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Research Article
Teaching Parents Read, Ask, Answer, Prompt
Strategies via Telepractice: Effects on Parent
Strategy Use and Child Communication
Cheri Dodge-Chin,
a
Sandra Shigetomi-Toyama,
a
and Emily D. Quinn
b
a
Speech-Language Pathology Program, Rocky Mountain University of Health Professions, Provo, UT
b
Department of Pediatrics, Oregon Health
& Science University, Portland
ARTICLE INFO
Article History:
Received May 14, 2021
Revision received August 20, 2021
Accepted October 12, 2021
Editor-in-Chief: Holly L. Storkel
Editor: Megann McGill
https://doi.org/10.1044/2021_LSHSS-21-00075
ABSTRACT
Purpose: This study aimed to explore the feasibility of a telepractice communi-
cation partner intervention for children who use augmentative and alternative
communication (AAC) and their parents.
Method: Five children (aged 3;4–12;9 [years;months]) with severe expressive
communication impairments who use AAC and their parents enrolled in a ran-
domized, multiple-probe design across participants. A speech-language pathol-
ogist taught parents to use a least-to-most prompting procedure, Read, Ask,
Answer, Prompt (RAAP), during book reading with their children. Parent instruc-
tion was provided through telepractice during an initial 60-min workshop and
five advanced practice sessions (M= 28.41 min). The primary outcome was par-
ents’correct use of RAAP, measured by the percentage of turns parents ap-
plied the strategies correctly. Child communication turns were a secondary, ex-
ploratory outcome.
Results: There was a functional relation (intervention effect) between the RAAP
instruction and parents’correct use of RAAP. All parents showed a large, imme-
diate increase in the level of RAAP use with a stable, accelerating (therapeutic)
trend to criterion after the intervention was applied. Increases in child communi-
cation turns were inconsistent. One child increased his communication turns.
Four children demonstrated noneffects; their intervention responses overlapped
with their baseline performance.
Conclusions: Telepractice RAAP strategy instruction is a promising service de-
livery for communication partner training and AAC interventions. Future research
should examine alternate observation and data collection and ways to limit
communication partner instruction barriers.
Successful communication depends on a communi-
cation partner’s ability to use language support strategies.
Using support skills is particularly important for commu-
nication partners who interact with children with severe
communication impairments, including those who use
augmentative and alternative communication (AAC) sys-
tems (Kent-Walsh et al., 2015). Common AAC systems
include communication boards and portable devices with
communication applications and voice output (Douglas
et al., 2014; Iacono et al., 2011). Children who use AAC
have multiple communication partners, including thera-
pists, educators, peers, and families (Kent-Walsh et al.,
2015; Senner et al., 2019). Parents are key communication
partners because they spend the most time with their chil-
dren and provide communication support during common
family routines, such as storybook reading (Douglas et al.,
2017). Parents of children who use AAC frequently re-
quire training to use AAC systems and language support
strategies (Biggs et al., 2018, 2019; Kent-Walsh, 2003).
A growing body of research has demonstrated that
teaching parents to effectively use AAC systems and language
support strategies increases their children’s communication
Correspondence to Cheri Dodge Chin: cheri@superpowerspeech.com.
Publisher Note: This article is part of the Forum: Speech and Lan-
guage Tele-Intervention: The Future Is Now. Disclosure: The authors
have declared that no competing financial or nonfinancial interests
existed at the time of publication.
Language, Speech, and Hearing Services in Schools •1–19 •Copyright © 2021 American Speech-Language-Hearing Association 1
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skills (Allen et al., 2017; Biggs et al., 2018; Kent-Walsh
et al., 2015; Shire & Jones, 2015). In the field of AAC,
communication partner instruction involves a therapist
teaching a communication partner to use an AAC system
and language support strategies while interacting with an
individual who uses AAC. Communication partner in-
struction interventions support communication develop-
ment by using language support strategies, such as model-
ing AAC systems and increasing child communication
opportunities (Shire & Jones, 2015).
Shire and Jones (2015) conducted a systematic re-
view of communication partner interventions to examine
the effects on communication partner fidelity and commu-
nication skills of children who used AAC. One random-
ized controlled trial (Romski et al., 2010) and 12 single-
case studies, which included 105 children with neurodeve-
lopmental disabilities and their communication partners
(parents, paraprofessionals, and therapists), met eligibility
criteria. An overlap metric, the improvement rate difference
(IRD; Parker & Vannest, 2009), was calculated for each
single-case experimental design study. Estimates ranged
from 0.25 to 1.00 (small to large) for communication part-
ner fidelity and from 0.09 to 1.00 (small to large) for child
communication outcomes. Eta squared was the effect size
reported for the group design (Romski et al., 2010), with
estimates ranging from 0.02 to 0.27 (no effect to small ef-
fect) for communication partner fidelity and from 0.14 to
0.59 (not significant to moderate) for child communication
outcomes. Methodological quality ratings were inconsistent
(weak to strong); most studies (> 50%) lacked replications
across three or more subjects, visual analysis reporting, and
adequate data points in each phase. Findings from this review
suggest promising evidence of the effect of communication
partner interventions on both child and caregiver out-
comes. The high risk of bias for the individual studies,
however, suggests additional rigorous research is required.
A second systematic review by Kent-Walsh et al.
(2015) investigated the effects of communication partner
instruction on communication outcomes of individuals
who use AAC. Seventeen studies, which included 53 indi-
viduals who used AAC and their communication partners,
met the inclusion criteria. Researchers calculated the mean
IRD for each design; estimates ranged from 0 to 1 (none
to strong); the mean IRD across studies was 0.83, indicat-
ing a large effect of communication partner instruction on
communication skills. Kent-Walsh et al. (2015) analyzed
subgroups by calculating the mean IRD for studies sharing
similar participant and intervention characteristics. They
found large IRD estimates (0.98–0.99) for studies that in-
cluded five or more adult instructional components (e.g.,
guided practice and role play) and specific strategy instruc-
tion. This review replicates previous findings (Shire &
Jones, 2015) and provides preliminary evidence that com-
munication partner instruction interventions with multiple
adult instructional components and strategy instruction
may have large effects on child communication outcomes.
Recent reviews have suggested that between 20% and
30% of AAC interventions involved shared reading
(Gevarter & Zamora, 2018; Shire & Jones, 2015). Shared
reading is a beneficial context for communication interven-
tions for several reasons. Shared reading allows children with
language delays to participate in natural activities that include
joint attention and scaffolded language (Soto & Dukhovny,
2008). Within the activity, children who use AAC can focus
on communication without additional fine or gross motor de-
mands (Kent-Walsh, Binger, & Hasham, 2010). AAC sys-
tems can be created with preselected AAC vocabulary tar-
geted for stories and symbols that illustrate targeted language
concepts (e.g., Rosa-Lugo & Kent-Walsh, 2008).
Methods for Teaching Communication Partners
Communication partner instruction typically includes
multiple training sessions (65 min to 3.5 hr), followed by
three to five practice/coaching sessions (e.g., Binger et al.,
2018; Douglas et al., 2014; Kent-Walsh, Binger, & Hasham,
2010). Training sessions consist of a description of the tar-
geted strategies, verbal practice, and role play (e.g., Kent-
Walsh, Binger, & Malani, 2010); they are often provided in
a workshop format. Practice sessions involve communication
partners using targeted strategies, followed by an opportu-
nity for parents to ask questions and reflect (e.g., Douglas
et al., 2017).
Therapists often use an instructional framework to
deliver efficient, consistent, and accurate communication
partner instruction (Kent-Walsh et al., 2015). These
frameworks are based on adult learning theories and strat-
egy instruction principles; they include activities to pro-
mote generalization, including role playing, discussion,
problem solving, and performance feedback (Kent-Walsh
& McNaughton, 2005; Knowles, 1973; Kolb, 2014; Palis
& Quiros, 2014). Communication partner instructional
frameworks may include multiple educational approaches,
such as direct teaching, therapist modeling, communica-
tion partner reflection, and opportunities for questions
(Douglas et al., 2014; Kent-Walsh, 2003). One promising
instructional framework is Improving Partner Applications
of Augmentative Communication Techniques (ImPAACT;
Kent-Walsh & Binger, 2013). ImPAACT is an eight-step
program to teach communication partners targeted AAC
and language support strategies (see Kent-Walsh &
Binger, 2013, for a full description).
Strategies Taught to Communication Partners
AAC Modeling
AAC modeling is one language support strategy fre-
quently taught to communication partners with strong
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evidence of improving children’s expressive communica-
tion skills (Biggs et al., 2018; O’Neill et al., 2018; Romski
et al., 2010; Sennott et al., 2016). AAC modeling involves
communication partners pointing to vocabulary on the
AAC system as they speak. For example, a communica-
tion partner says, “The boy goes home,”and points to the
symbols GO and HOME on the AAC system. This strat-
egy supports comprehension by pairing a spoken word
with a visual symbol (Romski et al., 2010). AAC model-
ing also demonstrates how to use an AAC system to sup-
plement or replace speech (Sennott et al., 2016). Most
communication partner interventions involve AAC modeling
as a component of training (Biggs et al., 2018; Kent-Walsh
et al., 2015; O’Neil et al., 2018). We use the term AAC
modeling, but this strategy is also called augmented input
(Allen et al., 2017), aided AAC modeling (Binger & Light,
2007), aided language modeling (Drager et al., 2006), and
augmented communication input (Romski et al., 2010).
Read, Ask, Answer, Prompt
Storybook reading is a common activity for communi-
cation partner training (Shire & Jones, 2015). One evidence-
based storybook reading instruction model is Read, Ask,
Answer, Prompt (RAAP; Binger et al., 2008, 2010; Kent-
Wash, 2003; Kent-Walsh, Binger, & Malani, 2010; Rosa-
Lugo & Kent-Walsh, 2008). RAAP uses a least-to-most
prompting procedure to teach language support strategies
to communication partners during shared book reading.
RAAP is a multicomponent prompting procedure that in-
corporates five naturalistic language support strategies:
(a) AAC modeling, (b) expectant pauses, (c) open-ended
questions, (d) verbal prompts, and (e) linguistic expansions
(see Binger et al., 2010, for a full description). The strate-
gies are embedded into a sequenced least-to-most prompt-
ing procedure during storybook reading: (a) Read a page
in the book; (b) Ask a question; (c) Answer the question;
and, in some studies, (d) Prompt (Binger et al., 2010;
Kent-Walsh, 2003; Kent-Walsh, Binger, & Hasham, 2010;
Rosa-Lugo & Kent-Walsh, 2008). The communication
partner verbally prompts each step while using AAC
modeling by pointing to corresponding symbols on the
AAC system. After verbally prompting and modeling, the
communication partner waits 5 s. If the child takes a com-
municative turn, the communication partner responds and
turns the page. If the child does not take a turn, the com-
munication partner prompts with the next RAAP step
until all steps are complete. The goal of RAAP is to en-
courage children who use AAC to increase language and
turn-taking in structured activities. Previous RAAP train-
ing interventions included an instructional training work-
shop (2–3.5 hr), followed by multiple (three to 11) 10-min
advanced practice/coaching sessions.
Six studies have taught RAAP steps to 29 communi-
cation partners during book reading interventions (Binger
et al., 2008, 2010; Kent-Walsh, 2003; Kent-Walsh, Binger,
& Hasham, 2010; Kent-Walsh, Binger, & Malani, 2010;
Rosa-Lugo & Kent-Walsh, 2008). Across studies, 29 com-
munication partners increased RAAP strategy use immedi-
ately after application of the intervention; all partners met
the learning criterion (80%–90% accuracy). Within the in-
terventions, the children increased their communication
turns, semantic concepts, and multisymbol utterances
(Binger et al., 2010; Kent-Walsh, Binger, & Hasham,
2010; Rosa-Lugo & Kent-Walsh, 2008). RAAP has dem-
onstrated promising effects on parent strategy use and
child AAC communication skills during instruction and
book reading activities. To our knowledge, all RAAP
studies have occurred during in-person interventions.
Expanding Access to Communication Partner
Instruction Through Telepractice
Families of children who use AAC frequently expe-
rience barriers to in-person intervention, such as limited
time, travel, transportation costs, and access to AAC ex-
perts (Douglas et al., 2017; Hall et al., 2014). Telepractice
is one service delivery option with the potential to mini-
mize these challenges by increasing access to knowledge-
able therapists while reducing the need for travel (Douglas
et al., 2018). Telepractice involves a licensed clinician
using telecommunication technology to implement inter-
ventions, consultations, or assessments (American Speech-
Language-Hearing Association [ASHA], n.d.). Before the
rapid changes in service delivery due to the public health
impacts of COVID-19, telepractice was less common in
the discipline of communication sciences and disorders,
with 2% of speech-language pathologists (SLPs) reporting
provision of services via telepractice (ASHA, 2015). The
COVID-19 pandemic has facilitated the wide-scale
adoption of telepractice models; however, clinicians lack
sufficient research to inform their service delivery.
Douglas et al. (2014, 2017, 2018, 2021) have provided
preliminary evidence that communication partners can
learn naturalistic language strategies within general child-
centered activities following telepractice training. How-
ever, no known telepractice studies provide clear, struc-
tured, and reproducible guidelines specifically for story-
book reading activities. Additional studies are required
to determine whether telepractice is feasible, acceptable,
and appropriate for communication partners and children
who use.
Research Questions
The primary purpose of this study was to investigate
the effects of telepractice instruction on parents’use of
RAAP strategies. The secondary aim was to examine
whether child communication skills improved when their
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parents learned to use RAAP strategies. Our primary re-
search question was, “Is there a functional relation be-
tween telepractice instruction and parents’RAAP strategy
use during storybook reading?”We also asked a second-
ary, exploratory question: “Is there an increase in chil-
dren’s symbolic communication turns after their parents
participated in the telepractice RAAP instruction?”It was
hypothesized that after the training workshop, parents
would show an immediate increase in the level of accurate
RAAP strategy use, measured by the percentage of turns
parents implemented RAAP correctly. It was also hypoth-
esized that the children would demonstrate an immediate
increase in symbolic communication turns after parent
training, measured by the percentage of turns the children
communicated symbolically.
Method
Research Design
This study used a randomized, multiple-probe, across-
participants design to evaluate the feasibility of teleprac-
tice RAAP instruction across five parent–child dyads.
Multiple-probe, across-participants design studies involve
the sequential introduction of the independent variable;
this design works well within educational and clinical re-
search when evaluating several participants with similar
behavior (Ledford & Gast, 2018). The study design
allowed for five potential demonstrations of a treatment
effect during five different points in time (Ledford & Gast,
2018; Reichow et al., 2018). When analyzing multiple-
probe, across-participants design graphs, investigators de-
pict each participant with a different A–B comparison and
refer to these individual AB comparisons as tiers (repre-
sented as stacked rows on the multiple-probe design
graph). A web-based spinner randomized each parent–
child dyad to a tier so that the order of intervention was
randomized across dyads (Ledford & Gast, 2018; Reichow
et al., 2018).
Five parent–child dyads completed a sequence of
three phases: baseline, intervention, and maintenance.
Phase change decisions were response guided and based
on the primary dependent variable, correct use of RAAP
strategies (Ledford & Gast, 2018; Tate et al., 2014). Base-
line sessions and data collection began concurrently for all
dyads. The RAAP intervention was applied sequentially
across tiers. After at least three baseline sessions, with sta-
ble baseline performance across tiers, Dyad 1 began the
RAAP intervention while Dyads 2–5 continued baseline
sessions. After a treatment effect was observed for Dyad 1
and following stable baseline performance across tiers,
Dyad 2 began the RAAP intervention while Dyads 3–5
continued baseline sessions. The establishment of a treatment
effect and stable baseline performance continued until the
RAAP intervention was applied to all five dyads.
Participants and Recruitment
This study was conducted remotely throughout Oregon
and was approved by the institutional review board
(1606525–3) at Rocky Mountain University of Health
Professions. Families of children with severe communica-
tion impairments were recruited through social media and
e-mail. Five parent–child dyads indicated interest, com-
pleted the informed consent process, and met study inclusion
criteria. Each dyad received five books and a $50 Amazon
gift card as an incentive for their participation.
Participant selection criteria were adapted from previ-
ous AAC communication partner training interventions
(Binger et al., 2010; Douglas et al., 2017) and designed for
remote delivery due to the public health impacts of COVID-
19. The interventionist assessed participants by asking par-
ents to complete a demographic questionnaire and a 10-min
book reading screening when the parent read books from
the child’s home in a typical manner. The interventionist
guided the parent through portions of the International Clas-
sification of Functioning, Disability and Health–Children
and Youth Version for AAC Profile (ICF-CY AAC;
Rowland et al., 2009), a rating scale designed to understand
the impact of communication impairments at school and
home for children who use AAC (Rowland et al., 2009).
Parent inclusion criteria were (a) parent or custodial
caregiver of a child aged 3.0–12.11 years with a severe
communication impairment, (b) English as a primary lan-
guage, (c) high school diploma (or equivalent), and (d) ap-
plication of RAAP strategies in fewer than 25% of oppor-
tunities during the book reading screening. Child inclusion
criteria were (a) aged 3.0–12.11 years, (b) medical or edu-
cation diagnosis of a developmental delay per parent re-
port, (c) hearing and vision within functional limits per
parent report, (d) recognition of familiar symbols per par-
ent report, (e) ability to point to pictures observed during
reading screening, and (f) average-to-moderate receptive
communication limitations and moderate-to-complete ex-
pressive and literacy limitations (compared with typically
developing peers) per parent report on the ICF-CY AAC.
Children who had difficulty attending to 10 min of book
reading, as evidenced by eloping during book reading
greater than 2 times, throwing or pushing away the book
more than 2 times, or attending to less than 50% of the in-
teraction, were excluded from the study. All dyads were
required to have access to technology and the Internet for
videoconferencing and video and recording.
Four children were of preschool age (3;4–4;10
[years;months]) with diagnoses of autism, apraxia, or Down
syndrome; one child was of school age and had comorbid
diagnoses of autism and Down syndrome. Parents reported
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that all children had severe-to-complete expressive limita-
tions compared with their same-age peers. There were no
inclusion criteria regarding former experiences with aided
AAC or picture symbol systems such as SymbolStix
(SymbolStix Prime, n.d.). Two children had some experi-
ence with AAC per parent report; Child 1 was familiar
with picture symbols, and Child 2 had picture communica-
tion cards and a voice output device (TouchChat by Sal-
tillo), but the AAC system was rarely used in the home.
Table 1 shows parent and child demographic characteristics.
The interventionist, a certified SLP, was a clinical doc-
toral student in speech-language pathology. She had 19 years
of experience working with children who use AAC. She
conducted eligibility assessments and the baseline, inter-
vention, and maintenance sessions for all participants.
Setting and Materials
All baseline and intervention sessions were synchro-
nous, provided via videoconferencing. Participants were at
their individual homes, and the interventionist conducted
sessions from her home office. Four dyads completed the
study indoors, seated on a couch or the floor. Child 2
moved between locations inside and outside of her home.
On the occasions that a child changed locations, the inter-
ventionist instructed the parent to reread the book page.
Maintenance sessions were completed at home, indepen-
dently video-recorded by the parent, and e-mailed to the
interventionist.
Books
Parent–child dyads received five Little Critter (My
First I Can Read) books by Mercer Mayer. Little Critter
books have been used in previous RAAP interventions
(Binger et al., 2010; Kent-Walsh, 2003; Kent-Walsh,
Binger, & Hasham, 2010). These books met the criteria de-
termined by Kent-Walsh (2003), including (a) illustrations;
(b) text that is appropriate for the receptive language level
of the children as determined by parents; and (c) at least 10
page spreads, defined as two adjacent pages with story text
and pictures. All books contained 14 page spreads.
AAC System
The interventionist created one laminated communi-
cation board for each Little Critter book that contained
36 vocabulary words organized in 6 × 6 rows (see Supplemen-
tal Material S1). Communication boards were identical
across dyads. Each communication board had 24 identical
core words, which represented high-frequency, general-
purpose concepts (e.g., “go”), and 12 fringe words that
represented book characters, actions, and objects specific
to each book (e.g., “Critter”and “ball”). Core words were
consistent across books, selected from word lists generated
from observing child conversations (Banajee et al., 2003;
Fried-Oken & More, 1992), and the interventionist’s clini-
cal experience. Each vocabulary word was depicted in a
rectangle (1.07 in. × 1.48 in.) containing text (18-point font)
above SymbolStix images (SymbolStix Prime, n.d.). Each
core word background color matched the Modified
Fitzgerald Key, a method of color-coding vocabulary by
parts of speech (Beukelman & Mirenda, 2020). All fringe
words had a white background. Participants had no exposure
to the boards before the study.
Telepractice Equipment
All five parent–child dyads used personal computers or
mobile devices to participate in telepractice sessions using
Google Meet software (Google LLC, 2020). The intervention-
ist provided families with a phone selfie stick tripod, UBeesize
51-in. extendable tripod stand. Four of the five dyads used a
smartphone for baseline and intervention sessions with their
child. One dyad initially used a smartphone, then switched
to a laptop computer during intervention sessions and
for the maintenance probe because of difficulties with the
tripod (such as twisting it to get a good view angle).
Procedure
The study involved three conditions: baseline, inter-
vention, and maintenance. Before the first baseline session,
the interventionist e-mailed a calendar invitation with an
embedded hyperlink to the meeting room and written di-
rections for using Google Meet software. Table 2 outlines
Table 1. Participant demographics.
Dyad
Adult
partner
Child Limitations
Age (years;months) Disability Sex Receptive Expressive Literacy
1 Father 3;8 Male Down syndrome Mild Complete Complete
2 Mother 12;8 Female Down syndrome and autism Moderate Severe Severe
3 Mother 4;10 Male Down syndrome Moderate Complete Complete
4 Mother 3;9 Male Apraxia None Severe Severe
5 Mother 3;4 Male Apraxia None/mild Severe Severe
Note. Limitations were measured by parents in relation to the child’s typically developing peers. None = typical skills; Mild = mildly delayed
skills; Moderate = moderately delayed skills; Severe = severely delayed skills; Complete = the child has a complete limitation and cannot yet
perform this skill.
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Table 2. Overview of phases.
Components
Baseline Intervention Maintenance
Training workshop Advanced practice
Total sessions 3 (Dyad 1) to 7 1 5 1
Duration 3.35–17.33 min (M= 9.9) 60 min 18.2–40.82 min (M= 28.41) 10.73–18.97 min (M= 12.66)
Frequency 1–3 times/week Once 3 times/week Once
Materials Books, AAC board, and video
equipment
Books, AAC board, and video
equipment
Books, AAC board, and video
equipment
Books, AAC board, and video
equipment
Setting Home Home Home Home
Activities 1. Provide opportunity for parent
questions
2. Parent reads book with child
3. Provide opportunity for parent
questions
1. Instruct and model language
strategies with AAC system
and RAAP
2. Guide parent through practice
and role plays
3. Parent self-reflection
1. Provide opportunity for parent
questions
2. Rehearse RAAP steps
3. Provide performance feedback after
parent reads first page spread
4. Ask parent to read the rest of the
story with RAAP strategies
5. Review sessions performance with
parent
6. Parent self-reflection
1. Instruct parent to video
themselves reading one story
with child using RAAP
Interventionist role Observer Trainer and coach Coach and observer Observer
Note. AAC = augmentative and alternative communication; RAAP = Read, Ask, Answer, Prompt.
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study procedures, and Supplemental Material S3 includes
a detailed list of procedural steps within each phase.
Baseline Phase
Baseline sessions were conducted at least once per
week for totals of three (Dyad 1) to seven (Dyads 4 and
5) sessions. Three baseline sessions at 0% accuracy were
considered sufficient to predict the approximate value of
the following data points (Ledford & Gast, 2018). Fre-
quency and number of sessions for Dyads 2–5 were re-
sponse guided; they were dependent upon phase changes
for the previous tier and continued until all dyads began
intervention.
Baseline sessions included three activities: time for
parent questions, parent–child book reading, and an addi-
tional opportunity for parent questions. At the start of
each baseline session, the interventionist asked the parents
if there were any questions. Next, the interventionist
instructed the parents to read a randomly selected Little
Critter book in a typical manner and keep the correspond-
ing communication board within reach. After the reading
activity, the parents had the opportunity to ask questions.
The interventionist observed through videoconferencing
(Google Meet) during the baseline sessions without pro-
viding feedback, except to help with technical difficulties.
The therapist offered technical support for sound or place-
ment of materials.
Intervention Phase
RAAP strategy. RAAP uses naturalistic language strat-
egies (i.e., AAC modeling, expectant pausing, and responding
to communication attempts) within a least-to-most prompting
procedure. The goal of RAAP is to teach communication
partners a systematic way to encourage children with AAC to
communicate expressively within storybook reading activities.
As depicted in Figure 1, the strategies are embedded into the
four-step prompting procedure: (a) Read a page in the book
while modeling the AAC system, then pause expectantly (5 s);
(b) Ask a question while modeling the AAC system, then
pause expectantly; (c) Answer the question while modeling the
AAC system, then pause expectantly; and (d) Prompt verbally
(e.g., “Your turn”) while modeling the AAC system, then
pause expectantly (Binger et al., 2010; Kent-Walsh, 2003;
Kent-Walsh, Binger, & Hasham, 2010; Rosa-Lugo & Kent-
Walsh, 2008). Parents were taught to proceed through each
sequential step until the child communicated. When the child
communicated symbolically, their partner was taught to ex-
pand the utterance by adding words. When the child com-
municated nonverbally, their partner responded with a re-
lated comment or question. Parents received individual
Figure 1. Read, Ask, Answer, Prompt strategy steps and examples. AAC = augmentative and alternative communication.
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instruction on using the RAAP strategy, initially in a 60-min
training workshop, followed by five 30-min advanced
practice sessions (three per week, for 1.5 weeks).
Parent training workshop. Immediately following the
last baseline session (< 2 days), parents individually partici-
pated in a 60-min, synchronous training workshop. The in-
terventionist modified the ImPAACT training protocol
(Kent-Walsh & Binger, 2013) for telepractice use (see
Table 3). The workshop included three sequential activities:
(a) a slideshow presentation, (b) guided practice with
coaching, and (c) self-reflection. First, the interventionist
presented a slideshow that defined each strategy and pro-
vided a rationale, and she modeled each step (see Supple-
mental Material S2). Next, parents demonstrated their
learning by repeating, recalling, modeling, and role-playing
the RAAP steps while reading a Little Critter book. Ini-
tially, the interventionist provided specific performance
feedback, such as “Those were great words to model on
the board because they applied directly to the text.”As the
parents increased their skills, feedback was generalized. The
interventionist led parents through guided self-reflection
questions (e.g., “Could you use any of this training in differ-
ent parts of your day?”), provided an opportunity for ques-
tions, and reviewed the upcoming sessions. Parents received
a PDF of the presentation to review after the training.
Advanced practice sessions. Advanced practice sessions
included six sequenced activities and continued until the par-
ents individually met the performance criterion, applying
RAAP correctly during ≥85% of opportunities in two con-
secutive sessions. First, the interventionist asked if there were
questions. Then, the interventionist instructed the parents to
rehearse all RAAP steps and provided prompts if needed.
Next, the parents randomly chose a Little Critter book and
began reading with their child. The interventionist provided
feedback after the first page spread on RAAP strategy
use. If the parents demonstrated errors, the interventionist
reminded them of the missed steps (e.g., “Wait five seconds
before moving onto the next step.”). Next, the interventionist
directed the parents to read the stories independently and ap-
ply RAAP strategies. The interventionist provided no addi-
tional feedback during independent practice. When the read-
ing was complete, the interventionist gave the parents spe-
cific performance feedback (“You did a great job pausing
for five seconds.”). Finally, the interventionist asked the par-
ents to reflect on their strategy use and children’scommuni-
cation (e.g., “What do you think went well?”) and planned
for using RAAP strategies later in the day.
Maintenance Phase
One week after intervention sessions were complete,
the interventionist e-mailed parents to request the comple-
tion of one maintenance session and a social validity
form. The interventionist directed parents via e-mail to
video themselves reading a Little Critter book with their
child and “use the strategies that you learned.”Parents
did not receive reminders on using a communication board
or any of the RAAP strategy components. Four of the five
parents e-mailed the completed video to the interventionist
for data collection. One family was unable to e-mail their
maintenance video to the interventionist.
Table 3. Improving Partner Applications of Augmentative Communication Techniques (ImPAACT) modifications for telepractice.
ImPAACT program step Instructional activities Modifications for teletherapy
1. Pretest and commitment •Illustrations of interactions with and
without strategies
•Formal commitment
•No-pretest or video demonstrations
•Commitment read and verbally agreed upon
(no signature)
2. Strategy description •Visual aid/handout with a brief
description of each skill
•Description of language facilitation strategies
(model, expectant pause, respond; MER)
•Description of Read-Ask-Answer-Prompt (RAAP)
•Images added to each description to aid in memory
3. Strategy demonstration •Model strategies and explanation
of each step
•MER and RAAP strategies modeled and explained
through synchronous video conferencing
4. Verbal practice of strategy steps •Verbally stating and repeating steps •No modifications
5. Controlled practice feedback •Multiple opportunities to practice
the steps
•Feedback faded over time
•Each RAAP strategy practiced within the books
that would be used in the intervention
•Feedback faded when appropriate
6. Advanced practice and feedback •Opportunities to practice in natural
environments with communication
partners
•This step was not implemented
7. Posttest and commitment •Video review and analysis of adult
implementing steps
•Create a plan for maintenance and
generalization
•No video reviews
•Instead of a plan, parents were asked to consider
times in the day these steps could be used
8. Generalization •Support in generalizing the steps •Supported parents to consider ways and times
they could generalize the steps
Note. Strategy step descriptions were based on goal and instructional activity descriptions provided in Kent-Walsh and Binger (2013).
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Outcome Measures
Parent RAAP Strategy Use
The primary dependent variable was parents’correct
RAAP strategy use during shared book reading, measured
by the percentage of opportunities that parents applied
RAAP strategies correctly. Parent strategy use was observed
using a trial-based event recording system, with 13 total op-
portunities to respond during each book (one per page
spread). As described in the intervention procedures above,
the RAAP strategy used a least-to-most prompting proce-
dure. The interventionist taught the parents to implement
each RAAP step until the child communicated symbolically
or the parent reached the last step, “Prompt.”The perfor-
mance criterion was the parents’correct use of RAAP dur-
ing ≥85% of opportunities in two consecutive sessions.
The intervention ended after at least five sessions and per-
formance criterion fulfillment (≥85% use of strategies).
Child Symbolic Communication Turns
We measured child communication turns as an ex-
ploratory outcome. Although the focus of the study was
determining the feasibility of parent strategy implementa-
tion, we were still interested in capturing any potential
changes in child communication. The metric was the per-
centage of turns that the children communicated symboli-
cally. The interventionist measured communication turns
using a trial-based event recording system, with 13 total op-
portunities to respond during each session (one turn per
page spread). Symbolic communication turns (a) contained
one or more spoken words, manual signs, or picture sym-
bols (Brady et al., 2012); (b) were directed toward their par-
ent; (c) made sense in the context of the book; and (d) were
judged by the parent to be meaningful, rather than imita-
tive or rote (Douglas et al., 2014). Words were defined as
verbal approximations containing the same number of syl-
lables and at least one correct consonant and vowel sound.
Manual signs were defined as a signed word when the
handshape, movement, and placement were consistent with
an American Sign Language sign. Picture symbols were de-
finedaspicturesonacommunicationboardtowhichthe
child pointed. Examples of symbolic communication be-
haviors included speaking intelligible words, signing to
the parent, or pointing to a symbol on the AAC system.
Intentional, socially directed points to a book image were
coded as symbolic communication turns (commenting).
Social Validity
The interventionist e-mailed parents a questionnaire
form 1 week after completing the intervention. This electronic
form contained 14 questions, which assessed the acceptability
of the intervention’s goals, procedures, and outcomes. Social
validity questions included the participants’perceived benefits
and drawbacks of learning new communication strategies,
amount of instruction/coaching time, the telepractice service
delivery model, and whether their children increased their
communication skills. Parents rated nine questions on a
Likert-type scale (1 = strongly disagree to 5 = strongly agree)
and answered five questions with open-ended responses.
Procedural Fidelity
The interventionist used a procedural checklist to as-
sess her adherence to the baseline procedures and the
ImPAACT protocol. She kept a journal to note any
changes or differences between sessions or dyads. The inter-
ventionist used a procedural checklist throughout all sessions
(see Supplemental Material S3).
Upon each dyad’s study completion, a clinical doc-
toral student checked procedural fidelity by direct obser-
vational recording. The secondary observer was trained to
100% agreement using demonstration videos and used a
multistep procedural checklist. Procedural fidelity was col-
lected in 20%–21% of baseline and advanced practice ses-
sions. See Table 4 for a summary of the secondary ob-
server’s procedural fidelity data. Procedural fidelity data
were obtained for the first RAAP training workshop (20%)
and demonstrated 90% fidelity; one procedural error was
noted (modeling before explaining a step). No additional
training workshops were observed due to adequate fidelity
and the investigator’s use of the procedural checklist.
Six baseline sessions (21% of sessions) were observed
for procedural fidelity. Because of delayed recording by the
interventionist, the secondary observer could not mark Steps
1–3 as completed in several sessions. Although procedural
fidelity was low (average 74%, range: 50%–100%), all errors
were related to unrecorded steps (e.g., greeting the partici-
pantsoraskingiftheyhadanyquestions)andnotinstruc-
tional errors. Five advanced practice sessions (20% of
sessions) were observed and demonstrated adequate proce-
dural fidelity (average 89%, range: 72%–100%). Interventionist
errors during advanced practice sessions were related to ask-
ing parents if they had questions, order of instruction, and
Table 4. Secondary data on the investigator’s procedural reliability.
Dyad Baseline Instruction training Intervention
1 50%
a
90% 100%
2 83%
a
—100%
3 83%, 100% —91%
4 66%
a
—73%
a
5 66%
a
—82%
a
Average 74% 90% 89%
Note. Em dashes indicate data not observed.
a
Lower procedural fidelity noted due to a delay in starting the
video recording.
Chin et al.: Teaching Parents RAAP Strategies via Telepractice 9
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greetings. Specified errors did not include the addition or de-
letion of any instructional components.
Reliability of Dependent Variables
The interventionist was the primary coder, and the
secondary coder was a clinical doctoral student in speech-
language pathology. Before coding data for the study, the
interventionist provided a synchronous coaching session,
using Google Meet, to teach coding procedures to 100%
agreement. Following the synchronous session, the second-
ary coder completed two asynchronous video sessions.
The secondary coder was trained until a 90% interobserver
agreement was reached for the parents’use of RAAP
strategies and child communication turns.
The secondary coder reviewed 20% of randomly se-
lected video-recorded sessions across phases. Table 5 sum-
marizes the reliability of dependent variables across all
five dyads. The average interobserver agreement was ac-
ceptable (> 80%; Ledford & Gast, 2018) for parent and
child outcomes. Average agreement was 97% for parent
RAAP strategy use (baseline = 96%, intervention = 98%)
and 95% for child communication turns (baseline = 93%,
intervention = 97%). When the interobserver agreement
was < 90% (two sessions), the interventionist and second-
ary coder rereviewed data and discussed coding discrepan-
cies to minimize observer drift.
Data Analysis
Structured visual analysis was the primary analytical
approach (Ledford & Gast, 2018). Baseline stability for
the primary dependent variable was defined as at least five
baseline data points in which the last two data points did
not accelerate or three consecutive baseline data points at
zero. The interventionist expected an immediate increase
in level and an accelerating (therapeutic) trend immediately
upon intervention implementation for both dependent vari-
ables. A functional relation for the primary research ques-
tion was assessed by analyzing the level, trend, stability,
overlap of data, and immediate level changes within and
between phases and determining whether changes between
phases were replicated consistently across dyads (Ledford &
Gast, 2018). Maintenance data were not considered across
dyads because only one data point was collected.
Secondary statistical analyses were conducted to
quantify the differences between phases and corroborate
the results of visual analysis. After completing a summative
structured visual analysis, all statistical analyses were con-
ducted and calculated in RStudio using the SingleCaseES R
package (Pustejovsky & Swan, 2018). A nonoverlap metric
and a parametric effect size were selected to quantify re-
sults because both approaches have advantages and limi-
tations (Pustejovsky, 2019; Pustejovsky & Ferron, 2017).
The nonoverlap of all pairs (NAP; Parker & Vannest,
2009) was selected as the nonoverlap metric because of
all overlap-based methods. NAP is least sensitive to bias
associated with procedural factors such as baseline and
intervention phase length, which is particularly relevant
in multiple-baseline designs (Pustejovsky, 2019). NAP
quantifies nonoverlapping data by evaluating the extent
to which all possible pairs of data overlap in adjacent
conditions (NAP ¼1
mn Pm
i¼1Pn
j¼1qijÞ. The log response ra-
tio increasing (LLRi; Pustejovsky, 2019) was calculated
to estimate the magnitude of effects. LRRi is the natural
log of the ratio of conditional means (LRRi ¼ln μB=μA
ðÞÞ;
it was selected because it is robust to procedural variabil-
ities impacting other metrics. It is appropriate for depen-
dent variables measured counts or proportions and can be
converted to a percentage change (Pustejovsky, 2019;
Pustejovsky & Ferron, 2017).
Results
Is There a Functional Relation Between
Telepractice RAAP Instruction and Parents’
RAAP Use During Storybook Reading?
The structured visual analysis results suggest strong
evidence of a functional relation (intervention effect) be-
tween the RAAP instruction and parents’RAAP use (see
Figure 2). During baseline, all parents demonstrated sta-
ble, zero-celerating data at 0% RAAP use. After the inter-
ventionist delivered RAAP instruction, all five parents
showed an immediate moderate-to-high increase in level
Table 5. Interobserver agreement for dependent variables across
participants and phases.
Parent RAAP strategy use
Parent
Baseline
M(range)
Intervention
M(range)
1 100% 100%
2 100% 92%
3 100% 100%
4 85% (69%–100%) 100%
5 100% 96% (92%–100%)
Average 96% 98%
Child communication turns
1 92% 100%
2 100% 92%
3 96% (92%–100%) 92%
4 81% (62%–100%) 100%
5 100% 100%
Average 93% 97%
Note. RAAP = Read, Ask, Answer, Prompt.
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Figure 2. Read, Ask, Answer, Prompt (RAAP) strategy steps correctly applied by adult participants.
Chin et al.: Teaching Parents RAAP Strategies via Telepractice 11
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(range: 46%–92%), with a positive (therapeutic) accelerating
trend to criterion. Two weeks after the last intervention ses-
sion, Parents 1, 2, and 5 maintained their data (100%, 100%,
and 92%, respectively). Parent 3’s maintenance data (4 weeks
after intervention) dropped from 92% to 77%. There were no
overlapping data points between thebaselineandintervention
phases. NAP values were 1.0 for all parents. LLRi was not
assessed for parent outcomes, because it cannot be calculated
for outcomes with baseline data points consistently at zero.
Do Children’s Symbolic Communication
Turns Increase After Parents Were Taught
RAAP Strategies via Telepractice?
Results for children’s symbolic communication turns
were inconsistent across children. Only Child 2 demon-
strated a stable baseline for symbolic communication
turns because phase change decisions were based on the
primary dependent variable, parent RAAP accuracy. Once
intervention began, there was no change in level for Chil-
dren 1 and 4 (see Figure 3). There was an immediate in-
crease in level for Child 5 and a latent change in level for
Children 2 and 3 (with overall accelerating trends). There
was no evidence from the visual analysis that age or diag-
nosis affected intervention data. NAP and LRRi were cal-
culated for all participants; LRRi values are unstable
when data points are zero (Pustejovsky, 2019).
Child 1
During baseline, Child 1 demonstrated a moderate-
to-high level of communication turns with an overall ac-
celerating trend and moderate variability (range: 46%–
77%). After the training workshop, there was an immedi-
ate decrease in level. Data demonstrated moderate vari-
ability with accelerating and decelerating trends (range:
38%–69%). The NAP was 0.33 (SE = 0.22, 95% CI [0.09,
0.72]). The LRRi estimate was −0.13 (SE = 0.19, 95% CI
[−0.51, 0.25]), which converts to a −12% change. Two
weeks after the intervention, a probe demonstrated a mod-
erate change between intervention and maintenance and
high levels in data.
Child 2
Child 2 had a stable, low level of communication
turns in baseline (range: 0%–8%). Immediately after the
intervention began, there was a small and low-level
change in data (8%), followed by a large change to a
moderate level (62%). The data decreased to a low level
(8%), then accelerated toward a low/moderate level (31%).
The NAP was 0.96 (SE = 0.05, 95% CI [0.59, 1.00)]). The
LRRi estimate was 2.33 (SE = 1.08, 95% CI [0.21, 4.44])
and 923% when converted to a percentage change. Two
weeks after the intervention, a maintenance probe showed
a decrease in level from 31% to 0%.
Child 3
Child 3 demonstrated low levels of communication
turns in baseline with moderate variability and no trend
(range: 0%–23%). After the training workshop, there was
a latent increase in level from 0% to 31%, followed by
variable low levels and an accelerating trend (intervention
range: 0%–38%). NAP was 0.72 (SE = 0.18, 95% CI
[0.37, 0.91]). The LRRi estimate was 0.72 (SE = 0.18,
95% CI [0.37, 0.91]), which converts to an 82% change.
Four weeks after the intervention, the maintenance probe
showed a low level of communication turns (n= 15%).
Child 4
During baseline, Child 4 demonstrated highly vari-
able data with low-to-moderate levels and no trend (range:
9%–54%). Immediately after the training session, the data
remained at a low level. Data were variable across the in-
tervention phase with both accelerations and decelerations.
NAP was 0.63 (SE = 0.18, 95% CI [0.31, 0.86]). The
LRRi estimate was 0.27 (SE = 0.43, 95% CI [−0.58, 1.12])
and 31% when converted to a percentage change. There
were no maintenance probe data for Dyad 4.
Child 5
Child 5 demonstrated low-to-moderate levels of com-
munication turns across baseline (range: 15%–61%). Data
were primarily stable with some variability, including one
outlier (n= 61%). Following the training workshop, there
was an immediate change to a high level of data. Interven-
tion data demonstrated limited variability with a decelerat-
ing trend (range: 92%–100%). NAP was 1.0 (SE =0.02,
95% CI [1.00, 1.00]). The LRRi was 1.03 (SE = 0.18, 95%
CI [0.68, 1.39]) and 181% when converted to a percentage
change. Two weeks after the intervention, a maintenance
probe demonstrated a small change and high levels in data.
Social Validity
All parents completed an online questionnaire at the
end of the study. As shown in Table 6, participants agreed
or strongly agreed that the study provided sufficient in-
struction and was worth their time. They also agreed that
they were using the study’s strategies in other parts of
their day, indicating high acceptability of procedures. Two
parents strongly agreed that their child was communicat-
ing more by the end of the study, indicating acceptability
of the children’s results. No objective measures of social
validity were collected.
Discussion
The purpose of this study was to explore the feasi-
bility of providing RAAP, a communication partner
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Figure 3. Symbolic communication turns taken by child participants.
Chin et al.: Teaching Parents RAAP Strategies via Telepractice 13
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intervention, to children who use AAC and their parents
using telepractice. The primary aim was to examine the ef-
fects on parents’use of RAAP strategies, and the second-
ary, exploratory aim was to investigate the effects on child
communication turns. Parents immediately increased and
maintained RAAP strategy use to mid/high levels follow-
ing the intervention. There was a functional relation be-
tween the RAAP intervention and parents’correct use of
RAAP strategies, with five replications demonstrated
across participants. Nonoverlap and parametric effect size
estimates complemented visual analysis results that the
change from baseline to intervention was significant for
all five parents. Additionally, the four parents who com-
pleted the maintenance video demonstrated continued
mid-to-high levels of strategy use after the intervention.
The exploratory, secondary research question demon-
strated inconsistent results. The intervention was socially
valid, as evidenced by the parents’agreement that they re-
ceived sufficient training and generalized the strategies.
Although there may have been a Hawthorne effect for so-
cial validity questions, data regarding the parents’growth
in skills and children’s maintenance data mirrored the par-
ents’perceptions. This study is the first to provide prelimi-
nary evidence that the ImPAACT framework and RAAP
strategies can be successfully delivered via telepractice.
This study responds to recent calls for AAC research
with a strong methodological design (Kent-Walsh &
Binger, 2018). It addresses many methodological issues in
prior communication partner intervention research (Shire
& Jones, 2015). This study implemented rigorous design
features that minimized the risk of bias and controlled for
threats to internal validity. The interventionist used struc-
tured visual analysis and two different methods to describe
the overlap between phases and magnitude of effects.
There was a randomization of participant tiers, with each
dyad beginning the intervention only after reaching a sta-
ble baseline and having the previous tier reach a treatment
effect. The results of the primary dependent variable were
replicated 5 times and included no adverse effects or data
trends. Interobserver agreement for data collection was
high. Although procedural fidelity results were not 100%,
no interventionist errors were due to instructional omis-
sions or additions. This study provided a list of precise
and detailed steps that other interventionists can replicate
(see Supplemental Material S3).
Parents’RAAP Strategy Use
This study adds to previous research in three impor-
tant ways. First, it replicates findings of prior RAAP
Table 6. Social validity questions and summary ratings by parents.
Question
Session rating
M(range) Description
1. This research study taught me new ways of communicating with my child. 4.2 (3–5) Agree
2. My child was communicating more by the end of the study. 3.4 (2–5) Neutral
3. I have taught these strategies to other family members for when they speak with my child. 4.6 (4–5) Strongly agree
4. I was provided with sufficient instruction and coaching. 5 Strongly agree
5. This study was worth my time. 4.4 (4–5) Agree
6. I would recommend that others participate in this study. 4.6 (4–5) Strongly agree
7. I am using strategies in this study in other areas of my child’s day. 4.6 (4–5) Strongly agree
8. The online-only format worked well for me. 4.2 (2–5) Agree
9. I would consider participating in a similar study. 4.6 (4–5) Agree
Responses to open-ended questions
What did you like about this study?
•“Clear steps and workable curriculum”
•“The detailed instructions and new ideas”
What aspects of this study would you like to see changed?
•“I would like to see the picture cards have bigger pictures on them to make them easier to point to. I also wonder if this study would
help by not just reading but also applying this technique to playing with toys.”
What did you learn?
•“How to create an opportunity for my child to provide original responses and take ownership over his communication, however much
or little he can.”
•“Wait and then wait some more. He’ll only respond if I wait.”
Did your child communicate more as a result of this study? If yes, can you give examples?
•“Yes. She did respond a few times to the pages. Giving her time to respond before moving on to the next pages helped.”
What else would you like to learn about helping your child communicate?
•“I’m trying to create our own board to keep the momentum going.”
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studies research, which showed communication partner in-
struction effectively increases parents’use of language sup-
port strategies. Results regarding parents’correct use of
RAAP strategies were consistent with previous research
indicating the positive effects of RAAP strategy instruc-
tion (e.g., Rosa-Lugo & Kent-Walsh, 2008) on communi-
cation partner behavior.
Second, this study demonstrated the positive effects
of 1 hr of communication partner training. Previous com-
munication partner training sessions were 65 min to 3 hr
long (e.g., Douglas et al., 2014; Kent-Walsh, 2003) with
three to six modules (Douglas et al., 2018; Kent-Walsh,
2003; Kent-Walsh, Binger, & Hasham, 2010). Visual analysis
of this study demonstrates an immediate and mid- to high-
level change in RAAP strategies after one module and
60 min of training. All parents strongly agreed that they re-
ceived sufficient instruction and coaching. This study provides
promising evidence that parents may only require 1 hr of
training, allowing more individuals to access the intervention.
Third, this study expands research on telepractice
communication partner interventions. Douglas et al. (2014,
2017, 2018) taught parents and educational assistants gen-
eral (nonsequenced) strategies for various activities using
online training and subsequent in-person practice sessions.
These interventions taught communication partners to pro-
vide opportunities for communication, wait for the child’s
communication, and respond to the child’s communication.
In 2021, Douglas et al. created a telepractice-only study.
They taught the parents and siblings of one child to prepare
the AAC, show AAC modeling, wait for the child, and re-
spond to communication attempts. This study expands the
work of Douglas and colleagues (2014, 2017, 2018) by pro-
viding specific and sequenced communication partner strate-
gies within storybook reading (see Supplemental Material S3).
It demonstrates that communication partners can quickly
learn AAC modeling with novel communication boards.
Children’s Communication Turns
There were inconsistent results for the secondary, ex-
ploratory outcome, child communication turns. We ex-
pected the children’s communication turns to increase af-
ter the intervention; however, the results were inconsistent.
Child 5 demonstrated an immediate and high-level change
in data following the introduction of the intervention.
Two children (Child 2 and Child 3) demonstrated delayed
intervention effects with accelerating trends and some
overlapping data between phases. Although Child 1’s data
overlapped baseline data, his maintenance data increased
after the intervention. Child 4 did not demonstrate inter-
vention effects, and due to technical difficulties, a mainte-
nance video could not be analyzed.
Although the results were not consistent with previous
RAAP studies (Binger et al., 2010; Kent-Walsh, Binger, &
Hasham, 2010; Rosa-Lugo & Kent-Walsh, 2008), not all
communication partner training interventions demonstrate
consistent, large, or immediate changes in communication
outcomes (e.g., Nunes & Hanline, 2007; Romski et al.,
2010; Shire & Jones, 2015). There are multiple possible ex-
planations for the results. First, the children in this study
represented a heterogeneous group; they ranged from pre-
school to late elementary school and had various diagnoses.
Child 2 was the only female child participant. She was
7 years older than the next oldest participant and had co-
morbid autism and Down syndrome diagnoses.
Second, the participants mayhavedifferedintheir
prebaseline familiarity with AAC. Previous RAAP studies
used familiar AAC and symbol systems when available (e.g.,
Binger et al., 2008, 2010; Kent-Walsh, Binger, & Hasham,
2010). This study, however, used a novel communication
board. In addition, there were no inclusion or exclusion cri-
teria or assessment of pre-intervention AAC or picture sym-
bol knowledge.
Third, there were no objective measures of the chil-
dren’s receptive language skills. In previous RAAP studies
(Binger et al., 2008, 2010; Kent-Walsh, 2003; Rosa-Lugo
& Kent-Walsh, 2008), the child participants had receptive
language skills at or above the 2-year-old level, as mea-
sured by standardized or observational assessments. Be-
cause of telepractice and COVID-19 precautions, the inter-
ventionist relied on parent reports to assess their child’s
communication skills and met specified eligibility criteria.
Fourth, the children in previous studies demon-
strated multiple pre-intervention communication turns
(Kent-Walsh, 2003; Rosa-Lugo & Kent-Walsh, 2008),
whereas the majority (three) of the children in this study
demonstrated no communication turns in at least one
baseline session. Minimal communication turns in baseline
may be representative of lower turn-taking skills.
Finally, intervention intensity (dosage, frequency)
may not have been sufficient to lead to an immediate in-
crease in the level of child communication. Previous re-
search supports the need for multiple, frequent interven-
tions by a clinician to impact the language skills of chil-
dren with Down syndrome and cognitive impairments
(Yoder et al., 2014). Children in the current received five
30-min intervention sessions, in which their communica-
tion partners received telepractice coaching only up to the
first page spread (approximately the first 10 min). How-
ever, in previous training studies, most parents reached
the performance criterion within one to two advanced
practice sessions, indicating that they used the strategies
with fidelity. Children participated in four to five interven-
tion sessions in which their parents were using the RAAP
strategies at fidelity. In prior RAAP communication part-
ner studies, dyads received additional practice and feed-
back before intervention data were collected (Kent-Walsh,
Binger, & Malani, 2010; Rosa-Lugo & Kent-Walsh, 2008).
Chin et al.: Teaching Parents RAAP Strategies via Telepractice 15
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This extra practice and interventionist feedback may have
affected child outcome measurements. Future studies may
explore the impact of treatment intensity and duration on
child communication outcomes. Additional explanations
of child outcome differences were the limitations of the
study design, including coding methods, measurement sys-
tem, explained in greater detail in the Limitations section.
Limitations
Although the study was carefully designed and in-
cluded randomization to reduce potential experimenter
bias, several potential limitations exist. The most impor-
tant limitation was the observational measurement system
used. Previous studies of child communication outcomes
included direct observation of the children and their AAC
systems (e.g., Binger et al., 2008, 2010; Kent-Walsh,
Binger, & Hasham, 2010). Within this study, however, a
single camera point of view and lack of voice output lim-
ited child observation. When direct observation was not
possible, due to movement, placement of materials, or par-
ticipant positioning, communication turn measures were
calculated based on parents’responses to their children.
Study results relied upon parent behavior. Communication
turns may have been missed if they were not directed to-
ward the parent or camera. In this study, symbolic commu-
nication was measured as a percentage of opportunities;
children had a maximum of 13 opportunities within 10- to
25-min book reading sessions. Using a percentage-of-oppor-
tunities, metric may have constrained or underestimated
child communication turns and changes between phases.
A second potential limitation is the eligibility cri-
teria for child participants. As mentioned earlier in the
Discussion section, this study’s inclusion and exclusion
criteria were inconsistent with prior RAAP studies. It is
difficult to determine if some of the outcome inconsis-
tencies were due to differences in child development, lan-
guage, or communication skills, which the interventionist
did not directly observe. Additionally, no criteria took
previous AAC experiences (including AAC systems and
SymbolStix familiarity), which may have affected parent
and child outcomes.
A third potential limitation is the risk of selection
bias. Recruitment occurred primarily through social media
groups; families interested in the study were more likely
those already involved with support and training. The par-
ticipant sample also lacked diversity regarding race, eth-
nicity, language, diagnoses, and rurality. All families were
White, spoke English, lived in urban or semi-urban areas
within Oregon, and had access to high-speed Internet. The
study’s results may not replicate with families with re-
duced access to health and education services, with access
to low-speed broadband Internet, with a variety of ages,
and in rural areas or who speak languages other than
English. All child participants had some knowledge of
AAC systems, although their experience varied. Findings
may be different for families exposed to an AAC system
for the first time as part of a communication partner in-
tervention. In future studies, investigators may explore
family demographic characteristics to recruit a sample rep-
resentative of families with cultural, linguistic, and AAC
experience adaptations to be feasible and acceptable to
families of diverse backgrounds.
A final, minor potential limitation is the number of
baseline sessions. Dyad 1 had three baseline data points
before moving into the intervention phase. Although
therewasastablebaselineandno increasing trend (three
consecutive data points at zero), having less than five base-
line points introduces a potential source of bias, although
relatively low. Dyads 2–5 had five or more baseline data
points.
Future Research
This study highlights the complexity of observation-
ally coding early symbolic communication skills via tele-
practice. Future studies should carefully consider their
measurement and coding systems, making adaptations for
measuring communication behaviors via telepractice. These
adaptations can include exploring multiple camera angles,
creating operational definitions that specify how to code
symbolic communication, placing a secondary coder at the
child’s location, providing coders with copies of all com-
munication systems to improve accuracy, and using AAC
systems with voice output. Alternative measurement sys-
tems, such as frequency count, should be considered in fu-
ture studies to capture the potentially small, but clinically
important, changes in child outcomes.
In addition, future studies should examine the ef-
fects of maintenance skills over time. This study calcu-
lated only one maintenance datum; the long-term sus-
tainability of strategies is unknown. Had parents pro-
vided RAAP strategies for more extended periods, it is
possible that child communication turns may have in-
creased to a greater degree. The interventionist can col-
lect additional maintenance data at 6, 8, and 12 weeks
post-intervention.
The effects of telepractice RAAP interventions are
critical for communication partners who struggle with the
in-person challenges of time, travel, lack of AAC experts,
and health (such as the impacts of COVID-19). For exam-
ple, previous RAAP communication partner instruction
studies have conducted small-scale efficacy trials (under
ideal conditions). Future studies should consider examin-
ing the effects of communication partner instruction in
routine clinical practice (i.e., within a typical school day)
or with larger groups (i.e., all special education staff in a
school). Future studies should explore the minimum
16 Language, Speech, and Hearing Services in Schools •1–19
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training time needed for behavior changes. Studies may
find that less time or a combination of asynchronous (to
be completed at any time) and synchronous RAAP train-
ing and coaching is effective. If true, more communication
partners may be able to participate in RAAP training.
Clinical Applications
This study shows that it is feasible for adult commu-
nication partners to learn RAAP strategies following tele-
practice training and coaching. RAAP strategy use is par-
ticularly relevant for school settings because of its use in
shared reading. Interventionists can train school-based
communication partners (i.e., teachers and support staff)
during teacher preparation time using the study’s detailed
telepractice procedures. This study’s telepractice proce-
dures, including just 1 hr of training, may be valuable for
large or remote districts, where in-person training may be
difficult to schedule due to travel, access to experts, or
limited consultation time.
Conclusions
The results of this study provide preliminary evi-
dence that communication partners can learn research-
based communication partner strategies (i.e., RAAP) with
a telepractice service delivery model. Following a 1-hr
training, all parent communication partners increased and
maintained RAAP strategies. The intervention effect was
replicated 5 times. One child demonstrated an immediate
intervention effect, and two children showed latent in-
creases. This study includes step-by-step procedures for im-
mediate clinical use. Future research should explore alter-
nate observation and data collection and additional ways
to limit barriers to communication partner instruction.
Author Contributions
Cheri Dodge-Chin: Conceptualization (Lead), Data
curation (Lead), Formal analysis (Lead), Investigation
(Lead), Writing –original draft (Lead). Sandra Shigetomi-
Toyama: Conceptualization (Supporting), Investigation
(Supporting). Emily D. Quinn: Writing –review & editing
(Supporting).
Acknowledgments
The materials for this research were funded through a
graduate student research support grant from Rocky
Mountain University of Health Professions. The authors
would like to thank Sandi Stewart for her contribution as
a research assistant in this study. They would also like to
thank the children and their families who participated in
the research.
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