Questions from the Book

What are some of the factors to consider in setting goals as priorities for individuals who rely on AAC?

Factors to consider in setting goals as priorities include 1) strategies and skills that are most important to the individual who relies on AAC; 2) those that are valued by family, friends, and community; 3) those that will have the greatest impact on functioning in real-life situations; 4) those that can be used regularly in the real world; and 5) those that are most likely to be learned successfully

Describe five different formats that can be used to assess symbol representation skills. What are the advantages or disadvantages of these different approaches?

The five formats for assessing symbol representation skills are 1) receptive labeling, 2) yes/no, 3) visual matching, 4) functional requesting, and 5) functional question/answer format. In receptive labeling, the person conducting the assessment presents the individual with two or more symbols and asks the individual to indicate one item from the array presented in response to the spoken label. This format is straightforward and efficient but requires that the individual understands the spoken labels, has the visual skills to perceive the symbols provided, and has the motor skills to indicate a selection (e.g., by giving the item, pointing, touching, or looking at it). In the yes/no format, the assessor holds up one symbol and asks, "Is this a ?" This format makes fewer demands on motor and visual abilities but makes heavier demands on cognitive and linguistic abilities because the individual must be able to understand the spoken question and then confirm or deny the truth of the question. In addition, results may be difficult to interpret because the individual has a 50% probability of being correct by guessing. In cases where the receptive labeling and yes/no formats are not appropriate because the individual does not understand the task expectations or the spoken labels presented, visual matching can be helpful. In visual matching, the team provides the individual with a single object; places two or more symbols, one of which matches the object, on the table; and then asks the individual to match the object to the corresponding symbol using eye gaze, pointing, or another selection option. Alternatively, the team may give the individual a single symbol to match to the correct object within an array. This format is useful for assessing the individual's understanding of symbols for objects, but it does not lend itself to assessing understanding and use of symbols to represent descriptors, relational terms, questions, and social words. A further disadvantage of the receptive labeling, yes/no, and visual matching formats is that they assess understanding of symbols but do not effectively assess the person's use of symbols to communicate. An advantage of the functional requesting and functional question/answer formats is that they do assess the person's functional use of symbols to communicate in natural contexts. In functional requesting, the AAC team provides symbols representing two or more of the items and activities available within a specific natural context, being sure to include one of the individual's preferred options (e.g., the team conducts the assessment at snack time and presents two or more snack choices, including one the individual is known to prefer). This provides the opportunity for the individual to make a functional request for the preferred item. As soon as he or she indicates a choice, the team responds immediately by providing the item corresponding to the symbol selected, then observes to confirm this is the item that the individual wanted. The functional question/answer format assesses the individual's functional use of symbols during conversational exchanges. After identifying concepts the individual understands that are related to a specific context (e.g., talking about his or her family), the team sets up a situation that provides the opportunity for communication by asking a meaningful question, presenting two or more symbols, and then waiting for the individual to respond. To communicate successfully in this format, the individual must understand the task expectations, the questions, and the symbol options presented and must be motivated to participate. A consideration common to all five formats is that AAC symbols and symbol assessment tasks are often new to individuals with complex communication needs. Therefore, it is most appropriate to use dynamic assessment whereby the AAC team first teaches the individual the new symbols and then tests the individual's understanding and use. Sometimes individuals with complex communication needs may have difficulty understanding the task requirements, which may mask their demonstration of symbol understanding. It may be important to use a third-party model to demonstrate task requirements.

What are potential goals for intervention with beginning communicators who are at the early stages of symbolic development (i.e., learning their first words)? For these beginning communicators, the goals of intervention are to help the individual

• Develop a robust and diverse vocabulary to express a wide range of concepts. • Develop greater competence expressing needs and wants (e.g., initiate requests for objects and activities). • Increase turn taking and joint attention in social interactions. • Make comments, answer questions, and ask questions about ongoing activities.

3.1. What is meant by the principle of planning AAC intervention for today and tomorrow? This principle means that teams planning AAC intervention should always be making two sets of decisions: those that address the person's present needs (today) and those that are made with the person's future in mind (tomorrow).

• Today decisions should help the individual to meet immediate communication needs that are considered priorities, and these decisions should be aligned with his or her current capabilities and any constraints identified during assessment. • Tomorrow decisions should be based on the opportunities, needs, and constraints that the team expects the person to have in future along with capabilities the person is likely to have in future. As AAC intervention progresses and as the person's opportunities, needs, constraints, and capabilities change over time, today continually becomes tomorrow. Reassessment may be required as needs, skills, and environmental supports and constraints change, resulting in new or adapted intervention plans.

What is the difference between grid displays and visual scene displays? What and the advantages and disadvantages of these different layouts.

-Grid displays represent each language concept with an isolated graphic symbol and organize the symbols in rows and columns, forming a grid pattern. Advantages: They can accommodate a diverse range of vocabulary concepts; allow for use of a few symbols or many depending on the individual's needs and capabilities; can be personalized or tailored to use in spe-cific settings/contexts; and support a wide range of communication outcomes. Disadvantages: Grid displays present language concepts in a decontextualized way and do not capture the contexts in which language is learned and used; they do not preserve the functional relationships among people, actions, and objects as experienced in the real world. This makes them difficult for or unsuited to some individuals who require AAC (e.g., very young children or others at the beginning stages of communication development; adults with severe chronic aphasia). -Visual scene displays use integrated scenes, typically photographs, of meaningful and motivating events within the individual's life, thereby organizing vocabulary concepts according to the activities, routines, and events within which the individual learns and uses language for communication. Advantages: They have high personal relevance for the individual; they are effective in supporting communication for beginning communicators with developmental disabilities and adults with significant language/cognitive limitations due to acquired conditions such as aphasia or traumatic brain injury. Disadvantages: Visual scene displays do not support more advanced language development (e.g., morphology and syntax).

What is meant by the following principles that underlie functional communication training: 1) functional equivalence, 2) efficiency and response effectiveness, and 3) goodness of fit between the individual and his or her environment?

1. Functional equivalence means that the replacement behavior that is taught must fulfill the same communicative function that the challenging behavior currently fulfills. For example, if an individual currently engages in self-injurious behaviors to communicate rejection of a nonpreferred object, the replacement behavior that is taught should fulfill the same communicative function, rejection. 2. Efficiency and response effectiveness mean that the replacement behavior should be as easy as, or easier than, the challenging behavior for the individual to perform, and communication partners should consistently respond by recognizing and honoring the individual's communication. For example, if the individual signals no to reject a nonpreferred object, the object should be quickly removed; in this way, the individual learns that he or she can use the socially acceptable behavior to get the desired result. (If it is not possible to honor the individual's expressed wishes [e.g., for safety or medical reasons] the individual should nevertheless be provided some degree of choice/control within the situation.) 3. Goodness of fit refers to the idea that environmental adaptations, designed to fit the individual's needs and skills, are often the best way to reduce challenging behaviors. For example, if a student eats lunch in a separate room with an aide and often demonstrates aggressive behaviors to protest, allowing the student to eat lunch in the cafeteria with classmates may reduce the behavior. A visual schedule is a tool used to help an individual understand the activities of his or her daily routine so that the individual consistently knows what to expect next and when and how to transition from one activity to the next. The schedule helps ensure the person understands what is going on, feels in control, and can transition smoothly between activities. Using visual schedules can reduce challenging behaviors. Visual schedules represent 1) the main activities of the day and/or 2) specific steps within a multistep activity. They vary in format and complexity; they may be low- or high-tech and may represent activities/events using real objects, tangible symbols, photographs, line drawings, videos, or written words. The AAC team should make decisions about how to represent activities and how to organize them in a logical sequence based on the needs and skills of the beginning communicator.

Describe three key considerations in delivering AAC services to people with intellectual disabilities. Three key considerations in delivering AAC services to people with intellectual disabilities are

1. Personalizing intervention to meet needs and skills. The cognitive impairments that characterize intellectual and developmental disability may result from any of a number of different syndromes and conditions, which vary in how they typically affect spoken and written communication. Teams should be aware of and attentive to typical characteristics associated with specific disabilities as well as the individual's unique needs and capabilities. 2. Eliminating opportunity barriers. Opportunities to participate meaningfully in society and interact with others in different contexts (e.g., home, school, work, community) are often limited by low expectations and negative social attitudes toward people with intellectual disabilities. Teams should work to ensure that fundamental communication rights are supported and that inclusive, natural opportunities for communication are available. 3. Addressing challenging behaviors. People with intellectual and developmental disabilities may use challenging behaviors to express themselves when they do not have another effective way to communicate. Teams should use positive behavior supports to prevent these behaviors and should teach functional communication skills as alternative, socially appropriate behaviors.

Many people who rely on AAC experience crime or abuse during their lives. How can AAC systems be designed to deal with crime and abuse at the moment and later during legal and counseling activities?

AAC systems can be set up to ensure that a person who relies on AAC includes the vocabulary needed to report crimes or abuse. Both children and adults should be provided with the communication supports they need to advocate for themselves and report what events are happening in their daily lives, who they are with throughout the day, and how different people interact with them. For adults, vocabulary should support communication related to six contexts: college life, sexuality, crime reporting, management of personal assistants, health care, and transportation. People who rely on AAC should be provided with information about abuse and available supports as well as the information they need to access legal services

What is meant by the term beginning communicator? To whom does this description refer?

A beginning communicator is someone who is at the early stages of communication development and is learning the skills needed to participate in daily life. Beginning communicators may be at any of the following stages: 1. Preintentional—These communicators do not yet understand they can communicate with others and impact others' behavior. 2. Intentional but presymbolic—These communicators engage in purposeful communication behavior, directed at a partner, to achieve a goal. They use signals (e.g., reaching for, pushing away, vocalizing) but do not yet use symbols (e.g., spoken words, manual signs, aided AAC symbols). 3. Early symbolic development—These communicators are learning their "first words" (using speech, signs, or aided AAC symbols). 4. Learning to combine symbols—These communicators have learned a range of symbols and are beginning to combine them to communicate more complex messages. Beginning communicators include infants, toddlers, and preschoolers with a range of developmental disabilities (e.g., autism spectrum disorder, cerebral palsy, Down syndrome, intellectual disabilities), as well as older children and adults with severe developmental disabilities who are learning early communication skills.

What is a signal dictionary? Why is it important?

A signal dictionary is an AAC tool used to help communication partners recognize the communication behaviors demonstrated by individuals with complex communication needs and respond to these behaviors consistently. AAC teams should provide signal dictionaries that include the following elements for each signal: • A description of the signal • The signal's meaning • The response required of the communication partner Signal dictionaries can be posted so communication partners can easily refer to them. They may use print, photo, or video formats.

How do the roles of an AAC specialist and an AAC daily facilitator differ?

AAC intervention specialists, who have greater expertise in AAC, take on a leadership role in coordinating intervention for the child or adult who requires supports. Specialists' responsibilities may include implementing low- and high-tech AAC options, obtaining materials and technologies, coordinating the team of professionals involved, instructing and training individuals who rely on AAC and important communication partners, monitoring the effectiveness of AAC interventions, and recommending needed changes. Specialists may work in educational, medical, or rehabilitation settings or in private practice. AAC facilitators provide the day-to-day support needed by the person who relies on AAC. They may be family members, friends, or staff members in care settings. AAC facilitators' responsibilities may include maintaining (charging and cleaning) AAC technology, programming new messages or words in low- or high-tech systems, instructing unfamiliar communication partners, and serving as a liaison with other AAC personnel and AAC companies.

How might AAC interventions vary across the life span to benefit individuals with Down syndrome?

AAC interventions for people with Down syndrome may vary across the life span to meet their changing communication needs with different communication partners across different contexts. Communication needs are likely to change as follows: Early childhood: Infants and toddlers with Down syndrome are typically delayed in their speech development, and they need AAC from an early age to support expressive communication and language development. Childhood through early adulthood: Once individuals with Down syndrome acquire speech, they may rely on it as a primary means of communication throughout their childhood and adolescence. For communication with familiar partners, speech may be sufficient into early adulthood. However, typically, their speech is difficult to understand, and individuals with Down syndrome may require access to AAC to clarify their spoken communication, especially when they are talking about novel topics or with unfamiliar partners. Early adulthood: As individuals with Down syndrome enter adulthood, they are likely to interact with others across a wider range of contexts (e.g., school, work, routine daily living activities, community participation, health care). They will therefore encounter many unfamiliar communication partners and will likely need AAC either to supplement speech or as their primary mode of communication. Late adulthood: As individuals with Down syndrome age, they are at risk for Alzheimer's disease. As a result of this degenerative condition, they may require AAC to support comprehension and expression.

Describe the communication challenges faced by individuals with cerebral palsy.

Communication challenges faced by individuals with cerebral palsy may include • Severe challenges with motor control that limit mobility, natural speech, and writing • Articulation disorders and impaired speech intelligibility • Laryngeal and velopharyngeal dysfunction • Language delays or disorders, which may be compounded by limited access to language-learning opportunities • Other communication difficulties related to intellectual disabilities, hearing impairments, and/or vision impairments

What type of individual might wish to use activation on release?

Activation on release requires the individual to retain direct contact with the display until the desired symbol or representation is located, then release contact in order to select it. This might be used by individuals who • Wish to use the display for hand stability • Move too slowly or inefficiently to use timed activation successfully

How does social closeness communication differ from social etiquette communication?

Again, these two types of communication interaction serve different goals. Social closeness communication establishes, maintains, or develops social engagement to build interpersonal relationships. An example is friends attending a school concert and applauding and cheering for the performers. The specific content of the message often matters less than the interaction itself and the feeling of connection it creates. In contrast, social etiquette communication is used not to build closeness but to adhere to social expectations for politeness. An example is saying, "Excuse me," after accidentally bumping into someone on the subway.

Define aided AAC. What Is meant by low-tech aided AAC and high-tech aided AAC? What are the advantages and disadvantages of each?

Aided AAC requires some type of external aid or device to support communication, either low- tech or high- tech -Low- tech aided AAC refers to nonelectronic systems such as communication boards or books of photographs, picture symbols, or written words; alphabet boards; picture exchange systems; and visual schedules. Advantages: These systems may be more easily understood and used by communication partners than are many unaided forms of AAC (e.g., manual signs). A wide range of low- tech systems are available to fit differ-ent people's communication needs and capabilities. Low- tech systems can be used in many contexts and do not break down as do high- tech systems. Disadvantages: Since aided AAC requires external equipment, it may not always be readily available for communication. When using aided AAC, the individual has to first locate and then communicate the target concept or message, so aided AAC may be slower than unaided AAC. Aided AAC systems require person-alization of the type of representations or symbols used, organization and layout, selection or access tech-niques, and output in order to meet the needs and capabilities of the individual with complex communication needs. Although low tech aided AAC can be effective in one- on- one interactions, it is not as effective for communication in large groups or at a distance. -High- tech aided AAC refers to electronic technologies with AAC applications (apps) that produce speech, text, or electronic output. Advantages: AAC technologies typically provide speech, print, and/or digital output that can be easily understood by the partner. These may provide access to a wider range of concepts and messages than most unaided and low- tech aided AAC systems. Disadvantages: As with low- tech systems, AAC technologies should be personalized (e.g., type of representations or symbols used, organization and layout, selection or access techniques, and output) to meet the individual's needs and capabilities. In order to use AAC technologies, the individual has to divide attention between the partner, the technology, and the shared activity; the individual has to search for, locate, and then select the target concepts. Unlike low tech AAC, high tech systems are dependent on functioning electronic technology. Like low- tech systems, they may not always be easily available for communication.

What are some of the key considerations for ensuring that an AAC assessment is reliable and valid? What are some of the key considerations when assessing individuals from different cultural and linguistic backgrounds?

An AAC assessment must be reliable, meaning it produces consistent results, and valid, meaning it measures what it is intended to measure. Key considerations for ensuring that an AAC assessment is reliable and valid include 1) whether the team conducting the assessment is skilled and knowledgeable in AAC, 2) whether necessary accommodations are in place to support the participation of the individual with complex communication needs in the assessment, 3) whether the assessment is meaningful based on the person's life experiences, 4) whether it is appropriate given the individual's cultural and linguistic background, 5) whether the sample of behavior assessed is sufficient to determine strengths and challenges, and 6) whether the team adheres to the principle that while the present is observable, the future is unknown (that is, the team should avoid broad prognoses or labels that impact the person's future). When assessing individuals from different cultural and linguistic backgrounds, it is important to understand that a person's background significantly impacts his or her life experiences. Specific considerations to keep in mind include possible differences in cultural values, beliefs, and communication styles as well as differences between the home language(s) and what is used in the broader community. Additionally, teams may face a lack of culturally appropriate assessment and intervention approaches and/or a lack of culturally appropriate AAC (e.g., symbols and speech output). They may not have had the training needed to deliver culturally competent services to individuals from different backgrounds.

1. What is an encoding technique? Why are encoding techniques used? Provide at least 3 examples of encoding techniques.

An encoding technique is a technique in which complete words, phrases, or sentences are stored in AAC technology and each stored message is assigned a code of some type. The individual who relies on AAC uses this code to retrieve the entire word or message. Encoding techniques are used to • Increase access to vocabulary, because a relatively small number of representations (e.g., letters, line drawings) can be used in various combinations as codes to retrieve single words or messages • Improve communication rate or reduce fatigue, because they reduce the number of selections required to communicate a word or message Examples of encoding techniques include 1. Truncation codes that abbreviate words according to the first few letters only (e.g., hamb = hamburger) 2. Contraction codes that include only the most salient letters of the word (e.g., hmbgr = hamburger) 3. Iconic encoding, such as Unity, which utilizes iconic codes, specifically combinations of symbols (line drawings)

What is an environmental adaptation intervention? Describe an example.

An environmental adaptation intervention is one that alters some aspect of the day-to-day environment for an individual with complex communication needs. Its purpose is to remove any barriers that could be interfering with the person's use of AAC. Examples of environmental adaptations include space and location adaptations and physical structure adaptations. • Space adaptations address physical barriers that interfere with the person's use of AAC in a given space. Moving or rearranging furniture to make more room for AAC equipment is an example of a space adaptation. • Location adaptations involve changing the location of the person who relies on AAC. An example of a location adaptation to support social interaction is moving a student who relies on AAC to sit with classmates at lunch rather than being fed by an aide at a separate table by herself. • Physical structure adaptations involve specific changes to the environment beyond space and location, such as modifying a school desk to allow for mounting the student's AAC technology.

What types of individuals should be considered for AAC supports?

Any individual who cannot effectively meet his or her day-to-day communication needs through oral speech should be considered for AAC supports. People who rely on AAC are very diverse in their backgrounds, capabilities, and communication needs; what they have in common is that their spoken (and/or written) communication is temporarily or permanently inadequate to meet all of their communication needs. These difficulties in speaking or writing may result from a variety of conditions, including both developmental and acquired conditions. Developmental conditions that may result in the need for AAC supports include severe intellectual disability, cerebral palsy, Down syndrome, autism spectrum disorder, and developmental apraxia of speech. Acquired conditions that may result in the need for AAC supports include amyotrophic lateral sclerosis, multiple sclerosis, traumatic brain injury, stroke, high-level spinal cord injury, and a range of degenerative cognitive and linguistic disorders. Increasingly, it is understood that AAC interventions may benefit not only people with severe communication impairments but also infants and toddlers who are at risk for speech development, individuals who use natural speech but require AAC to supplement or clarify their speech, and individuals who require AAC to support comprehension.

Why is it important to assess the participation patterns and unmet communication needs of the individual? How can this be accomplished?

Assessing the individual's participation patterns and unmet communication needs helps the team get to know the individual, determine goals for communication, define the contexts that are priorities for intervention, and determine the requirements for AAC systems. In sum, it gives the team a big picture view of the individual that informs subsequent assessment and intervention. Participation patterns and unmet communication needs can be assessed through several means: conducting interviews with the individual and family, investigating the individual's social networks, completing communication needs surveys, and/or completing participation inventories.

Who should be involved in AAC assessment? Why is it important to include the individual who relies on AAC and his or her family

Assessment and intervention should involve a team consisting of the individual with complex communication needs, family members and/or caregivers, other significant communication partners, and professionals from a range of disciplines. It is essential to involve the individual who relies on AAC in making all assessment and intervention decisions; that individual will be affected the most by these decisions. Similarly, the person's family will be greatly affected, so AAC assessment and intervention must involve family members as well. It is also important to involve any other communication partners who spend a significant amount of time with the individual— for example, teachers and other educators, coworkers, and/or caregivers. Finally, the team should involve professionals with the expertise needed to address specific challenges relevant to assessment and intervention (e.g., language challenges, needed environmental adaptations). These professionals include speech-language pathologists; occupational and/or physical therapists; psychologists; counselors; audiologists; vision specialists; social workers; and medical, educational, or vocational personnel as well as the people who manage the natural environments where the individual spends time.

Why is it important to personalize vocabulary/messages for individuals who rely on AAC?

Because each individual has unique experiences, no two people have identical vocabularies. Individuals who rely on AAC therefore should have access to personalized vocabulary and messages that include the names of specific people, locations, interests, and activities in their lives as well as preferred expressions.

Why is it important to work closely with family and other communication partners when planning intervention for beginning communicators?

Beginning communicators rely on family and other regular communication partners to ensure that they have meaningful communication opportunities, effective means to communicate, and the supports they need to do so successfully. Involving familiar communication partners maximizes outcomes and helps these communicators generalize the skills they are learning. Because these partners are usually well attuned to the kinds of signals the individual makes, they can also be helpful in fostering intentional communication skills.

What are the differences between synthesized and digitized speech?

Both are forms of electronic speech but with the following differences: • Synthetic speech can be generated either from recordings of an individual's natural speech or through another means, such as entering text into AAC technology to generate speech. The resulting synthesis is based on a human voice or voices. Synthetic speech is generated from stored speech data to express the message the individual has indicated. • Digitized speech consists primarily of natural speech that has been recorded, stored, and reproduced; the reproduced speech is therefore a close replica of the original speech entry. This approach can be used by individuals who expect to lose the ability to speak and wish to record a bank of spoken messages in their own voice that they will be able to use in future. Digitized speech cannot be used to convert text to speech.

How is suspected childhood apraxia of speech defined?

Childhood apraxia of speech refers to a disorder that involves impairment in the precision and consistency of the movements required for speech and that occurs without apparent neuromuscular deficits such as abnormal reflexes or abnormal tone. Although there are no validated diagnostic features that differentiate it from other speech sound disorders in children, experts agree on the following typical characteristics: • Inconsistent errors on consonants and vowels in repeated productions of syllables or words • Lengthened and disrupted coarticulatory transitions between sounds and syllables • Inappropriate prosody, especially in the realization of lexical or phrasal stress Children with this diagnosis demonstrate difficulties with planning and programming the movements needed for speech, and they speak with reduced intelligibility.

What is communicative competence? Individuals who require AAC need to develop knowledge, judgment, and skills in four interrelated domains to build communicative competence. What are these domains?

Communicative competence is the ability to express needs and wants, interact socially, and share information so as to participate successfully in a range of different environments and contexts (e.g., educational, vocational, health care, and community living). It comprises the skills and understanding needed to communicate effectively with others in daily life. To build communicative competence, an individual who relies on AAC must develop (and integrate) knowledge, judgment, and skills in four domains: linguistic, operational, social, and strategic. 1. Linguistic—This domain consists of language skills, including • Receptive and expressive language skills in the spoken language used by the family and community • Skills in the language code of the AAC system the person uses 2. Operational—This domain consists of the skills needed to access and use AAC, including • Skills to produce unaided AAC • Technical skills needed to operate low- or high-tech aided AAC systems 3. Social—This domain consists of the skills needed to use AAC effectively in social interactions, including • Sociolinguistic or pragmatic skills • Sociorelational or interpersonal skills 4. Strategic—This domain consists of the skills needed to cope with or bypass any ongoing short- or long-term limitations to communication. These limitations may be due to specific individual impairments, external barriers, or the nature of AAC. Strategies include the use of • Introductions and regulatory phrases to teach new communication partners how to interact effectively with the person who relies on AAC • Humor to initiate interactions and put new communication partners at ease • Conversational repairs to resolve communication breakdowns • Other strategies to address specific linguistic, social, or operational limitations

What are the differences between core vocabulary and personalized vocabulary in an AAC system?

Core vocabulary consists of relatively common words used fairly frequently by a variety of individuals in different situations. Core vocabulary includes • Function words such as a, the, it • Content words that occur frequently in everyday communication, such as go, want Core vocabulary is not unique to an individual. In contrast, personalized vocabulary consists of vocabulary words and messages that are specific or unique to the individual. For example, personalized vocabulary includes • Words that name specific people, locations, and activities in the individual's life (e.g., Jennifer, Ocean City, synagogue) • The individual's preferred expressions Although standard core vocabulary lists based on research studies exist, core vocabulary should not be the sole focus of intervention. Vocabulary and message selection should be tailored to the individual and should include personalized vocabulary, based on input from the individual who relies on AAC and/or people close to that person, as well as core vocabulary.

How do the greeting, small talk, information-sharing, and wrap-up stages in a conversation differ from each other?

Each stage of the conversation serves a different purpose, and therefore the way AAC teams and people who rely on AAC manage vocabulary selection and messaging will vary across these different stages. • Greetings are used to initiate social interactions; they are often fairly generic but must be selected with attention to cultural appropriateness, age and status of the people who will be interacting, and variety. • Small talk is used to initiate and maintain social interactions. It may form the entire basis of some social interactions; for other interactions, small talk may be used to transition into information-sharing. • Information-sharing encompasses several types of interactions: telling a story; describing a procedure; or having a content-specific, back-and-forth conversation. These interactions are richer in detail, more specific to the individual, and more associated with social closeness than are the other stages of conversation. • The wrap-up stage consists of remarks meant to end an interaction. Like greetings, these remarks may be somewhat generic but should be chosen with attention to the setting where they will be used.

Why are those who interact with people who rely on AAC referred to as communication partners rather than listeners?

Effective communication often requires the people involved to co-construct messages. They collaborate to establish meaning. For this reason, people who interact with individuals who rely on AAC are referred to as communication partners.

3.9. How would you evaluate AAC intervention? What types of measures would you use? How would you use evaluation data?

Evaluation of AAC intervention should examine whether the individual has acquired, generalized, and maintained the target strategies or skills. Potential measures include • Graphs/tables of data about the person's communication performance across sessions over time; comparison of baseline performance to performance during and after intervention (acquisition of the target skill) • Regular checks to ensure the individual is using a learned strategy or skill in new situations and with new communication partners (generalization) • Regular checks to ensure the individual continues to use the strategy/skill on a long-term basis following instruction (maintenance) In addition to these measures of communication performance, it is important to collect person-centered measures including the satisfaction of the individual who relies on AAC and the satisfaction of his or her family members and other significant communication partners. Evaluation data should be examined to determine whether the individual is making consistent progress/ gains with a target strategy or skill over time. If not, it is important to meet with the AAC team—including the individual with complex communication needs and his or her family—to • Examine the intervention and instruction • Determine the potential source of the problems • Determine what modifications might be made (e.g., changing the goal or the instructional procedures/context/ intensity) Following any modifications, data should be collected on the modified intervention to assess its effectiveness.

Why would a person who can formulate messages through letter-by-letter spelling choose to store and retrieve whole messages with his or her AAC device?

Even when a person can formulate messages using letter-by-letter spelling, being able to retrieve stored whole messages may be beneficial or necessary for certain purposes: • To communicate important messages immediately (e.g., "This is hurting me") • To more easily communicate a lengthy, frequently used message (e.g., introducing oneself) • To more easily communicate messages used at times when the person typically experiences fatigue and letter-by-letter spelling would be highly demanding (e.g., dinnertime, bedtime)

What is evidence-based practice? Why is it important in AAC intervention? What are the three main components that are used to make evidence-based practice decisions?

Evidence-based practice integrates research evidence, clinical expertise, and the perspectives of individuals who rely on AAC and other stakeholders to ensure AAC intervention is effective and efficient. This means that decisions about AAC assessment and intervention should be based on evidence from research along with input from people with clinical expertise in AAC and from people with complex communication needs and their families. The goal is to ensure that decisions the AAC team makes result in efficient, effective intervention, which requires that the team have knowledge of current research and have skills in translating this research to evidence-based practice.

How do feedback and output differ?

Feedback is provided on an individual's selections as he or she accesses AAC technology, that is, during the construction of a message. Two types of feedback are 1. Activation feedback, which lets the individual know that an item has been selected from the selection 2. Message feedback, which provides the individual with information about the message that has been formulated or selected An AAC system may provide either or both types of feedback or neither, and it may be visual, auditory, tactile, or proprioceptive. Output is the information an individual sends to his or her communication partners after constructing the message. It may consist of synthetic speech, digitized speech, photographs, video clips, print, gestures, manual signs, and nonelectronic aided symbols.

Provide 5 examples of aided AAC symbols or representations. What are the advantages and disadvantages of each one?

Five examples of aided AAC symbols or representations are real objects, partial or associated objects, photo-graphs, line drawings, and traditional orthography. -Real objects Advantages: Real objects are concrete and are easily understood and used by beginning communicators. Disadvantages: They allow for communicating only a limited range of messages and can be physically inconvenient to use. - Partial or associated objects (e.g., cat's bowl to represent feeding the cat) Advantages: These objects are concrete and relatively easy to learn. Disadvantages: They allow for communicating only a limited range of messages, can be physically inconvenient to use, and may require teaching the association between symbol and referent. Some associations may be artificial or abstract. -Photographs Advantages: Photographs are more portable than objects, are easily obtained from print or online sources, are easily accessed and personalized using mobile technologies, and have versatile uses and are easier than line drawings for some people to learn. Disadvantages: Abstract concepts such as descriptors are difficult to represent in photographs; photographs provide static representations and they may need to be supplemented with videos to communicate about dynamic events. - Line drawings Advantages: Line drawings are available as part of many commercial AAC symbol sets (e.g., PCS, Symbol-Stix), the sets include representations for a wide range of concepts; different symbol sets were developed for use for different populations, purposes, and levels of complexity; some have been translated into many languages; some allow for combining symbols to generate new concepts and more complex messages. Disadvantages: Careful consideration is necessary to choose appropriate line drawings to meet the individual's needs; representations in these symbol sets may not be easily understood for some concepts; line drawings may be harder to understand and use than objects or photographs. - Traditional orthography (spelling) Advantages: Traditional orthography allows for communicating any message using the letters of the alphabet. Disadvantages: Its use depends on literacy skills.

What are potential goals for intervention with beginning communicators who are intentional but not yet symbolic?

For these beginning communicators, the goals of intervention are to help the individual • Develop clear signals to express needs and wants and regulate the behavior of others (e.g., signals to express acceptance and rejection, communicate choices, and eventually request objects or activities). • Take turns consistently in social interactions and develop social closeness. • Demonstrate joint attention, that is, shift attention between the partner and a shared object of interest or shared activity.

What is the goal of intervention for beginning communicators who are preintentional?

For these communicators, the goal of intervention is to develop intentional communication, that is, purposeful communicative behavior directed toward a partner. In pursuing this goal, it is important for AAC teams to be aware of the potential indicators of intentional communication behaviors that individuals with complex communication needs are likely to demonstrate.

What is functional communication training? Why is it important?

Functional communication training (FCT) is an intervention designed to reduce challenging behaviors by teaching functionally equivalent, socially appropriate communication skills to replace the challenging behaviors. To use this intervention, the team follows these procedures: 1. Assess the behavior (via interviews, behavior logs, and/or observations) to form a hypothesis about its function—that is, the communication purpose or goal it serves for the individual (e.g., escaping a nonpreferred activity, requesting attention). 2. Conduct a functional analysis to test the hypothesis and determine the function of the behavior. 3. Select an alternative means of communication (i.e., AAC) that will result in the same goal and is as easy as, or easier than, the challenging behavior (e.g., signaling no). 4. Teach the individual this socially acceptable alternative communication using a most-to-least prompting hierarchy. 5. Teach caregivers to respond immediately to the individual's use of the alternative behavior so it ultimately replaces the challenging behavior. For functional communication training to succeed, it is crucial that the replacement communication taught is socially acceptable, functionally equivalent to the challenging behavior, and effective and efficient.

There are three key components to communicative competence: 1) functionality of communication in real-world contexts; 2) adequacy of communication to meet demands in daily interactions; and 3) sufficiency of knowledge, judgment, and skills. Describe why each of these is important and consider each component's implications for planning AAC intervention.

Functionality of communication in real-world contexts refers to the actual communication performance a person displays within the contexts of his or her daily life. This component is important because communication is not an end in itself but rather a means to an end; people communicate to achieve various goals, such as educational and workplace goals, participation in different communities, and personal expression and connections with others. It is important for AAC intervention to ensure that the person who relies on AAC can meet these communication goals. Consequently, AAC interventions should focus on the natural contexts of the person's day-to-day life, such as the home environment, classroom, and workplace. This approach makes it more likely the skills and strategies targeted will be functional and the person will be able to use them across a range of contexts to improve communication and enhance quality of life. Relatedly, communicative competence entails having adequate communication to meet the demands of the environment(s) and achieve the desired outcomes. Communicative competence can vary for the same person across different real-life contexts. For example, a person may be more effective in communicating with some partners than with others or for some purposes than for others. Because "competence" or "success" in communicating is defined in relation to an individual's goals, needs, and circumstances, it is important to take these goals, needs, and circumstances into account when planning intervention. A final important component of communicative competence is having sufficient knowledge, judgment, and skills across four domains—linguistic, operational, social, and strategic—to use AAC effectively to meet the individual's goals. The first two domains provide the tools a person needs to communicate; the latter two domains have to do with how a person uses those tools when interacting with others.

Why is it important to focus not only on the expression of needs and wants but also on social interaction?

Having meaningful social interactions is an important part of everyday life. For individuals without disabilities, these interactions extend far beyond simply expressing one's needs and wants; individuals with complex communication needs should similarly have the opportunity to engage in a wide range of social interactions, develop social relationships, and build social closeness. Learning to participate in these interactions and use social skills such as turn taking is a key component of communicative competence. Furthermore, some disabilities that can cause communication challenges are also associated with challenges in social interaction (e.g., autism spectrum disorder). For individuals with these disabilities to build communicative competence, intervention to teach social interaction skills such as turn taking is crucial.

How do fixed and dynamic displays differ?

On a fixed display, symbols and representations are "fixed" in a particular location. These displays are typically used on low-tech communication boards as well as in some AAC technologies. A dynamic display on a computer screen can be changed to a new set of symbols and has some means of navigating between different displays.

Parents may be concerned that using AAC will negatively impact their child's speech development. How would you respond to their concerns? How would you plan intervention?

If parents express this concern, it is important to listen to their concerns and be sure you understand them. Discuss two points with them: 1. AAC intervention is not a last resort, and trying AAC intervention does not imply that the child will always rely on AAC to meet all communication needs. AAC intervention is intended to supplement, not replace, interventions that are intended to enhance natural speech and/or writing. 2. Over two decades' worth of research has shown that AAC intervention does not have a negative impact on speech development; in fact, the opposite is true. AAC intervention helps ensure that the child can communicate effectively with others and can participate more fully in his or her environment. In turn, the ability to communicate effectively and to participate more fully in the environment increases the likelihood the child will make good progress toward his or her goals, including speech development goals. In short, AAC intervention will not harm and almost certainly will help the child. For this reason, intervention planning should usually include both AAC approaches and approaches that enhance natural speech and/or writing. To determine what balance is appropriate for an individual, it is important to consider that individual's specific needs, capabilities, and preferences along with those of the family.

The parent of a child with severe motor limitations who cannot use direct selection wishes to know the difference between directed scanning and automatic scanning. What would you tell this parent?

In a directed scanning system, a person activates a switch, causing a cursor or other indicator to move through a preset scanning pattern, and then releases the switch to select an item from the display. In an automatic scanning system, the cursor or indicator scans items continuously according to a preset pattern. To select an item or group, the person activates a switch to make the indicator stop at his or her choice. Which choice is better for this child depends on the nature of the child's motor limitations. If the child has some trouble activating a switch but can sustain activation once it occurs and then release the switch accurately, directed scanning could be helpful. If the child can activate a switch but struggles to sustain the activation or release the switch, an automatic scanning system might be better.

What is the difference between the sender-receiver and the co-construction models of communication?

In a sender-receiver model of communication, one person sends a message (e.g., by speaking) and another person receives that message (e.g., by listening). The message is implicitly treated as something only one person is involved in constructing In a co-construction model of communication, the message is treated as something that both people construct together through their interaction. For example, if a person who relies on AAC begins to spell a word and the communication partner predicts what word is intended before it has been spelled out in full, the two are co-constructing a message.

What is meant by the terms direct selection and scanning? How do these differ?

In direct selection, the individual directly indicates the intended representation from the available selection set. This can be done in many ways, such as by • Pointing with a finger or other body part (including eye gaze) or with equipment such as a laser or light pointer • Depressing a key or surface using a finger, other body part, or body-part extension such as a headstick • Typing • Using speech-recognition technology In scanning, the individual waits while representations are offered. When the target representation is offered, the individual provides a signal or activates a switch.

What is prediction, and how is it used?

In prediction techniques, the process of retrieving words or messages is dynamic. Individuals are offered options based on the portion of a word or message that has already been formulated. Prediction can be used in several distinct ways: • Communication partners might be able to predict entire words or messages on the basis of a few letters or words the individual selects (e.g., predicting "I would like to go home now" based on selection of the word "home"). Individuals will have different preferences about whether they want their communication partners to suggest predictions; therefore, the AAC team should confirm this is the individual's preference. • AAC technologies may offer prediction based on the particular language model and algorithms used by the application. These technologies can predict words or (less often) messages on the basis of frequency of use, recency of use, grammatical rules, and so forth. These technologies are similar to smartphone predictive text features used by many people who do not rely on AAC.

What are some indicators of intentionality used by beginning communicators?

Indicators of intentional communication include • Behaviors directed toward the communication partner to achieve a goal (e.g., obtain a preferred item, reject a nonpreferred item, sustain social interaction) • Persistence of the behavior until the goal is achieved • Cessation of the behavior once the goal is achieved • Substitution of another behavior if the first means is not successful • A change in the quality of the behavior if the first attempts are not successful (e.g., increasing the intensity of the behavior) Beginning communicators with developmental disabilities often express intentionality via • Eye gaze directed toward the communication partner or object • Orientation of their head or face toward or away from the partner or object • Vocalizations directed toward the partner or object • Facial expressions directed toward the partner or object • Physical actions directed toward the partner or object (e.g., reaching for or pushing away) • Positioning of the body toward or away from the partner or object

Describe how individuals navigate between different AAC displays.

Individuals who navigate between different AAC displays have traditionally needed to do so using a separate menu page with • Symbols to represent each of the possible displays, organized in a grid layout • Forward, back, or home buttons to navigate to different displays or back to the main menu This approach, in which the individual starts at the main menu page and selects a symbol to navigate to a display, can be challenging for beginning communicators. Newer alternatives include • Using thumbnails of target AAC displays rather than isolated symbols on a separate menu page • Using navigation bars (with thumbnail displays) that are located adjacent to the main communication display and are always visible and available for use

What operational skills do individuals who require AAC need to develop? What challenges do they face in developing these skills?

Individuals who rely on AAC may need to develop or learn the operational skills to • Produce unaided AAC (e.g., produce the hand shape, orientation, position, and movement for a range of manual signs or gestures) • Technically operate low- or high-tech aided AAC (e.g., locate and select symbols, navigate to additional AAC displays) Potential challenges include • The motor, sensory perceptual, cognitive, and linguistic demands of learning the AAC system •Potential physical challenges that must be accommodated, such as fatigue, vision or hearing impairments, and specific seating or positioning needs • Lack of attention to teaching operational skills as part of AAC intervention

What language skills do individuals who require AAC need to develop? What challenges do they face in developing these skills? What interventions might be used to build semantic skills? What interventions might be used to teach morphosyntactic skills?

Individuals who rely on AAC need to develop language skills in both the spoken language used by the family and community and in the "language code" of the AAC system the person uses. Specific skills, along with potential challenges and interventions, are described here. Skills in the spoken language used by the family and community 1. Comprehension of spoken language (receptive language) so that the individual can participate effectively as both a listener and a communicator in social interactions. Challenges include the fact that AAC intervention often focuses primarily on developing expressive communication with less attention given to building receptive language skills. Other potential challenges to comprehension include hearing impairments, auditory processing difficulties, and/or significant language impairments. 2. Expressive skills in the spoken language, given that the individual may be able to rely on natural speech to meet some communication needs. By definition, people who rely on AAC are unable to use natural speech to meet all of their communication needs. However, depending on the person's profile, he or she may rely on natural speech to meet some communication needs, and intervention may address both AAC and speech production. 3. Skills to participate in bilingual environments, as needed. Individuals who live in bilingual communities must learn skills in the different spoken (and written) languages in order to develop the communicative competence required to participate in their families and broader communities. They must also develop the conditional knowledge to know when to use which language and with whom. Skills in the language code of the AAC system the person uses 1. Knowledge of AAC representations for a wide range of vocabulary concepts and word relationships. A potential challenge is that individuals who rely on AAC often must rely on communication partners to provide vocabulary for them. 2. Knowledge of how to combine AAC representations to communicate more complex messages successfully. Individuals who rely on AAC face several challenges to learning how to communicate more complex messages: • Many individuals communicate using brief (one- to two-word) messages or simple clauses, and often they use word order that differs from that of the spoken language (e.g., subject-object-verb). • These individuals often communicate through multiple modalities that have no common syntax or morphology. • AAC systems often provide little support for morphosyntactic aspects of language use and may emphasize nouns. • The length and complexity of the message unit conveyed by a single symbol can vary with the symbol. • Instruction in AAC often does not focus on morphosyntactic aspects of language. Interventions to teach morphosyntactic skills include • Teaching target structures via focused stimulation to provide repeated exposure and AAC modeling of how to produce the target morphosyntactic structures (e.g., morphemes used to indicate verb number and tense; structures used to form questions) • Conversation-based interventions to support use of targeted structures in scaffolded conversations • Explicit instruction that involves explanation of the target rules, practice distinguishing correct from incorrect forms, and practice correcting errors using AAC

What is the role of an informant in the message selection process for an individual who relies on AAC?

Informants are people who are very familiar with the individual who relies on AAC and/or with that person's communicative situation. An informant provides information and assistance to help ensure that the vocabulary and messages selected will meet the individual's communication needs. This role involves • Providing lists of potential vocabulary and messages • Providing information needed to make decisions about personalized vocabulary items (e.g., specialized vocabulary related to the individual's unique interests, hobbies, etc.) • Using methods such as communication diaries, checklists, and the like to help with vocabulary and message selection Informants may include • Spouses, parents, siblings, and other family members or caregivers • Teachers, employers, co-workers, peers, and friends • Experts in a particular content area the individual communicates about • Most important, the individual if he or she is able to perform this role

How is intellectual disability currently defined and evaluated?

Intellectual disability is characterized by difficulties in intellectual functioning as well as adaptive behavior. • Intellectual functioning refers to learning, reasoning, and problem-solving skills. • Adaptive behavior refers to assorted conceptual, social, and practical skills people typically learn and perform in daily life. Examples include reading a newspaper, socially interacting with others, and managing one's own health care. The support needs of people with intellectual disability are often evaluated using the Supports Intensity Scale-Adult Version. This assessment is used to • Evaluate support needs across seven domains (i.e., home living, community living, lifelong learning, employment, health and safety, social, and protection and advocacy) • Identify any exceptional medical and behavioral support needs

Why is assessment of receptive language skills important? What procedures can be used to assess receptive language? What are the advantages or disadvantages of these different approaches?

It is important to assess receptive language skills because they vary greatly among individuals with complex communication needs. Some individuals may have difficulty expressing themselves but have intact comprehension, whereas others may have significant challenges understanding spoken language. Receptive language can be assessed through several means: 1) reports from families and other communication partners, 2) norm referenced assessments of receptive language, 3) observations of the individual in the natural environment, and 4) criterion-referenced assessments of functional performance. Reports from families and other communication partners can be helpful because these people can share important information about the individual being assessed, such as the types of vocabulary, questions, and directions the person understands and the conditions under which the person understands this input. When assessing receptive language this way, it is important to ask for specific examples of what communication partners say and do and what makes them conclude the individual does or does not understand them; otherwise, the assessment may not give a completely accurate picture of the person's receptive language abilities. Norm-referenced language assessment instruments can be helpful for determining whether the individual demonstrates an impairment in receptive language compared to peers without disabilities. However, a disadvantage of norm-referenced tests is that they do not necessarily provide enough information to plan intervention. Furthermore, individuals with complex communication needs may be unable to participate in norm-referenced assessments without accommodations. Any changes to the standard procedures may change the task demands and render the norms invalid. Observations in the person's natural environment can be valuable because they provide information about the comprehension demands of that environment and the individual's ability to meet these demands. Again, however, these observations may not provide enough information to plan intervention; the observations may not capture the full range of comprehension requirements within the person's environment or the individual's full range of capabilities. Criterion-referenced assessments can be helpful for determining the individual's receptive language capabilities in specific domains. Procedures can be personalized to accommodate the capabilities and interests of the individual.

What is joint attention? Why is joint attention important?

Joint attention is the ability to coordinate one's attention to an object or activity and to a partner. For example, behaviors that demonstrate joint attention might include • Looking at a dog, then looking at one's partner to see if one's partner has noticed the dog • Looking at a dog because one's partner has pointed in the dog's direction • Upon seeing a dog, pointing at it so that one's partner will notice it Children without disabilities usually demonstrate behaviors related to joint attention starting at about 9 to 12 months of age. Joint attention is important for a person's development of symbolic language, because it allows a person to begin associating words and the objects/activities in the environment to which the words refer.

What is meant by just-in-time (JIT) AAC supports? How might they be used? What are the potential benefits?

Just- in- time supports are those provided just in time, that is, in the moment as they are required to enhance expressive communication and/or aid comprehension. Just- in- time AAC apps allow for vocabulary to be programmed in quickly so it can easily be added as new vocabulary needs arise during everyday interactions. Communication partners (e.g., speech- language pathologists, parents) may use just- in- time programming with young children to add vocabulary during daily interactions in response to their needs and interests. Individuals with complex communication needs may also use just- in- time programming as a means of having more agency in selecting and programming their own vocabulary and messages. Just- in- time programming can sup-port comprehension and expression of language concepts. Just- in- time programming's potential benefits include allowing individuals with complex communication needs to have more engagement in and control over programming their own vocabulary, ensuring required vocabulary is available immediately as needed and increasing overall communication participation in children and adults.

What are the key characteristics of autism spectrum disorder? How do these affect the provision of AAC services and supports?

Key characteristics of autism spectrum disorder include • Deficits in social communication and social interaction • Restricted, repetitive patterns of behavior, interests, or activities These characteristics begin to manifest during the developmental period, prior to age 3. Symptoms vary in nature and severity. However, individuals with autism spectrum disorder often have both receptive and expressive communication difficulties, including difficulties with speech development; gestures and other nonverbal forms of communication; vocabulary, syntax, and morphology; pragmatics; symbolic play; literacy learning; and executive function (e.g., problem solving, planning). They are also more likely to experience other associated difficulties, including intellectual impairments, difficulties with sensory processing, fine and gross motor difficulties, sleep disorders, and difficulties with emotional and behavior regulation. For these reasons, effective intervention depends on having expertise from professionals in multiple disciplines; collaborative planning among these professionals is essential. Specific priorities for planning intervention include • Promoting social communication that supports not only requests but also social interactions • Providing intervention across the life span and beginning as early as possible to optimize outcomes • Utilizing effective, evidence-based intervention techniques (Specific approach(es) should be selected on the basis of the needs and skills of the individual with autism spectrum disorder, environmental supports and barriers, and targeted outcomes.)

Why are literacy skills important? What specific literacy skills should be considered for assessment? Describe at least one approach to assess each skill.

Literacy skills are important in most people's daily lives to support education, employment, activities of daily living, social interaction, and information exchange; they are particularly important for people who rely on AAC because the ability to read and spell provides them with the capability to communicate any message. Depending on the individual, assessment of literacy skills may target knowledge of letter-sound correspondences, phonological awareness skills (e.g., sound blending, phoneme segmentation), single-word reading (i.e., decoding and sight word recognition), reading comprehension, spelling, and/ or written communication. Letter-sound knowledge can be assessed by saying a sound and asking the individual to point to, look at, or type the letter that represents that sound from an array of letter cards, an alphabet board, or a keyboard. Sound blending, a phonological awareness skill, can be assessed using these steps: present the individual with four (or more) AAC symbols; label each symbol to ensure that the representations are understood; say the word slowly, extending each sound for 1−2 seconds; and then instruct the individual to blend the sounds together to determine the word and select the symbol for the word. Similarly, phoneme segmentation can be assessed by presenting and labeling orally four (or more) photos or other AAC symbols, each beginning with a different sound, then saying a sound and instructing the individual to select the symbol of the word that starts with that sound. Single-word reading can be assessed in several ways; for example, the team may provide an array of four (or more) written words and then present a picture to the individual, who must match the picture to the correct written word within the array. Assessment of reading comprehension typically involves asking an individual to read a sentence or a longer passage and then answer questions about the content; both commercially available and functional, team-created assessment tools can be used for this purpose. Spelling can be assessed using commercially available instruments or functional, criterion-referenced assessments. In the latter approach, the team asks the individual to spell, letter by letter, a range of words relevant to their communication needs. Then the team determines the words that are spelled correctly, those that can be understood (even if they include some minor spelling errors), and those that demonstrate correct first letters (even if subsequent letters are not correct).

What is meant by multimodal communication?

Multimodal communication refers to use of more than one mode to communicate. People who rely on AAC typically rely on a number of different modes, unaided and/or aided, to communicate. They may use multiple modes to communicate a single message (e.g., supplementing speech with a gesture) or switch between modes depending on the circumstances (e.g., using gestures or signs to communicate some concepts and using AAC technology for other concepts, or using different modes to communicate with different partners or at different times of the day).

This includes chapters 1, 2, 3, 5, 6, 7, 9, 10, 11

No 4, 8, 12+

What are norm-referenced assessment and criterion-referenced assessment? Why is criterion-referenced assessment usually preferable to norm-referenced assessment for making AAC decisions?

Norm-referenced assessment is standardized; it compares the individual's performance of a given skill to that of peers without disabilities to determine whether there is any impairment or deficit. Criterion-referenced assessment is used to describe the individual's performance with respect to specific domains (e.g., the individual's understanding of wh-questions). The goal is to determine the individual's capabilities in this domain. Criterion referenced assessment is generally preferable for making decisions about AAC because it helps the team identify the individual's strengths and plan intervention to enhance skills. Individuals with complex communication needs often are unable to participate in norm-referenced assessments following standard procedures; they may require accommodations in order to participate, and these changes in procedures may limit the use of the norms. Norm-referenced assessments are less useful than criterion-referenced assessments because they do not provide comprehensive assessment of the individual's performance within a specific domain, and therefore they usually do not provide enough information to guide intervention planning.

What are the five types of opportunity barriers? How might they impact the individual's communication? What are the implications for intervention?

Opportunity barriers include policy, practice, attitude, knowledge, and skill barriers. Each type potentially limits or prevents the communication and participation of an individual with complex communication needs. Policy barriers result from legislative or regulatory decisions, such as hospital policies prohibiting use of certain types of electronic equipment. Practice barriers result from procedures or conventions that may not be official policies but are nevertheless common practice. For example, a student may be expected to leave district-funded AAC equipment at school at the end of the day, thus limiting communication opportunities at home. Attitude barriers result from people's attitudes or beliefs, such as the misassumption that a person who cannot communicate through speech has poor comprehension and is not capable of following a conversation. Knowledge barriers result from people lacking knowledge of or experience with AAC communication options. For example, communication partners may be unaware of AAC technologies available for an individual with complex communication needs or may be unfamiliar with how manual signs are used to communicate. Skill barriers exist when communication partners use interaction strategies that do not support the communication of the person who has complex communication needs. For example, communicating too rapidly, not waiting for the individual to communicate a message, and failing to provide access to required AAC technologies all present skill barriers.

How does AAC vocabulary and message selection differ for preliterate, nonliterate, and literate individuals who rely on AAC?

Preliterate and nonliterate individuals rely more on the AAC team and communication partners to select vocabulary and messages, whereas literate individuals can also use spelling to formulate messages. 1. Preliterate individuals do not yet have reading and writing skills. Typically, they have developmental disabilities; many (though not all) are younger children. Their AAC systems may use manual signs, photographs, line drawings, or videos to represent vocabulary concepts. AAC teams must ensure preliterate individuals are provided with • Vocabulary needed to communicate essential messages (e.g., vocabulary to request positioning changes) • Vocabulary that supports their language development (e.g., new words related to something they will soon experience or learn about) 2. Nonliterate individuals, because of language and cognitive limitations that stem from developmental or acquired disabilities, do not have the spelling skill needed to construct messages letter-by-letter. These individuals are not likely to learn or regain these spelling skills and typically cannot read. In choosing vocabulary and messages for these individuals, AAC teams • Focus on individual, functional communication needs • Select vocabulary appropriate to the individual's age and the contexts in which he or she communicates • Place less emphasis on developmental vocabulary, though some should be included 3. Literate individuals are able to read and spell and can therefore construct messages letter-by-letter or wordby-word and retrieve complete, stored AAC messages. To supplement the individual's letter communication, AAC teams may prepare messages for quick retrieval.

What psychosocial factors affect communicative competence? Why are these factors important? What interventions have been used to build motivation, positive attitudes, confidence, and resilience?

Psychosocial factors that affect communicative competence include • Motivation to learn the skills needed • Attitude (i.e., positive attitude needed to learn) • Confidence to try skills knowing one will not always succeed • Resilience to keep trying despite challenges and setbacks These factors are important because they affect a person's overall learning of skills, across different domains, that are needed to build communicative competence. When an individual who relies on AAC does not demonstrate one or more of the factors listed previously, the individual may • Decline to use available opportunities to communicate and/or form relationships • Reject potentially beneficial AAC options • Be unwilling to try new techniques and take risks • Give up quickly in the face of communication failures or setbacks Specific interventions that have been used to build motivation, positive attitudes, confidence, and resilience include • Teaching problem-solving skills and strategies such as the DO IT! strategy (describe the problem; outline potential ways to solve the problem; identify the best solution; take action; celebrate success!) • Mentoring programs in which adults who successfully use AAC work with children, adolescents, or adults who rely on AAC

What are sociolinguistic skills? Why are they important for individuals who require AAC? What challenges do they face in developing sociolinguistic skills? What interventions might be used to build sociolinguistic skills?

Sociolinguistic skills are the skills involved in pragmatic aspects of communication, including • Discourse skills such as taking turns, initiating and terminating interactions, and maintaining and developing topics • Skills to express various communicative functions, such as requesting attention, requesting information, providing information, and confirming Teaching these skills is important to build social competence and help ensure that people who rely on AAC can meet all of their communication needs and also enjoy successful communication and meaningful social interactions. Individuals need to develop these skills so they can • Express complex needs and wants; discuss personal care, medical needs, or other topics requiring nuanced and precise communication • Initiate and sustain social interactions, including those involving more complex communication (e.g., displaced talk, storytelling) • Exchange more complex information related to school or work, self-advocacy, and reporting of maltreatment A common challenge to learning these skills is that social interactions are often dominated by communication partners who use natural speech. In comparison, individuals who rely on AAC often use a limited range of communicative functions (such as requesting) and tend to respond to rather than initiate interactions. To maximize their communication and participation, it is important for intervention to target sociolinguistic skills. Interventions can include • Directly teaching individuals how to express more complex needs and wants • Teaching how to initiate and sustain social interactions through initiation and topic-setting strategies (e.g., use of visual supports or collections), conversational coaching, engaging in displaced talk about past or future events, and practicing narrative skills needed for storytelling Teaching how to exchange more complex information (e.g., describing, explaining, persuading), including information needed for self-advocacy or for reporting abuse or neglect

What are sociorelational skills? Why are they important for individuals who require AAC? What challenges do they face in developing sociorelational skills? What interventions might be used to build sociorelational skills?

Sociorelational skills are the interpersonal aspects of communication in which people need to be competent in order to form positive relationships. These include skills such as participating actively in interactions, demonstrating interest in partners, and projecting a positive self-image. These skills are important for forming positive social relationships; many people with developmental disabilities who rely on AAC report being isolated and lonely. Potential challenges to developing sociorelational skills include • Disabilities or deficits associated with impaired learning and/or use of social skills (e.g., autism spectrum disorder) • Limited social circles that do not provide enough opportunities to learn and use social skills with a variety of people • Lack of access to the vocabulary needed to support meaningful reciprocal social interactions • Policy and practice barriers that can isolate people who rely on AAC, limiting opportunities for social interaction • Attitude, knowledge, and skill barriers in society and among peers that limit meaningful opportunities for social interaction Interventions that might be used to develop sociorelational skills include • Teaching other-orientation skills, such as being a good listener, talking about the other person's interests, and using the other person's name • Teaching the use of nonobligatory turns/listener feedback so that the individual who relies on AAC can take a more active role in sustaining a conversation • Teaching active listening strategies such as LAF, Don't CRY (listen and communicate respect; ask appropriate questions to demonstrate interest and find out more; focus on what partners are saying; don't criticize communication partners; don't react hastily; and don't yakkity yak about yourself) • Teaching the use of partner-focused questions (i.e., asking about the other person and his or her interests) • Teaching how to give feedback to other people and manage/resolve conflicts

What is meant by strategic competence? Provide some examples of strategies that might be used to overcome limitations in linguistic, operational, and social skills.

Strategic competence comprises the various skills needed to cope with or bypass any short- or long-term limitations to communication. These limitations may be due to specific individual impairments, external barriers, or the nature of AAC. The following strategies might be used to overcome limitations in linguistic, operational, and social skills: 1. Linguistic • Ask the communication partner to write/type or point to symbols to augment spoken input and bypass comprehension difficulties. • Use mementos to bypass vocabulary limitations and establish the topic. • Ask the partner to provide choices to overcome vocabulary limitations. • Alert the partner that necessary vocabulary is not available. • Ask the partner to guess and provide clues to bypass vocabulary limitations. 1. Operational • Use telegraphic messages to enhance the rate of communication. • Ask the communication partner to predict as the message is spelled to reduce fatigue and enhance the rate of communication. • Have the partner assist in locating the appropriate page to help with navigational demands. • Prepare messages in advance to reduce the partner's waiting time. 2. Social • Use an introduction strategy to teach the communication partner what to do in interactions. • Use humor to maintain a positive rapport and put the partner at ease. • Use regulatory phrases to manage the interaction. • Use effective repair strategies as required to resolve communication breakdowns. • Utilize digital communication media to bypass the demands of face-to-face interactions and increase social networks.

What are the key components of the Participation Model? What is the goal of each of these components? Why are they important?

The Participation Model consists of two major, integrally linked processes: assessment and intervention. First, AAC assessment is conducted to gather information; this information is then used to design and implement AAC intervention based on the individual's functional requirements for participation in life activities. (Some initial AAC intervention may be needed so that the individual with complex communication needs can participate in a meaningful assessment.) In the Participation Model, assessment begins with identification of the individual's participation patterns and unmet communication needs. This information helps the team get to know the individual, determine goals for communication, define the contexts that are priorities for intervention, and determine the requirements for AAC systems. Next, the team identifies what environmental supports are available to the individual and what factors might create opportunity barriers—that is, barriers that limit the person's opportunities to communicate. Then the team assesses the individual's capabilities and identifies any access barriers—that is, conditions that affect the individual's ability to access AAC supports, such as limits to motor capabilities. This assessment process is comprehensive, touching on many different aspects of the individual's daily life. The goal of this thorough assessment process is to ensure that AAC supports and intervention are responsive to the individual's needs and capabilities and that the individual has the opportunity and supports required to communicate. Following these assessment processes, the team uses the information gathered to plan and implement intervention with the individual and his or her communication partners; the team later evaluates the effectiveness of the intervention and follows up as needed. Linking intervention to assessment in this way is important because it makes intervention more effective: It helps the team select and personalize AAC supports, determine which skills and strategies require instruction, and identify environmental or partner supports needed to increase participation.

What is the central goal of AAC intervention?

The central goal of AAC intervention is to help people whose speech is not sufficient to meet their day-to-day communication needs interact with others and to support their learning and development. This includes helping these individuals • Learn their native language • Meet their personal needs • Participate and be included in different communication settings (e.g., home, school, work, recreational activities) • Establish and maintain their social roles • Communicate accurately to guide their personal and medical care

What informants should be recruited to suggest personalized vocabulary for a preliterate child, a nonliterate teenager, a man with amyotrophic lateral sclerosis, or a woman with chronic, severe aphasia? What roles might these informants play?

The following informants should be recruited to suggest personalized vocabulary for those individuals. Preliterate child Different informants can suggest • Vocabulary to communicate essential messages consisting of words the child already knows • Appropriate developmental vocabulary consisting of words the child does not yet know 1. Parents or other family members can suggest • Essential vocabulary needed to communicate about the child's day-to-day experiences, routines, and activities across different environments • Essential vocabulary needed to communicate about special caregiving needs (e.g., medical care, positioning needs) • Appropriate developmental vocabulary related to the child's interests (e.g., outer space) and anticipated future experiences (e.g., upcoming trip to planetarium) 2. Teachers can suggest essential and developmental vocabulary related to educational and social experiences that take place at school as well as daily school routines (e.g., names of people and places at school, terms for upcoming social studies unit). 3. Professionals who work with the child in a caregiving or therapeutic role can suggest essential and developmental vocabulary related to the child's caregiving or therapeutic experiences. 4. Depending on the child's age and cognitive abilities, he or she may be able to suggest vocabulary related to any of the preceding areas. 5. Depending on their age and cognitive abilities, the child's friends may be able to suggest vocabulary related to everyday experiences and interests. Nonliterate teenager Different informants can suggest • Vocabulary to meet the person's day-to-day functional communication needs • Some developmental vocabulary to address new situations and participation needs; however, developmental vocabulary receives less emphasis for nonliterate than for preliterate individuals 1. Parents or other family members can suggest • Essential vocabulary to communicate about day-to-day experiences, routines, and activities across different environments • Essential vocabulary needed to communicate about special caregiving needs • Developmental vocabulary as needed 2. Teachers or other educational professionals can suggest essential vocabulary and, as appropriate, developmental vocabulary related to the teenager's educational experiences. 3. Other professionals who work with the teenager in a caregiving or therapeutic role can suggest functional vocabulary needed for caregiving or therapeutic experiences. 4. Depending on age and cognitive abilities of the teenager and his or her peers, they may be able to suggest vocabulary related to any of the preceding areas. Men with amyotrophic lateral sclerosis Amyotrophic lateral sclerosis is a degenerative disease that will cause this man to lose motor functioning as his disease progresses, which will affect his ability to speak and to type. If he is literate and if his disease is in its early stages, he may still be able to meet some communication needs through letter-by-letter spelling. However, personalized vocabulary should be selected with awareness that he will need to rely more on programmed vocabulary and messages as his amyotrophic lateral sclerosis progresses. Different informants can suggest • Vocabulary to communicate about day-to-day experiences, routines, and activities across different environments. • Vocabulary to meet the man's day-to-day functional communication needs, including medical and caregiving needs. • Whole messages he must be able to communicate quickly (e.g., communicating about pain, positioning needs, feeding needs, toileting needs). • Whole messages he will need to use frequently and/or at times when he is feeling fatigued (e.g., introductory message, messages needed at dinnertime). 1. The individual can suggest vocabulary related to any of the areas listed previously. His input should be obtained as early as possible (e.g., before his ALS has progressed to the point that he can no longer use speech to communicate about himself, his life, and the vocabulary it would be valuable for him to have in an AAC system). 2. Spouses, parents, children, and other family members can suggest vocabulary related to any of the areas listed previously. 3. Employers, co-workers, and/or teachers can suggest vocabulary needed to participate at work and/or in educational experiences. 4. Friends and peers in the community can suggest vocabulary needed to participate in social experiences and pursue personal interests. 5. Professionals who work with the man in a medical, caregiving, or therapeutic role can suggest vocabulary needed for him to participate in those experiences. Woman with chronic, severe aphasia Because this woman has chronic, severe aphasia, she can be expected to have global difficulty retrieving or generating words. Even if she was previously literate, she should not now be expected to use letter-by-letter spelling to meet her communication needs. Different informants can suggest • Vocabulary to communicate about day-to-day experiences, routines, and activities across different environments • Vocabulary to meet the woman's day-to-day functional communication needs, including medical and caregiving needs • Whole messages she must be able to communicate quickly • Whole messages she will need to use frequently and/or at times when she is feeling fatigued 1. The individual may suggest some vocabulary related to the areas listed previously if she is able to do so, but her aphasia will likely limit her ability to be an informant. 2. Spouses, parents, children, and other family members can suggest vocabulary related to any of the areas listed previously. 3. Friends and peers in the community can suggest vocabulary needed to participate in social experiences and pursue personal interests. 4. Professionals who work with the woman in a medical, caregiving, or therapeutic role can suggest vocabulary needed for her to participate in those experiences. 5. If the woman is able to continue working, employers and co-workers can suggest vocabulary needed to participate at work

. How might you teach beginning communicators to request preferred objects or activities? Comment on shared activities? Ask questions?

The following strategies can be used to teach beginning communicators these skills: 1. Request preferred objects or activities • As the individual learns symbols, map them onto existing daily routines to communicate choices (e.g., use symbols, not objects, to provide a choice). • Teach generalized requesting in which the individual uses a signal to get the partner's attention, initiates a request using one symbol (such as want), and then indicates a choice among two or more options. • Teach the Picture Exchange Communication System (PECS) in which the individual gives the partner the symbol representing a desired item/activity in exchange for receiving the item itself. • Teach conditional requesting in which the individual learns both when to request and when not to request. 2. Comment on shared activities • Weave opportunities to comment into a range of ongoing day-to-day activities. • During activities, reduce joint attention demands on the individual by holding the AAC system close to the partner's face or signing/gesturing within the person's focus of attention so as to minimize the attentional shifts needed. • Reduce joint attention demands by incorporating shared activities into AAC technologies. • Provide instruction in which the communication partner does the following: • Encourages the individual to choose the activity • Plans/sets up an opportunity for commenting • Pauses and focuses attention on the individual to indicate the commenting opportunity • Prompts as required • Immediately responds, recognizing and expanding on the comment • Provides models of AAC along with speech throughout 3. Ask questions • Provide access to AAC to ask questions (e.g., programming question words/phrases in AAC technologies, teaching signs to ask questions). • Set up opportunities for the beginning communicator to ask questions. • Model how to ask questions using AAC along with speech. • Wait and allow the individual the opportunity to ask questions. • Prompt as required. • Immediately respond to questions asked.

How might you teach beginning communicators to combine symbols to communicate more complex requests, comments, or questions?

The following strategies can be used to teach beginning communicators to combine symbols for these different purposes: • Continue to work on developing vocabulary that represents a wide range of semantic concepts (agents, actions, objects, locatives, descriptors, etc.) • Target symbol combinations to teach, starting with communication functions the individual already expresses using single symbols • Use explicit instruction and/or naturalistic intervention that includes the following strategies: • Set up motivating opportunities to use symbol combinations to express a range of functions. • Model the use of two-word messages using speech and AAC. • When the individual produces/selects a single symbol, wait expectantly for him or her to express a longer message. · Prompt as required. • Respond immediately to these messages by fulfilling the intent. • Expand on the message and model use of more complex messages.

Communicative competence rests on knowledge, judgment, and skills in four interrelated domains. What are these four domains? Describe why each domain is important.

The four domains are the linguistic, operational, social, and strategic domains. 1. In the linguistic domain, communicative competence means • Having receptive and expressive language skills in the native language(s) spoken by one's family and community (including, for people who use more than one language, the ability to "code-switch" between languages as needed) • Understanding and being able to use the "language code" of one's AAC system This domain is important because all of the skills it includes are necessary for a person who relies on AAC to meet all of his or her communication needs 2. The operational domain consists of the technical strategies and skills needed to • Access and operate one's aided AAC system • Produce unaided AAC fluently or automatically This domain is important because when a person needs to exert a lot of time and conscious attention to operate aided AAC or produce unaided AAC, cognitive resources are expended that instead should be devoted to other communication processes. 3. The social domain consists of the skills a person needs to use AAC effectively in interpersonal interactions. This domain includes • Sociolinguistic or pragmatic skills, such as knowing how to take turns in conversation, initiate and maintain topics, and communicate for different purposes, such as requesting information or expressing an opinion • Sociorelational or interpersonal skills that make a person a valued communication partner, such as demonstrating interest in the other person and participating actively in communication All of the skills within the social domain are important for a person to participate effectively in his or her environment and build positive social relationships. 4. Competence in the strategic domain entails having the skills to overcome temporary or permanent limitations within the other three domains. Competence in this domain is important because individuals who rely on AAC may encounter limitations due to the nature of their disability or due to environmental barriers or constraints, and they will require strategies to overcome these limitations.

What are the goals of seating and positioning? What are the key principles that should guide appropriate seating and positioning?

The goals of seating and positioning are to maximize comfort and allow rest; provide security and ensure safety; maximize functional use of unaided and/or aided AAC; promote attention; inhibit reflex patterns that may interfere with intentional motor acts; and minimize the development of fixed deformities that may result from limited movement. Three key principles that should guide appropriate seating and positioning are as follows: 1) ensure equipment promotes functional weight bearing; 2) position the pelvis for stability and mobility; and 3) pursue proper body alignment. An additional overarching guideline is that the team provides the least amount of seating and positioning support needed to achieve the greatest level of function.

What is the role of an AAC finder, and who might fill this role?

The role of an AAC finder is to identify persons with complex communication needs and refer these individuals and their families to appropriate AAC service providers. This role requires knowledge of the local AAC services and resources that are available. Professionals such as school and medical personnel may fill this role; in addition, physicians may certify AAC prescriptions for the funding of AAC technologies and intervention services.

How does the communication of needs and wants differ from information transfer?

These two types of communication interaction fulfill different purposes or goals. The goal of expressing one's needs and wants is to regulate the behavior of one's communication partner. The interaction focuses on a desired object or action—for example, the goal of expressing hunger is to ensure one obtains food. These interactions are highly predictable, their content is important, and there is little tolerance for communication breakdowns. In contrast, the goal of information transfer is not to regulate another person's behavior but to share information with that person. The interaction focuses on the information to be shared, such as telling a communication partner about a movie one saw over the weekend. These interactions are not predictable, but nevertheless, their content is important, and there is little tolerance for communication breakdowns.

Describe three key considerations in delivering AAC services to people with cerebral palsy.

Three key considerations in delivering AAC services to people with cerebral palsy are 1. Using a team approach. Expertise from professionals in multiple disciplines is needed to ensure effective intervention. 2. Ensuring access. Impairment to muscle movement, coordination, and posture may limit learning and communication opportunities for individuals with cerebral palsy, as may architectural, transportation, and attitudinal barriers in the community. It is essential that intervention ensures access to meaningful opportunities for learning and communication. Access can be addressed via positioning and seating adaptations, adaptive play and leisure activities, and assistive technology. 3. Planning intervention across the life span. People with cerebral palsy typically live well into adulthood, so AAC teams must plan ahead to ensure their communication needs are met across different contexts in the long term. Their needs and skills will change over time, and AAC intervention must be designed to address these changes.

Why might individuals who are literate require access to phrases and longer messages? Individuals who are literate and can spell out messages letter-by-letter may nevertheless require quick access to phrases and longer messages, for purposes of

Timing enhancement (i.e., ensuring the individual can communicate important messages quickly in certain situations rather than spelling them out) • Message acceleration (i.e., speeding up the individual's overall communication rate by programming lengthy words or messages that are used frequently) • Fatigue reduction (i.e., making communication more efficient and less tiring by programming in messages the person needs to use frequently and/or at times of day when he or she typically experiences fatigue)

How does the AAC team assess the individual's motor capabilities to determine potential access to unaided and aided AAC?

To assess motor capabilities, the team needs to 1) identify persistent reflex patterns; 2) assess motor performance for unaided AAC; 2) assess seating and positioning requirements, as described in question 2.10; and 3) assess motor performance to control aided AAC. This is done with expert input from occupational and physical therapists. Assessment of reflex patterns focuses on specific involuntary muscle responses, common among people with certain disabilities, that may interfere with intentional motor control, such as the rooting reflex, the asymmetrical tonic neck reflex, and the symmetrical tonic neck reflex. Unaided AAC may include use of head movements, gestures, or manual signs, each of which requires a specific shape and position relative to the body, a specific orientation, and a specific movement. The AAC team must consider the range of hand shapes and movements that are already within the individual's motor repertoire and might be used for expression, which ones the individual might acquire with instruction and practice, and which ones may be outside the individual's functional repertoire. Assessment may be done through observation in a variety of natural contexts, imitation tasks, or requests to perform functional tasks that involve certain hand movements. To assess motor capabilities to determine access to various aided AAC techniques, the following protocol may be used: 1. Interview the individual and family and gather background information about the individual's access needs, capabilities, and environments. 2. Observe the individual engaged in practical, functional activities to glean a preliminary sense of motor capabilities. 3. Investigate the individual's capabilities and determine the features required in the access technique. 4. Trial potential access techniques and compare performance across techniques. 5. Select the best access approach(es) and personalize them. 6. Teach operational use. 7. Implement the technique in the individual's daily environment(s). 8. Evaluate progress and monitor use.

In direct selection access, what is meant by the word dwell, and what capabilities does the successful use of dwelling require of an individual who relies on AAC?

To dwell means not only to identify a representation but also to maintain contact with it for a set time period in order to select it. For example, timed activation by directing one's gaze or touching for a predetermined time involves dwell. Systems that allow for dwell activation reduce the likelihood of unintentionally activating a representation from a display. Depending on the AAC system used, the individual will need to have the motor skills necessary to dwell on the desired item for the predetermined time period. This time period can be adjusted to meet individual needs.

What are some of the tools that AAC teams might use to help select vocabulary and messages? What are the advantages and disadvantages of these different tools?

Tools the team might use to select vocabulary and messages include the following: • Blank sheet. This approach allows informants who know the individual well to record his or her important interests, but it is challenging because it lacks structure. • Categorical framework. This approach has the same advantages as a blank-sheet approach but provides more structure through the use of category headings (e.g., items of clothing). • Autobiographical materials, such as journals and social media accounts. These provide direct information about vocabulary and expressions the individual has used in the past. • Environmental or ecological inventories, created by observing and documenting vocabulary used by the individual's peers during frequently occurring activities, then reducing this list to the most important words. This approach is helpful for selecting essential functional vocabulary. • Communication diaries, or records an informant creates that document needed words throughout the course of a day. • Vocabulary checklists, which make it easy for informants to select potentially needed words; it is important to ensure any checklists used are appropriate to the person's age, developmental needs, and daily experiences. • Language models in AAC technology (i.e., vocabulary programmed by the technology's manufacturer).

Describe at least two different instructional approaches that are used with beginning communicators who have developmental disabilities to teach early communication skills. Describe at least two different instructional approaches that are used with school-aged children, adolescents, and adults with developmental and acquired conditions to teach more advanced communication strategies and skills.

Two approaches used to teach communication skills to beginning communicators who have developmental disabilities are responsive social pragmatic intervention and explicit instruction. 1. In responsive social pragmatic intervention, parents and other communication partners are taught to respond to the child's communicative attempts by responding to the child's interests, fulfilling the intent of the child's communication attempts, and modeling communication skills for the child using AAC and speech. 2. In explicit instruction, a person who is a beginning communicator receives highly structured instruction, presented in massed trials that allow for many opportunities for practice and for feedback on correct and incorrect responses. In this behavioral approach, trials are repeated and prompts are faded gradually until the learner can produce the correct response independently. Two different instructional approaches that are used with school-aged children, adolescents, and adults with developmental and acquired conditions to teach more advanced communication strategies and skills include: 1. Strategy instruction that includes the following steps: Identify the target strategy or skill to be taught; explain the strategy to the individual and discuss why it is important; demonstrate how to use the target strategy; discuss situations in which the individual should (or should not) use the strategy; set up situations for the individual to use the strategy during naturally occurring interactions (and role plays to provide additional practice if appropriate); provide guided practice, prompting the individual to use the target strategy or skill successfully, and provide feedback on performance; evaluate progress and adjust intervention as required to improve effectiveness; and check for generalization and long-term maintenance 2. Coaching approaches that rely on explanations of the target strategies and skills, typically accompanied by demonstrations as well as opportunities to practice the strategies and skills with feedback on performance

How might AAC be integrated with natural speech in interventions for children with childhood apraxia of speech? What factors impact the relative balance between AAC and natural speech interventions?

Typically, AAC is implemented along with intervention focused on improving the child's natural speech production. Intervention may provide repetitive practice in planning, programming, and production of natural speech. If the child cannot use speech to meet all of his or her communication needs, AAC intervention should be used to support the child's functional communication and language development while enhancing speech production. Factors that impact the balance between AAC and speech intervention include • Parental priorities (note that AAC intervention does not inhibit speech development) • Potential of AAC intervention to stimulate language development if the child cannot practice language skills orally • Need for AAC intervention to support communication (for individuals with severe speech impairments) or supplement speech • Use of AAC to support literacy learning • Use of AAC to practice speech production

1. Define unaided AAC and provide at least four examples. What are the advantages and disadvantages of these unaided AAAC options.

Unaided AAC is AAC that individuals produce using only their bodies, without any external equipment or device. Examples are vocalizations or natural speech, gestures (conventional and idiosyncratic), and manual signs (key word signing, fingerspelling, and tactile signing). -Vocalizations or speech Advantages: If the individual retains some intelligible speech, it can be used to communicate some messages to specific partners in some situations. Natural speech can be a highly efficient means of communication that is readily accessible. Speech can be supplemented as needed with gestures or aided symbols (e.g., alphabet supplementation) to increase intelligibility. Even when speech is not intelligible, vocalizations can still be used to communicate for a limited range of purposes (e.g., to communicate emotion or intent, to respond to questions [e.g., yes, no, I don't know]). Disadvantage: Since individuals with complex communication needs are unable to rely on natural speech to meet all their communication needs, the range of messages that can be communicated via speech typically is limited. -Gestures Advantages: Gestures are always accessible because they require only the body to communicate; they typically do not require complicated movements and are relatively quick and easy to produce. Most people in a culture understand common contextual gestures (e.g., pointing at a desired object), representational gestures (e.g., miming eating), and conventional gestures (e.g., nodding yes). Disadvantage: The range of messages that can be communicated is limited, and some gestures can be interpreted only in context. - Advantages: Manual sign systems provide access to a wide range of concepts for expression. Since manual signs require only the body, they are always readily available and may be more easily integrated into communication interactions. Disadvantage: Manual sign systems require complex motor skills— specific hand shapes, positions, orienta-tions, and movements. As a result, some individuals with complex communication skills may have difficulty learning to produce manual signs. Furthermore, manual sign systems are not easily understood by many communication partners; use of manual signs typically needs to be supplemented with other AAC supports.In practice, when AAC interventions target manual signs, they often involve key word signing, in which the communication partners use manual signs for the critical words in a sentence as they speak. This approach may limit the range of manual signs that are available to individuals with complex communication needs and may thus limit their communication. Key word signing does not provide access to a robust language system. -Fingerspelling Advantage: In theory, individuals who can use fingerspelling have the means to communicate a wide range of messages to communication partners who are familiar with this mode of communication. Disadvantage: Fingerspelling requires well developed motor skills as well as literacy capabilities. Most communication partners are not skilled in receiving messages via fingerspelling. -Tactile signing Advantages: Tactile signing is a more complex form of manual signs used to support comprehension as well as expression with individuals with deaf- blindness. Theoretically, this approach allows comprehension and expression of an infinite number of messages Disadvantage: Tactile signs are difficult to learn; they require well- developed motor, tactile, and language skills. Furthermore, very few people are skilled in tactile signing, restricting the number of potential communication partners.

What are the similarities and differences between aided and unaided AAC input used in conjunction with speech?

Unaided input, such as gestures and signs, can be useful because this type of input is always available and does not require any equipment; it is relatively easy to incorporate it into one's communication along with speech. Aided AAC, such as writing or pointing to symbols while speaking, can also be used to provide input to a person who relies on AAC. This method requires having the symbols/materials available and is not always used as extensively as unaided input.

Describe visual difficulties that might be experienced by individuals who rely on AAC. Describe the potential impact on designing AAC supports.

Visual difficulties that might be experienced by individuals who rely on AAC include difficulties with visual acuity, visual fields, oculomotor functioning, light sensitivity, color sensitivity, and cortical visual impairment. For this reason, it is important to work with appropriate vision specialists to assess the individual's vision to determine the overall functionality and appropriateness of AAC approaches that rely on vision. For aided AAC techniques, visual abilities/difficulties will impact the personalized design of the AAC display, including decisions about the type, size, placement, spacing, and colors of representations as well as illumination and positioning of the display, partner, and other materials, for example. Additional considerations include use of horizontal, vertical, grid, or visual scene display layouts; avoidance of cluttered AAC displays; any needed adjustments to head and body position; use of nonreflective surfaces and/or sunglasses to reduce glare; contrast between colors; grouping of symbols by internal color; and more.

Describe six to seven different ways that AAC grid displays can be organized. When might each organization be used.

Ways that AAC grid displays might be organized include the following: 1. Schematic grid layouts or activity displays, which organize symbols according to the typical routines and activities of a person's day. These might be used with preschool children, who tend to organize concepts schematically, and with older beginning communicators with severe disabilities. 2. Taxonomic grid displays, organized by superordinate categories such as food, places, and clothing. These might be used with older children who have developed these types of categorization skills and by individuals who rely on AAC primarily for clarification. 3. Semantic- syntactic grid displays, organized according to the parts of speech and the relationships among them (e.g., agents, actions, descriptors, objects, locatives). This organization may be used for individual AAC displays within a schematic grid system; it is intended to support language development (i.e., communication of more complex messages). 4. Pragmatic Organization Dynamic Display (PODD) which combines different organizational strategies and includes symbols for navigational strategies, pragmatic starters, and conversational repair. This approach might be used when an individual needs different grid structures to serve different communication functions (e.g., activity displays for predictable activities, taxonomic displays for less predictable messages). 5. Alphabetical grid displays, organized by letter sequence, like a dictionary. These might be used with literate individuals who rely on AAC to clarify their speech and are able to manage the navigation needed to locate a word or message. 6. Chronological grid displays, organized according to the chronological sequence of events, such as a visual schedule for one's day. These might be used to help individuals manage day- to- day transitions, especially if doing so is challenging for them.

People who rely on AAC manage their message preparation in several different ways. How does word-by-word message preparation differ from letter-by-letter spelling?

Word-by-word message preparation involves selecting individual words or phrases (or symbols representing them) that are predicted by or stored within AAC technologies. This involves the preselection of the vocabulary to be used and limits the possible range of messages that can be communicated. Letter-by-letter spelling can be used to compose any message the individual chooses, but this method of message preparation can be time consuming.