a greater research base exists concerning interventions in which these layouts are used. However, the limited consideration of emerging evidence-based practices suggests additional research is needed that addresses both practices and outcomes related to implementing VSDs. In relation to the practices, one line of research could identify the pitfalls and challenges that practitioners face when implementing VSDs; another could focus on determining the efficacy of this layout for individuals with various etiologies and communication goals. Such studies could seek to illustrate individual characteristics or communication situations that are best served by each type of display layout. Use of Background Color. Using background color to support sentence structure is a common clinical recommendation reported by SLPs, yet this practice has not been explored in the literature. Future research could ask what effect background color cues have on the proficiency of constructing a grammatical sentence. Using background color as a cue to word class category requires the child to understand and apply multiple concepts, that is, he or she must understand that words belong to different word class categories and that the color behind the symbol denotes that category. Research is needed to determine the effect of background color on the visual processing of the display and how this may vary given individual characteristics. Supporting the Development of Motor Planning. Future research is needed to examine the impact of supporting motor planning. The Language Acquisition through Motor Planning (LAMP; The Center for AAC and Autism, 2009) intervention combines principles of neurological and motor learning to teach language. The motor planning aspect stresses the importance of maintaining consistent locations of symbols. Rather than learning the meaning of the symbol representation, the child learns the locations that result in the desired communication. For instance, rather than learning the specific characteristics of the symbol representing HUG through repeated practice in visually searching for and locating the symbol, the child learns the specific motor movements required to access that symbol. One potential challenge of this approach occurs if an individual is ever required to deconstruct the learned motor pattern (cf. Light & Lindsay, 1991). Once component skills are learned as one motion, it is effortful to then break the group process back into its component parts (Fitts & Posner, 1967). Thus, if sentence construction is based solely on a motor plan, rather than knowledge of language structure, a transition to a new system would require starting over and learning new patterns. Empirical research is needed to determine how the act of learning the motor patterns influences learning and using language in the act of communicating. Additionally, the use of LAMP intervention has been focused on individuals with autism spectrum disorders. Research should seek to identify the benefits and challenges of this intervention across etiologies. Augmentative and Alternative Communication

AAC Display Design Decisions Tools to Support Decision-making. Future research that identifies a comprehensive framework to support clinical decision-making would have clinical utility. Such an approach has been suggested in relation to completing an assessment (a) to aid in device selection (Dietz, Quach, Lund, & McKelvey, 2012), (b) to assess dysarthria and the potential for AAC for individuals with amyotrophic lateral sclerosis (Hanson, Yorkston, & Britton, 2011), and (c) to determine functional seating and positioning for children with cerebral palsy (Costigan & Light, 2011). A checklist or flowchart could support practitioners as they consider various features related to selection and representation of vocabulary, and arrangement and visual features of associated symbols. This tool may offer a double-check mechanism for clinicians who regularly support children who use AAC, perhaps limiting the danger of decision making that over-emphasizes previous success with another child rather than a clear focus on the needs of the current child. Additionally, clinicians who have a more varied caseload and support only a small number of children who use AAC could benefit from a checklist guiding them through the components associated with designing a display. Through a comprehensive consideration of the critical features of a display in relation to the child’s needs and abilities, this tool may help clinicians demonstrate decisions that balance experience with empirical evidence. Creation of such a tool requires research that identifies the features that are important and the factors that may influence the relative importance of any one feature. Education and Experiences of Clinicians. Replication and expansion of the current survey is needed in order to fully characterize practices at different levels of experience and geographic location. A more in-depth exploration of the training and clinical practice across years of experience may provide insight into factors that influence display decisions. With only two individuals outside of the United States providing responses, it was not possible to report on international practices. Further research is needed to identify practices and challenges that may differ as a result of geographical factors (e.g., policies, training, resources). Additionally, future research should seek to validate that reported practices are, in actual fact, those that practitioners follow. For example, a qualitative study using in-depth interviews that focus on specific children within a practitioner’s caseload could offer a description of actual display designs created that includes practitioner rationales, as well as outcomes related to both the child and the display designs. Limitations of the Study Perhaps the most critical limitation of this study is the small number of participants who completed the full survey. A true response rate cannot be calculated due to the recruitment method of posting the notice on list serves; it can be reported that 192 individuals initially © 2015 International Society for Augmentative and Alternative Communication

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accessed the survey. The survey was very detailed, asking participants to respond to multiple open-ended questions. This may have contributed to attrition of participants, resulting in only 77 who completed the entire survey. However, analysis showed that the responses of those who did not complete the full survey were quite similar to the responses of the 77 who did. It is possible that those who took the survey are not representative of all SLPs who work with children under 10 who use AAC, as they may have had a particular interest in modifications that go into designing AAC displays. For instance, participants were primarily located through postings to list serves associated with AAC and other assistive technology. It is possible the SLPs who were members of those list serves were more interested in display design, or simply discussing their practices. Additionally, although the inclusion criteria required a minimum of 1 year of experience providing services to children who use AAC, individual experiences could be vastly different. It is possible that one participant’s caseload included only a handful of children who use AAC, while another practitioner with the same years of experience may have worked exclusively with children who use AAC. Other unknowns include pre-service education, formal/informal in-service trainings, and extent and type of teaming, all of which may contribute to the ways in which a practitioner designs an AAC display. On the one hand, such different experiences could contribute to different responses provided by participants in the current study. On the other hand, if this was the case, the similarities and differences seen across these participants particularly illuminates the challenges of display design. This small sample of participants recognized the need to individualize displays, but demonstrated a variety of approaches and rationales for the designs they create. Finally, in the section of the survey described here, participants were asked to describe their decisions when designing displays in general. They could have been thinking of one child or several children as they completed the survey. Responses may be based on some memory of related display design issues, but it is impossible to determine how accurate those memories were. Furthermore, participants might have felt that this task was asking them to justify their professional actions, introducing the possibility of social desirability bias (Podsakoff, MacKenzie, Lee, & Podsakoff, 2003; Nederhof, 1985), which occurs when participants provide responses that reflect their belief in the desirability of a particular response rather than their true feelings. It is difficult to know if a response is truly reflective of what a participant believes is the best practice. Survey design methods and statistical analyses can be utilized to reduce the influence of social desirability bias (Nederhof, 1985; Podsakoff et al., 2003). Although responses in the current survey may have reflected a social desirability bias, the selfadministered and anonymous nature of the survey may have reduced the likelihood of such bias.

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Conclusion

References

The survey results indicate that the majority of SLPs are modifying and individualizing aided AAC displays for children under 10 years of age. Furthermore, clinical practices related to supporting a range of communicative functions, making vocabulary selection decisions, and collaborating with team members, including supporting partner modeling, appear to be practices commonly utilized by clinicians. Many of these practices have an existing research evidence base. However, other practices represent areas in which future research is needed such as creating VSDs, utilizing symbol background color, and supporting motor planning. Research examining the effect of such design decisions may strengthen an evidence-based approach by adding empirical support to commonly observed clinical recommendations. Specifically, research should answer the question of what advantage the feature in question offers, and to whom? Addressing this question could help identify best practices toward designing AAC displays. Once best practices are identified, a next step may be to determine how best to support clinicians’ application of those best practices (e.g., what training, tools, and supports are needed to increase the use of desired practices?).

Adamson, L. B., Romski, M. A., Deffebach, K., & Sevcik, R. A. (1992). Symbol vocabulary and the focus of conversations: Augmenting language development for youth with mental retardation. Journal of Speech Hearing Research, 35, 1333–1343. doi:10.1044/ jshr.3506.1333 American Speech-Language-Hearing Association (2007). Scope of practice in speech-language pathology. Retrieved from http://www. asha.org/policy/SP2007-00283/ American Speech-Language-Hearing Association (2014). 2014 Schools survey report: SLP caseload characteristics. Retrieved from www.asha.org/research/memberdata/schoolsurvey/ Angelo, D. (2000). Impact of augmentative and alternative communication devices on families. Augmentative and Alternative Communication, 16, 37–47. doi:10.1080/07434610012331278894 Ball, L., Marvin, C., Beukelman, D., Lasker, J., & Rupp, D. (1999). Generic talk use by preschool children. Augmentative and Alternative Communication, 15, 145–155. doi:10.1080/0743461 9912331278685 Banajee, M., Dicarlo, C., & Stricklin, S. B. (2003). Core vocabulary determination for toddlers. Augmentative and Alternative Communication, 19, 67–73. doi:10.1080/0743461031000112034 Beukelman, D. (1991). Magic and cost of communicative competence. Augmentative and Alternative Communication, 7, 2–10. doi:10.1080/ 07434619112331275633 Beukelman, D., & Mirenda, P. (2013). Augmentative and alternative communication: Supporting children & adults with complex communication needs (4th ed.). Baltimore: Paul H. Brookes Publishing Co. Beukelman, D., Jones, R., & Rowan, M. (1989). Frequency of word usage by nondisabled peers in integrated preschool classrooms. Augmentative and Alternative Communication, 5, 243–248. doi:10 .1080/07434618912331275296 Beukelman, D., McGinnis, J., & Morrow, D. (1991). Vocabulary selection in augmentative and alternative communication. Augmentative and Alternative Communication, 7, 171–185. doi: 10.1080/07434619112331275883 Binger, C., & Light, J. (2007). The effect of aided AAC modeling on the expression of multi-symbol messages by preschoolers who use AAC. Augmentative and Alternative Communication, 23, 30–43. doi:10.1080/07434610600807470 Cafiero, J. M. (2001). The effect of an augmentative communication intervention on the communication, behavior, and academic program of an adolescent with autism. Focus on Autism and Other Developmental Disabilities, 16, 179–189. doi:10.1177/108835760101600306 Cafiero, J. M., & Delsack, B. S. (2007). AAC and autism: Compelling issues, promising practices and future directions. Perspectives on Augmentative and Alternative Communication, 16, 23–26. doi:10.1044/aac16.2.23 Costigan, F. A., & Light, J. (2010). A review of preservice training in augmentative and alternative communication for speechlanguage pathologists, special education teachers, and occupational therapists. Assistive Technology, 22, 200–212. doi:10.1080/10400435.2010.492774 Costigan, F. A., & Light, J. (2011). Functional seating for schoolage children with cerebral palsy: An evidence-based tutorial. Language, Speech, and Hearing Services in Schools, 42, 223–236. doi:10.1044/0161-1461(2010/10-0001) Dietz, A., Quach, W., Lund, S. K., & McKelvey, M. (2012). AAC assessment and clinical-decision making: The impact of experience. Augmentative and Alternative Communication, 28, 148–159. doi:10.3109/07434618.2012.704521 Dillman, D. A., Smyth, J. D., & Christian, L. M. (2009). Internet, mail, and mixed-mode surveys: The tailored design method. Hoboken, NJ: John Wiley & Sons. Drager, K. D., Light, J. C., Carlson, R., D’Silva, K., Larsson, B., Pitkin, L., & Stopper, G. (2004). Learning of dynamic display AAC technologies by typically developing 3-year-olds: Effect of different layouts and menu approaches. Journal

Notes 1. Qualtrics and all other Qualtrics product or service names are registered trademarks or trademarks of Qualtrics, Provo, UT, USA. http://www.qualtrics.com 2. The complete survey included five sections; the broad design questions were asked within Sections 1 and 2; the demographics questions were asked within Section 5. The case study specific questions asked in Sections 3 and 4 will be reported in another paper.

Acknowledgements This research was conducted in partial fulfillment of the first author’s doctoral training. The authors would like to thank student researchers Lauren Cherry, Marni Gruber, Samantha McDonald, and Paige McManus for their assistance on this project.

Funding The first author received funding from the U.S. Department of Education, doctoral training grant [#H325D110008].

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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AAC Display Design Decisions of Speech, Language, and Hearing Research, 47, 1133–1148. doi:10.1044/1092-4388(2004/084) Drager, K. D., Light, J. C., Speltz, J. C., Fallon, K. A., & Jeffries, L. Z. (2003). The performance of typically developing 2 ½-yearolds on dynamic display AAC technologies with different system layouts and language organizations. Journal of Speech, Language, and Hearing Research, 46, 298–312. doi:10.1044/10924388(2003/024) Drager, K. D., Postal, V. J., Carrolus, L., Castellano, M., Gagliano, C., & Glynn, J. (2006). The effect of aided language modeling on symbol comprehension and production in 2 preschoolers with autism. American Journal of Speech-Language Pathology, 15, 112–125. doi:10.1044/1058-0360(2006/012) Fallon, K. A., Light, J. C., & Achenbach, A. (2003). The semantic organizationpatternsofyoungchildren:Implicationsforaugmentative and alternative communication. Augmentative and Alternative Communication, 19, 74–85. doi:10.1080/0743461031000112061 Fitts, P. M., & Posner, M. I. (1967). Human performance. Belmont, CA: Brooks/Cole Publishing Co. Fleiss, J. L., Levin, B., & Paik, M. C. (2003). Statistical methods for rates and proportions. Hoboken, NJ: John Wiley & Sons, Inc. Fraenkel, P. (2006). Engaging families as experts: Collaborative family program development. Family Process, 45, 237–257. doi:10.1111/ j.1545-5300.2006.00093.x Fuller, D. & Lloyd, L. (1991). Toward a common usage of iconicity terminology. Augmentative and Alternative Communication, 7, 215–220. doi:10.1080/07434619112331275913 Gegenfurtner, K. R., & Rieger, J. (2000). Sensory and cognitive contributions of color to the recognition of natural scenes. Current Biology, 10, 805–808. doi:10.1016/S0960-9822(00)00563-7 Goossens’, C., Crain, S. S., & Elder, P. S. (1999). Engineering the preschool environment for interactive symbolic communication: 18 months to 5 years developmentally (4th ed.). Birmingham, AL: Southeast Augmentative Communication. Groves, R. M., Fowler, F. J., Couper, M. P., Lepkowski, J. M., Singer, E., & Tourangeau, R. (2009). Survey methodology (2nd ed.). Hoboken, NJ: John Wiley & Sons. Hanson, E., Yorkston, K. M., & Britton, D. (2011). Dysarthria in amyotrophic lateral sclerosis: A systematic review of speech characteristics, speech treatment and AAC options. Journal of Medical Speech-Language Pathology, 19, 12–30. Hetzroni, O. E., & Ne’eman, A. (2013). Influence of colour on acquisition and generalisation of graphic symbols. Journal of Intellectual Disability Research, 57, 669–680. doi:10.1111/j.13652788.2012.01584.x Hunt, P., Soto, G., Maier, J., Müller, E., & Goetz, L. (2002). Collaborative teaming to support students with augmentative and alternative communication needs in general education classrooms. Augmentative and Alternative Communication, 18, 20–35. doi:10.1080/aac.18.1.20.35 Johnson, J. M., Inglebret, E., Jones, C., & Ray, J. (2006). Perspectives of speech language pathologists regarding success versus abandonment of AAC. Augmentative and Alternative Communication, 22, 85–99. doi:10.1080/07434610500483588 Johnston, S. S., McDonnell, A. P., Nelson, C., & Magnavito, A. (2003). Teaching functional communication skills using augmentative and alternative communication in inclusive settings. Journal of Early Intervention, 25, 263–280. doi:10.1177/105381510302500403 Jones, S. D., Angelo, D. H., & Kokoska, S. M. (1999). Stressors and family supports: Families with children using augmentative & alternative communication technology. Communication Disorders Quarterly, 20, 37–44. doi:10.1177/152574019902000205 Kent-Walsh, J., & Binger, C. (2009). Addressing the communication demands of the classroom for beginning communicators and early language users. In G. Soto & C. Zangari (Eds.), Practically speaking: Language, literacy, and academic development for students with AAC needs (pp. 143–172). Baltimore, MD: Paul H. Brookes Publishing Co. Koppenhaver, D. A., & Erickson, K. A. (2003). Natural emergent literacy supports for preschoolers with autism and severe

© 2015 International Society for Augmentative and Alternative Communication

135

communication impairments. Topics in Language Disorders, 23, 283–292. doi:10.1097/00011363-200310000-00004 Koul, R., & Lloyd, L. (1994). Survey of professional preparation in augmentative and alternative communication (AAC) in speech-language pathology and special education programs. American Journal of Speech-Language Pathology, 3, 13–22. doi: 10.1044/1058-0360.0303.13 Kovach,T. M., & Kenyon, P. B. (2003).Visual issues and access to AAC. In J. Light, D. Beukelman, & J. Reichle (Eds.), Communicative competence for individuals who use AAC: From research to effective practice (pp. 277–319). Baltimore, MD: Brookes Publishing Co. Light, J., & Drager, K. (2005, November). Maximizing language development with young children who require AAC. Presented at the American Speech-Language-Hearing Association annual convention, San Diego, CA. Light, J., & Drager, K. (2007). AAC technologies for young children with complex communication needs: State of the science and future research directions. Augmentative and Alternative Communication, 23, 204–216. doi:10.1080/07434610701553635 Light, J., Drager, K. D., & Nemser, J. G. (2004). Enhancing the appeal of AAC technologies for young children: Lessons from the toy manufacturers. Augmentative and Alternative Communication, 20, 137–149. doi:10.1080/07434610410001699735 Light, J., & Lindsay, P. (1991). Cognitive science and augmentative and alternative communication. Augmentative and Alternative Communication, 7, 186–203. doi:10.1080/07434619112331275 893 Light, J., & McNaughton, D. (2013a). Putting people first: Re-thinking the role of technology in augmentative and alternative communication intervention. Augmentative and Alternative Communication, 29, 299–309. doi:10.3109/07434618.2013. 848935 Light, J., & McNaughton, D. (2013b). Literacy intervention for individuals with complex communication needs. In D. Beukelman & P. Mirenda (Eds.), Augmentative and alternative communication: Supporting children and adults with complex communication needs (4th ed., pp. 309–351). Baltimore, MD: Paul H Brookes Pub Co. Light, J., Page, R., Curran, J., & Pitkin, L. (2007). Children’s ideas for the design of AAC assistive technologies for young children with complex communication needs. Augmentative and Alternative Communication, 23, 274–287. doi:10.1080/07434610701390475 Marvin, L. A., Montano, J. J., Fusco, L. M., & Gould, E. P. (2003). Speech-language pathologists’ perceptions of their training and experience in using alternative and augmentative communication. Contemporary Issues in Communication Science and Disorders, 30, 76–83. Mayer-Johnson, R. (1992). The picture communication symbols. Solana Beach, CA: Mayer-Johnson. McFadd, E., & Wilkinson, K. (2010). Qualitative analysis of decision making by speech-language pathologists in the design of aided visual displays. Augmentative and Alternative Communication, 26, 136–147. doi:10.3109/07434618.2010.481089 Mizuko, M., & Reichle, J. (1989). Transparency and recall of symbols among intellectually handicapped adults. Journal of Speech and Hearing Disorders, 54, 627–633. doi: 10.1044/jshd.5404.627 Murphy, J., Markova, I., Collins, S., & Moodie, E. (1996). AAC systems: Obstacles to effective use. International Journal of Language & Communication Disorders, 31, 31–44. doi:10.3109/13682829609033150 Nederhof , A. J. (1985). Methods of coping with social desirability bias: A review. European Journal of Social Psychology, 15, 263– 280. doi:10.1002/ejsp.2420150303 Ogletree, B. T. (2012). Stakeholders as partners: Making AAC work better. Perspectives on Augmentative and Alternative Communication, 21, 151–158. doi:10.1044/aac21.4.151 Olin, A. R., Reichle, J., Johnson, L., & Monn, E. (2010). Examining dynamic visual scene displays: Implications for arranging and teaching symbol selection. American Journal of Speech-Language Pathology, 19, 284–297. doi:10.1044/1058-0360(2010/09-0001)

136

J. J. Thistle & K. M.Wilkinson

Podsakoff , P. M., MacKenzie, S. B., Lee, J.-Y., & Podsakoff , N. P. (2003). Common method biases in behavioral research: A critical review of the literature and recommended remedies. Journal of Applied Psychology, 88, 879. doi:10.1037/0021-9010.88.5.879 Ratcliff , A., Koul, R., & Lloyd, L. L. (2008). Preparation in augmentative and alternative communication: An update for speech-language pathology training. American Journal of Speech-Language Pathology, 17, 48–59. doi: 10.1044/10580360(2008/005) Romski, M. A., & Sevcik, R. A. (1996). Breaking the speech barrier: Language development through augmented means. Baltimore, MD: Paul H. Brookes Publishing Co. Romski, M. A., & Sevcik, R. A. (2003). Augmented input. In J. C. Light, D. R. Beukelman, & J. Reichle (Eds.), Communicative competence for individuals who use AAC: From research to effective practice (pp. 147–162). Baltimore, MD: Paul H. Brookes Publishing Co. Rosenbaum, D. A. (2009). Psychological foundations. In D. Rosenbaum (Ed.), Human motor control (2nd ed., pp. 93–134). Amsterdam; Boston, MA: Elsevier Inc. Ryan, G. W., & Bernard, H. R. (2003). Techniques to identify themes. Field Methods, 15, 85–109. doi:10.1177/1525822X02239569 Schlosser, R.W., & Sigafoos, J. (2002). Selecting graphic symbols for an initial request lexicon: Integrative review. Augmentative and Alternative Communication, 18, 102–123. doi:10.1080/07434610212331281201 Shane, H. C. (2006). Using visual scene displays to improve communication and communication instruction in persons with autism spectrum disorders. Perspectives on Augmentative and Alternative Communication, 15, 8–13. doi:10.1044/aac15.1.8 Snell, M. E., Brady, N., McLean, L., Ogletree, B. T., Siegel, E., Sylvester, L., … & Sevcik, R. (2010). Twenty years of communication intervention research with individuals who have severe intellectual and developmental disabilities. American Journal on Intellectual and Developmental Disabilities, 115, 364– 380. doi:10.1352/1944-7558-115-5.364 Stuart, S., & Ritthaler, C. (2008). Case studies of intermediate steps between AAC evaluations and implementation. Perspectives on Augmentative and Alternative Communication, 17, 150–155. doi:10.1044/aac17.4.150 Sutherland, D. E., Gillon, G. G., & Yoder, D. E. (2005). AAC use and service provision: A survey of New Zealand speech-language therapists. Augmentative and Alternative Communication, 21, 295–307. doi:10.1080/07434610500103483 The Center for AAC and Autism. (2009). What is LAMP? Retrieved from http://www.aacandautism.com/lamp Thistle, J. J., &Wilkinson, K. (2009).The effects of color cues on typically developing preschoolers’ speed of locating a target line drawing: Implications for augmentative and alternative communication display design. American Journal of Speech-Language Pathology, 18, 231–240. doi:10.1044/1058-0360(2009/08-0029)

Wilkinson, K. M, Carlin, M., & Jagaroo, V. (2006). Preschoolers’ speed of locating a target symbol under different color conditions. Augmentative and Alternative Communication, 22, 123–133. doi:10.1080/07434610500483620 Wilkinson, K. M., Carlin, M., & Thistle, J. (2008). The role of color cues in facilitating accurate and rapid location of aided symbols by children with and without Down syndrome. American Journal of Speech-Language Pathology, 17, 179–193. doi:10.1044/10583060(2008/018) Wilkinson, K. M., & Light, J. (2011). Preliminary investigation of visual attention to human figures in photographs: Potential considerations for the design of aided AAC visual scene displays. Journal of Speech Language Hearing Research, 54, 1644–1657. doi:10.1044/1092-4388(2011/10-0098) Wilkinson, K. M., & Snell, J. (2011). Facilitating children’s ability to distinguish symbols for emotions: The effects of background color cues and spatial arrangement of symbols on accuracy and speed of search. American Journal of Speech-Language Pathology, 20, 288–301. doi:10.1044/1058-0360(2011/10-0065) Wilkinson, K. M., O’Neill, T., & McIlvane, W. J. (2013). Eye-tracking measures reveal how changes in the design of aided AAC displays influence the efficiency of locating symbols by school-aged children without disabilities. Journal of Speech, Language, and Hearing Research, 57, 455–466. doi:10.1044/2013_JSLHR-L-12-0159 Williams, M. B., Krezman, C., & McNaughton, D. (2008). “Reach for the stars”: Five principles for the next 25 years of AAC. Augmentative and Alternative Communication, 24, 194–206. doi:10.1080/08990220802387851 Wormnæs, S., & Abdel Malek, Y. (2004). Egyptian speech therapists want more knowledge about augmentative and alternative communication. Augmentative and Alternative Communication, 20, 30–41. doi:10.1080/07434610310001629571 Wurm, L. H., Legge, G. E., Isenberg, L. M., & Luebker, A. (1993). Color improves object recognition in normal and low vision. Journal of Experimental Psychology: Human Perception and Performance, 19, 899–911. doi:10.1037//00961523.19.4.899 Xu, Y. (2002). Limitations of object-based feature encoding in visual short-term memory. Journal of Experimental Psychology: Human Perception and Performance, 28, 458–468. doi:http://dx.doi.org. ezaccess.libraries.psu.edu/10.1037/0096-1523.28.2.458 Yorkston, K., Honsinger, M., Dowden, P., & Marriner, N. (1989). Vocabulary selection: A case report. Augmentative and Alternative Communication, 5, 101–108. doi:10.1080/07434618 912331275076 Zangari, C., Lloyd, L., & Vicker, B. (1994). Augmentative and alternative communication: An historic perspective. Augmentative and Alternative Communication, 10, 27–59. doi: 10.1080/07434619412331276740

Supplementary material available online Supplementary Appendix A and B to be found online at http://informahealthcare.com/doi/abs/10.3109/07434618. 2015.1035798

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