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RESEARCH ARTICLE
Building Evidence-based Practice in AAC Display Design for Young
Children: Current Practices and Future Directions
JENNIFER J. THISTLE & KRISTA M. WILKINSON
Department of Communication Sciences and Disorders, The Pennsylvania State University, University Park, PA, USA
Abstract
Each time a practitioner creates or modi es an augmentative and alternative communication (AAC) display for a client, that prac-
titioner must make a series of decisions about which vocabulary concepts to include, as well as physical and organizational features
of the display. Yet, little is known about what factors in uence the actual decisions and their outcomes. This research examined
the design factors identi ed as priorities by speech-language pathologists (SLPs) when creating AAC displays for young children
(age 10 years and under), and their rationale for the selection of these priorities. An online survey gathered ratings and comments
from 112 SLPs with experience in AAC concerning the importance of a variety of factors related to designing an aided AAC
display. Results indicated that some decisions were supported by existing research evidence, such as choosing vocabulary, collabo-
rating with key stakeholders, and supporting partner modeling. Other decisions highlight areas for future research, including use
of visual scene display layouts, symbol background color, and supports for motor planning.
Keywords: Clinical practices; Display design; Survey; Augmentative and alternative communication
Introduction
Individuals with complex communication needs often
rely on augmentative and alternative communication
(AAC) to participate in communication interactions.
An AAC system encompasses a variety of methods to
support communication, such as gestures, sign language,
communication boards, and speech generating devices
(Beukelman & Mirenda, 2013). Techniques that utilize
tools outside of the body, such as a communication
board with graphic symbols or a computer programmed
with voice output, are called aided AAC. Substantial
evidence suggests the use of AAC interventions increases
language development with individuals with a variety of
communication disabilities (e.g., Binger & Light, 2007;
Drager et al., 2006; Romski & Sevcik, 1996).
Once a system is selected, AAC intervention requires
more than taking the device out of the box and hand-
ing it over to the individual. One of the challenges fac-
ing practitioners such as speech-language pathologists
(SLPs), special education teachers, and occupational
therapists is creating an aided AAC system that main-
tains an appropriate balance between the bene ts of the
communication afforded by the system, and the costs
of learning how to use it (Beukelman, 1991). Achieving
this balance requires determining the needs and abilities
of an individual, and using these characteristics of the
individual to drive the selection and design of the system
(Light & McNaughton, 2013a). For example, depend-
ing on the individual ’ s visual or motor access abilities,
the size of the symbols may or may not be an important
feature to manipulate (Kovach & Kenyon, 2003).
A 2006 survey examined SLPs ’ perceptions on
what contributes to success and abandonment of AAC
technology (Johnson, Inglebret, Jones, & Ray, 2006).
SLPs reported that an appropriate match between the
individual and the system is one factor that promotes
greater success with the device. Intrinsic abilities such
as motor, cognitive/linguistic, literacy skills, and sensory
perceptual skills must be assessed and compared to exter-
nal features of systems to determine the best match.
With the great variety of aided AAC technologies
available, matching external features to intrinsic abili-
ties is no small task. Ideally, practitioners are combining
their practical knowledge and experiences with avail-
able evidence to inform a trial-based, feature-matching
approach. However, such an approach may increase
the time it takes an individual to reach competence
with a system. Rather, if there are design decisions that
follow speci c patterns, these could potentially reduce
the number of trials needed to identify the best t for
Augmentative and Alternative Communication, 2015; 31(2): 124–136
© 2015 International Society for Augmentative and Alternative Communication
ISSN 0743-4618 print/ISSN 1477-3848 online
DOI: 10.3109/07434618.2015.1035798
Correspondence: Jennifer Thistle, Department of Communication Sciences and Disorders, HSS 112, University of Wisconsin-Eau Claire, Eau Claire,
WI 54702, USA. Tel: ⫹ 1 715 836 6015. E-mail: thistljj@uwec.edu
(Received 28 March 2014 ; revised 23 March 2015 ; accepted 24 March 2015 )
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AAC Display Design Decisions 125
© 2015 International Society for Augmentative and Alternative Communication
the individual. The rst step in identifying decision
processes that are more likely to result in positive
outcomes is to better understand the factors considered
by practitioners in designing AAC displays.
There has been limited research speci cally exploring
the kinds of decisions SLPs and other practitioners
make related to display design. One of the only studies
to date that examined this topic was a preliminary and
qualitative study using a hypothetical case study format.
Speci cally, McFadd and Wilkinson (2010) provided
six clinicians who specialize in the eld of AAC with a
partial list of vocabulary to include on an aided AAC
display. Clinicians selected additional vocabulary and
created a low-tech communication board for a hypo-
thetical student to use during snack time. Clinicians
were asked to narrate their thought processes while mak-
ing decisions regarding the selection and arrangement
of vocabulary on the display.
The clinicians in McFadd and Wilkinson (2010)
applied research-based recommendations by incor-
porating vocabulary that supported a variety of com-
municative functions (Adamson, Romski, Deffebach,
& Sevcik, 1992; Light & Drager, 2005). For example,
ve of the clinicians included verbs and social terms
to support a variety of interactions. Another clinician
only included object labels, but described her rationale
that those labels would support social communica-
tion by allowing the child and peers to talk about the
foods they were eating. Five of the six clinicians used
Boardmaker Picture Communication Symbols (PCS;
Mayer-Johnson, 1992) to represent the content, based
on the instruction from the researchers; the sixth pulled
similar types of images from the Internet because her
school did not have access to the Boardmaker program.
Choices related to arrangement of the symbols were
less consistent across clinicians. All clinicians organized
the vocabulary in some fashion, and those that included
different types of words (e.g., object, verbs, social-
regulatory) created subsets based on those types. How-
ever, the placement of the subsets varied. For instance,
some clinicians placed social-regulatory symbols along
the top row while others placed the same symbols along
the left-hand column. Still another clinician used spac-
ing within the page to separate types of words. Finally,
some clinicians used background color to distinguish
different symbol word classes while another placed the
symbols on a colored page to support navigation across
multiple pages.
One challenge when examining clinical practices lies
in the heterogeneity of individuals who can bene t from
AAC systems. Children with developmental disorders,
for example, may have very different needs and abilities
compared to adults with acquired disorders. The cur-
rent study focused on practitioners, speci cally SLPs,
working with young children (aged 10 years and under)
in an attempt to constrain some of the variability seen
in AAC decision-making. Even when limited to elemen-
tary school children, however, the caseloads of SLPs will
in uence the experiences upon which they draw when
designing AAC displays. In the 2014 American Speech-
Language-Hearing Association (ASHA) Schools Survey
(ASHA, 2014), the 55% of SLPs who regularly provided
AAC-related services reported serving an average of ve
students. This represents 10% of an elementary school
SLPs ’ average monthly caseload, and 20% of a resi-
dential/special day school SLPs ’ average monthly case-
load (ASHA, 2014). Furthermore SLPs who work in
residential/special day schools reported that 71% of their
caseloads consisted of students with severe communica-
tion impairments. It is likely, then, that SLPs will have
had different experiences designing AAC displays.
Professional preparation in AAC also may in u-
ence SLPs ’ comfort level with providing AAC ser-
vices, thereby affecting the decisions they make when
designing AAC displays. In a survey of 71 SLPs, 72%
rated their competence in providing AAC services as
fair to poor (Marvin, Montano, Fusco, & Gould, 2003).
Similar results emerged in surveys conducted in Egypt
(Wormnaes & Abdel Malek, 2004) and New Zealand
(Sutherland, Gillon, & Yoder, 2005). Such low levels of
competence may be precipitated by education and train-
ing provided by SLP programs. In a survey of SLP train-
ing programs, 33% of respondents felt that the majority
of their students were prepared to work with indivi-
duals who use AAC (Ratcliff, Koul, & Lloyd, 2008).
Just under half (47%) of the respondents reported that
only up to one quarter of their students receive clini-
cal practice in AAC. In a review of research conducted
from 1985 – 2009, Costigan and Light (2010) examined
surveys of pre-service AAC training programs in the
US, and reported that the majority of SLPs received
minimal to no pre-service training in AAC.
Thus, it is possible that the variability noted between
SLPs in McFadd and Wilkinson ’ s (2010) study re ected
the SLPs ’ educational background and experiences
with individualizing displays for the wide variety of
children who use AAC. If there are some practices that
professionals have found to be more successful than
other practices, it is important to identify the successful
approaches in order to reduce the number of trials of
different features that an individual who uses AAC must
go through.
Research Questions
This research addressed the following question: What
design factors do SLPs identify as priorities when
they create aided AAC displays for young school-aged
children, and what are their rationales for the selec-
tion of these factors as priorities? Through an online
survey, participants answered questions related to the
decisions they make regarding vocabulary selection,
symbol types and arrangement, and manipulation of a
variety of visual features (e.g., size, color, etc.) of aided
AAC displays. The responses were analyzed not only to
gain a broad view of the general clinical practices but
also to understand the factors that might in uence the
decision-making process.
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126 J. J. Thistle & K. M. Wilkinson
Augmentative and Alternative Communication
Method
Survey Development
Survey questions were developed and re ned through
initial pilot testing and reviews by experts in sur-
vey design. Initial questions were developed to target
decisions related to vocabulary selection, symbol types
and arrangement, and manipulation of a variety of
visual features of aided AAC displays. The initial pilot
survey from which the nal version was developed was
completed by three SLPs, with an average of 8 years
(range: 7 – 10 years) experience providing AAC services
to children. Feedback from the pilot participants ensured
that the focus of the questions centered on the goals
of the study. The university ’ s Survey Research Center
then reviewed the survey for structure and adherence
to survey design principles. As a result, demographic
questions were moved from the beginning to the end
of the survey, based on the rationale that it may be per-
ceived as less intrusive to answer personal demographic
questions at the end of the survey (Groves et al., 2009).
The nal version of the survey consisted of 42 ques-
tions intended to solicit information about two aspects
of display design: the principles guiding aided AAC
display design in general, and child-speci c decisions
driven by a given case study. Participants advanced
through the survey sequentially (answering the general
questions rst, then the child-speci c questions) and
received an error message if they attempted to advance
without completing a question. Therefore, as the survey
progressed, no questions could be skipped. Because
the survey could be abandoned prior to completion, a
greater number of responses were provided to questions
asked earlier in the survey than those that were asked
later.
The current study reports on responses related to
the rst section because the goal was to outline general
principles guiding aided AAC display design decisions.
Appendix A (to be found online at http://informahealth-
care.com/doi/abs/10.3109/07434618.2015.1035798)
presents these survey questions. The results of the
answers related to the speci c case will be reported in a
separate study.
Participants
Target participants were practicing SLPs who (a) main-
tained a current certi cate of clinical competence from
ASHA, (b) had at least 1 year of experience support-
ing individuals who use AAC, and (c) provided AAC
services to school-age children aged 10 and under. The
online survey was available for 12 weeks and partici-
pants were recruited through multiple contact points to
allow for adequate opportunity for responding and to
increase sample size (Dillman, Smyth, & Christian,
2009). Qualtrics
1 online survey software hosted the
web-based survey. Participants completed the survey at
a computer of their choosing and were able to take the
survey over multiple sessions if they chose to do so.
The University ’ s Of ce for Research Protections
provided human subjects approval for this research
project. An implied consent form was embedded as the
rst page of the online survey and participants were
advised that continuing the survey indicated consent.
Participants had the option of downloading the implied
consent form if desired.
Survey Distribution
Members of two list serves were contacted at three time
points. The list serves were the ASHA Special Interest
Group 12-Augmentative and Alternative Communication
(SIG-12) and Quality Indicators for Assistive Technol-
ogy (QIAT). A general recruitment notice describing the
study and soliciting participation was posted to each list
serve at the initial time point, 3 weeks later, and again
7 weeks from the initial posting. Throughout this data
collection period, in-person recruitment also occurred
during the ISAAC biennial convention. Finally, appeals
to personal contacts and postings on social media
websites provided additional advertising regarding
availability of the survey.
Data Analysis
The survey consisted of a mix of open-ended and
closed-ended questions. Descriptive methods of data
analysis were utilized due to the exploratory nature of the
questions and the goal of the survey to identify trends
to inform future research directions. Descriptive data in
the form of frequency tables were used to examine the
closed-ended questions.
The open-ended questions were coded for common
themes using scrutiny techniques (Ryan & Bernard,
2003). Like Ryan and Bernard, three research assis-
tants and the rst author initially identi ed themes
and subthemes by reading each response and listing
commonly repeated terms and identifying similarities
and differences in responses. Re nement of the themes
and subthemes occurred during a cycle of consensus
coding. The research team formally de ned the codes
in a codebook that contained the de nition as well
as examples and non-examples. A summary page
of the codes is presented in Appendix B (to be found
online at http://informahealthcare.com/doi/abs/10.3109/
07434618.2015.1035798). Two of the primary codes
were each further re ned into ve secondary codes, result-
ing in 16 possible codes. The primary codes were used
to identify responses that (a) were unclear to the coder,
(b) noted features the participant did not think were
important, (c) related to the child ’ s skills and abilities,
(d) related to the communication demands, (e) related
to the AAC device, and (f) related to key stakeholders
(e.g., clinicians, teachers, communication partners). The
secondary codes provided detail related to the child ’ s
abilities (e.g., vision abilities) and the communication
demands (e.g., functional vocabulary for the setting).
The rst author divided the responses into individual
thought units consisting of the smallest meaningful piece
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AAC Display Design Decisions 127
© 2015 International Society for Augmentative and Alternative Communication
of information contained in the response (Fraenkel,
2006). Typically, the thought units corresponded with
a participant ’ s sentence. However, when the participant
included a variety of ideas in one sentence, the result-
ing thought units were individual words or phrases.
Research assistants then assigned one code per thought
unit. Inter-observer agreement was assessed on the nal
coding of the thought units. Two research assistants
each independently coded thought units. After a period
of training, the coders reached a minimum Kappa
coef cient of .7 (Fleiss, Levin, & Paik, 2003). Coders
then individually coded all questions and subsequent
reliability was recalculated on 25% of the responses.
Agreement on each question was on average .76
(range .71 – .78). Kappa values of .4 – .75 are considered
good and values of .75 or greater signify excellent agree-
ment (Fleiss et al., 2003).
Results
Responses
In total, 192 individuals accessed the survey. Of those,
24 dropped out during the initial screening section,
17 were excluded because they did not meet the selec-
tion criteria, and two reported living outside the United
States, in Canada and South Africa. Due to the small
number of international participants, these responses
were excluded from the nal analysis.
Of the 149 eligible participants, 112 completed the
broad design questions
2 but provided only some demo-
graphic data, 77 completed the entire survey (including
all demographic data), and 37 did not complete the
primary questions. The presentation of the results fol-
lows the sequence of the survey, although demographics
and initial design decisions for the 77 participants who
provided that information will be described rst. A dis-
cussion of the clinical implications and future directions
follow the survey results.
Demographics
Of the 77 participants who provided complete demo-
graphic data, 60 (78%) were members of ASHA
SIG-12, and nearly half (48%) reported living in the
Northeast. Table I presents a summary of the demo-
graphic information, including distribution by geo-
graphical region, participant gender, and race/ethnicity.
One of the screening questions asked participants ’
years of experience supporting children who use AAC.
Thus, although only 77 participants completed the
demographics section of the survey, all 112 participants
provided years of experience. Table II presents the
proportion of participants who completed the broad
design questions but did not complete the demographic
questions and those who completed both sections by
their level of experience. The following results address
similarities and differences observed in responses across
the different levels of experience.
Initial Design Decisions
One of the rst decisions a clinician must make when
creating a new display for young children is whether to
modify the page set provided by the manufacturer. Of
the 77 participants answering this question, 60 (78%)
reported often or always making changes to the page
set provided by the AAC manufacturer, and 8 (10%)
reported rarely or never making changes to the page
set provided by the manufacturer. An examination of
the responses by level of experience did not reveal a
distinctive pattern related to experience level. Across
most experience levels, only 9% (5 out of 53) of the
participants reported rarely or never making changes.
However, 21% (3 out of 14) of the participants with
13 – 20 years of experience reported rarely or never
making changes. This difference in responding by partic-
ipants with this level of experience recurs throughout the
survey and will be explored in the Discussion section.
Decisions Related to Vocabulary Selection
SLPs often play a key role in choosing the display
content, including what concepts and communication
functions the content supports. Several themes emerged
in terms of decisions made by SLPs with regard to the
importance of child preferences, other stakeholders, the
role of core vocabulary, and the range of word classes
to include.
Table I. Percentage of Participants by Geographical Region, Gender,
and Race/Ethnicity.
Characteristic Participants (%)
n %
Geographic region
Northeast 37 48.0
Southeast 12 7.8
North Central 7 15.6
South Central 6 9.1
West/Mountain 15 19.5
Gender
Female 75 97.4
Male 2 2.6
Race/ethnicity
White/Caucasian 72 93.5
African American 1 1.3
Hispanic 3 3.9
Asian 1 1.3
Table II. Number and Percentage of Participants Completing the
Broad Design and the Demographic Questions Sections.
Years of
experience
Completed
demographic
questions ( n ⫽ 77)
Completed only broad
design questions
( n ⫽ 35)
n% n %
1 – 3 8 10.4 3 8.6
4 – 7 23 29.9 7 20.0
8 – 12 13 16.9 5 14.3
13 – 20 14 18.2 11 31.4
21 or more 19 24.6 9 25.7
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128 J. J. Thistle & K. M. Wilkinson
Augmentative and Alternative Communication
Child Preferences. The child ’ s preferences were noted to
be extremely or fairly important in vocabulary selec-
tion by 87% (97 out of 112) of respondents. Figure 1
illustrates the level of importance participants placed
upon the child ’ s preferences in their vocabulary selec-
tion process, for each level of clinician experience. All
of the participants with 1 – 3 years of experience felt the
child ’ s preferences were extremely or fairly important.
On the other hand, 28% (7 of 25) of respondents with
13 – 20 years of experience indicated that the child ’ s
preferences were only somewhat or not very important.
This accounted for half of the 13% (15 out of 112) of
all participants who felt that child ’ s preferences were
somewhat or not very important.
Additional Priorities. An open-ended question provided
some insight into what additional priorities respondents
felt were important when choosing vocabulary. Figure 2
illustrates the main categories of priorities identi ed by
participants by years of experience.
Key Stakeholders. As a whole, 46 of 112 (41%) partici-
pants mentioned collaborating with key stakeholders.
Once again, however, there was a somewhat unusual
pattern in the group with 13 – 20 years ’ experience, as
only 20% (5 out of 25) mentioned key stakeholders
compared to 41% (41) of the remaining 87 partici-
pants. Some participants mentioned speci c instances
that would in uence vocabulary selection. One wrote,
“ I add vocabulary based on family preferences too –
parents often like some of the politeness terms, for
instance. ” Other participants were more general in their
description and rationale of including key stakeholders:
“ I take into account what the family and classroom nd
important. ”
Role of Core Vocabulary. Clinicians with more than 13
years of experience reported choosing core vocabulary
based on frequency of words more often (15%, 8 out
of 53) than those with less than 13 years of experience
(8%, 5 out of 59). Some respondents prioritized core
vocabulary above the child ’ s or key stakeholders ’ pref-
erences. For instance, one participant stated, “ I would
ONLY consider the child ’ s vocabulary preferences
when I am including personal words that are part of
the child ’ s extended vocabulary set. These personal
extended vocabulary words are second on my list after
CORE vocabulary ” (emphasis provided by participant).
This quote also illustrates the challenge inherent in
design decision – many decisions in uence other deci-
sions, and trade-offs must be made. In this case, it seems
the participant was making a choice between providing
core vocabulary or personalized vocabulary.
Range of Word Classes. Most participants indicated that
they frequently used a variety of word forms in support
of language acquisition and use. Speci cally, partici-
pants incorporated subjects (82%, 92 of 112), actions
(97%, 109 of 112), objects (83%, 93 of 112), and emo-
tion words (84%, 94 of 112) most or all of the time.
Figure 3 shows the frequency with which participants
incorporate each of these types of words by their level
of experience. In all, 93% (26 out of 28) of participants
with the most experience reported incorporating emo-
tion words most or all of the time, whereas on average
81% (68 out of 84) of the clinicians with other levels of
experience incorporated emotion words most or all of
the time.
Decisions Related to Symbol Type
Following identi cation of appropriate content, SLPs
consider options regarding how best to represent that
content. The type of symbol representation was rated as
fairly or extremely important by 100% of participants
with 1 – 3 years ’
experience ( n ⫽ 11), but only 76% (77
out of 101) of all other participants. When asked what
factors in uence their choice of symbol type, 90% (10
out of 11) of the participants with 1 – 3 years of experi-
ences cited the child ’ s cognitive abilities as an impor-
tant consideration. Across all other experience levels,
just under half (45%, 45 out of 101) reported that the
child ’ s cognitive level should be considered.
Decisions Related to Visual Features of the Display
The visual nature of an aided AAC display allows for
manipulation of such features as symbol arrangement
Figure 2. Percentage of participants mentioning additional vocabulary
selection considerations beyond a child ’ s preferences, by years of
experience.
Figure 1. Percentage of participants who rated child ’ s preference in
vocabulary selection as either fairly/extremely important or not very/
somewhat important, by years of experience.
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AAC Display Design Decisions 129
© 2015 International Society for Augmentative and Alternative Communication
and display layout, symbol size, and use of color.
Three themes that emerged from this survey concerned
choices related to (a) the type of display layout, (b) the
use of black and white versus colored symbols, and
(c) the use of background color cuing.
Type of Display Layout. When asked to estimate the
percentage of hybrid or visual scene displays (VSDs)
participants design, 83% (64 out of 77) reported using
these displays less than 25% of the time, suggest-
ing grid-based displays were used most of the time.
Only 3% (2 out of 77) of participants reported using
VSD/hybrid displays more than 50% of the time.
Use of Symbol Internal Color. Of the 112 participants,
94 (84%) reported utilizing symbols that have inter-
nal color most or all of the time; only one participant
indicated very rarely using color symbols, but did not
provide a reason in the following open-ended question.
Despite the widespread use of symbol color, 78 (69%)
reported using black and white symbols some of the
time. Participants reported that black and white sym-
bols were used to highlight new symbols, when color
would not contribute to the meaning (e.g., prepositional
words), or when team members did not have access to
color printers.
Use of Background Color. Color can also be featured in
the background of symbols. All participants reported
using symbol background color at least sometimes, and
49 (43%) reported that they used it most of the time,
a trend that was consistent across all experience levels.
The top two reasons provided regarding use of back-
ground color were (a) to support development of gram-
matical skills through color coding parts of speech, and
(b) to draw attention to speci c symbols. Using back-
ground color as a cue to word class category re ects a
common clinical recommendation (Goossens ’ , Crain, &
Elder, 1999; Kent-Walsh & Binger, 2009); however, to
date there has been no research that speci cally exam-
ines if the dimension of color aids in learning appropri-
ate sentence structure.
Additional Decisions
When given the opportunity to discuss any additional
general factors not previously mentioned, 32% (36 out
of 112) of participants supported the use of consistency
in display design to support motor planning and auto-
maticity. In this approach, the location of previously
learned symbols on the display does not change as new
symbols are added to the display. Finally, an additional
feature participants consider was mentioned in response
to several different, unrelated, open-ended questions:
designing the display in a way that supports partner
modeling.
Discussion
The goal of AAC intervention for a child is to provide
support for participation and language development
across all environments, facilitating early communica-
tion (Light & Drager, 2005; Romski & Sevcik, 1996),
advancing linguistic growth and functional commu-
nication (Binger & Light, 2007; Drager et al., 2006;
Johnston, McDonnell, Nelson, & Magnavito, 2003), and
providing early literacy experiences (Koppenhaver &
Erickson, 2003; Light & McNaughton, 2013b). Design-
ing an appropriate AAC display is one part of AAC
intervention that may contribute to this goal. There are
Figure 3. Percent of participants indicating the frequency with which they include subjects, action words, descriptors, and emotion words in
displays, by years of experience.
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130 J. J. Thistle & K. M. Wilkinson
Augmentative and Alternative Communication
many factors to consider when designing an AAC dis-
play, including but not limited to appeal of the display
(Light, Drager, & Nemser, 2004; Light, Page, Curran, &
Pitkin, 2007), ease of use (Drager, Light, Speltz, Fallon
& Jeffries, 2003; Drager et al., 2004; Fallon, Light, &
Achenbach, 2003), and communicative functions sup-
ported by the display (Adamson et al., 1992; Romski &
Sevcik, 1996). Furthermore, these considerations must
be weighed against the needs and abilities of the child
who will be using the display (Light & McNaughton,
2013a). Certainly, as a eld, we are at times successful as
we strive toward this goal; at other times, however, we do
not succeed (Johnson et al., 2006; Snell et al., 2010).
In this study, SLPs reported considering a number of
factors in the development of AAC displays, suggesting
at least some awareness of the need for AAC systems to
be responsive to the needs of the child and team. This is
in line with the multifaceted nature of AAC intervention
that supports long-term success (Johnson et al., 2006).
The reported decisions regarding vocabulary selection
suggest that many clinicians prioritize the child ’ s prefer-
ence while also considering input from others. The Par-
ticipation Model presented by Beukelman and Mirenda
(2013) highlights the importance of considering the
interests and abilities of the child during the assessment
process and subsequent intervention. Along these lines,
in a survey of SLPs ’ perspective of AAC success and
abandonment, two of the top ve factors associated with
long-term success were the degree to which the device
(a) matched the individual ’ s physical capabilities, and
(b) was valued as a means of communication (Johnson
et al., 2006).
Research also illustrates the importance of involv-
ing a range of key stakeholders (e.g., the child, family,
teachers, specialists, etc.) at all stages of intervention
(Beukelman & Mirenda, 2013; Ogletree, 2012). Prac-
ticing a family-centered approach may reduce device
abandonment through the provision of supports that
result in a good t between device and family members
(Angelo, 2000; Jones, Angelo, & Kokoska, 1999). The
collaboration of various stakeholders, including SLPs,
teachers, and paraprofessionals, has been shown to
increase communication initiation and engagement and
decrease classroom assistance needed by students who
use AAC (Hunt, Soto, Maier, M ü ller, & Goetz, 2002).
Decisions regarding vocabulary selection highlighted
the inclusion of core vocabulary. While there is a breadth
of research describing typical vocabulary development
and listing commonly used words by age (Ball, Marvin,
Beukelman, Lasker, & Rupp, 1999; Banajee, Dicarlo, &
Stricklin, 2003; Beukelman, Jones, & Rowan 1989), the
effect of providing core vocabulary on language develop-
ment in children who use AAC has not yet been directly
studied. Furthermore, the provision of core vocabulary
to the exclusion of personalized vocabulary runs coun-
ter to both recommended practices for people who use
AAC (Williams, Krezman, & McNaughton, 2008) and
factors contributing to device success (Johnson et al.,
2006; Murphy, Markova, Collins, & Moodie, 1996).
Evidence suggests that providing children with a range
of vocabulary increases the frequency of using AAC
(Beukelman, McGinnis, & Morrow, 1991; Yorkston,
Honsinger, Dowden, & Marriner, 1989). Addition-
ally, research has illustrated that when provided with a
range of symbols across word classes, children who use
AAC learn and use those symbols for more complex
and varied communicative functions beyond request-
ing (Adamson et al., 1992; Light & Drager, 2005).
Thus, although the decision process for the provision
of vocabulary relies heavily on clinical experience and
stakeholder input, available evidence suggests that it is
critical to include a variety of word classes and vocabu-
lary speci c to the child.
When making decisions about the type of symbol to
use, nearly half (49%) of the clinicians said they con-
sider the child ’ s cognitive abilities. They may have been
relying in part on the literature base regarding iconicity
to inform their decisions (e.g., Fuller & Lloyd, 1991;
Mizuko & Reichle, 1989). Within this literature there
is strong evidence supporting the hypothesis that more
iconic symbols (i.e., symbols that have a high degree
of resemblance to the referent) are more easily learned
than those that are less iconic (for a complete review, see
Schlosser & Sigafoos, 2002). Clinicians also reported
other considerations (e.g., planning for the future,
device software, symbol availability) when choosing the
symbol type. Such extrinsic issues (e.g., team member
familiarity with speci c symbol sets) are often a consid-
eration when developing an AAC system; however, too
great a focus on designing a display in response to others
runs the risk of neglecting the child ’ s needs and abilities,
which could ultimately undercut the goal of AAC.
Once the vocabulary and type of symbol is chosen,
decisions related to the visual appearance of the display,
such as the layout type, use of color, and number or size
of the symbols, are made. There are numerous factors
to consider, which is likely to result in heterogeneous
decisions. However, the results of the survey highlighted
three factors that illustrate some consistency across
respondents: display layout, internal symbol color, and
background color.
Overall, grid-based designs were reportedly used
more often than VSDs. Historically, the layout of sym-
bols has been in a grid format, with individual con-
cepts represented by isolated symbols arranged in rows
and columns (Zangari, Lloyd, & Vicker, 1994). More
recently, a visual scene display layout, where concepts
are embedded within the context in which they natu-
rally occur, has been proposed (Light & Drager, 2007;
Shane, 2006; Wilkinson & Light, 2011). The research
with young children without disabilities suggests VSDs
may be an appropriate layout for beginning communi-
cators (Drager et al., 2003, 2004; Light & Drager, 2007;
Olin, Reichle, Johnson, & Monn, 2010).
Although the clinicians in the current study worked
with young children, no further caseload information
was collected. It is possible that low VSD usage rates
were a re ection of either caseloads that do not include
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AAC Display Design Decisions 131
© 2015 International Society for Augmentative and Alternative Communication
many beginning communicators or a lack of aware-
ness of VSDs, which were rst introduced in the early
2000s. If the latter is the case, it highlights the need for
pre-service training that is thorough and evidence based,
and for in-service training that provides information on
current research and newly emerging evidence.
A majority (84%) of SLPs reported using symbols with
internal color most of the time, suggesting a consistency
across clinicians with respect to this factor. Research
from the eld of visual cognitive science suggests color
plays a role in a variety of basic perceptual processes,
including drawing attention to objects, distinguishing
between similar objects, and contributing to object rec-
ognition (Gegenfurtner & Rieger, 2000; Wurm, Legge,
Isenberg, & Luebker, 1993; Xu, 2002). More closely
linked to AAC research, Wilkinson and colleagues have
examined the effect of arranging symbols based on their
internal color (Wilkinson, Carlin, & Jagaroo, 2006;
Wilkinson, Carlin, & Thistle, 2008; Wilkinson, O ’ Neill,
& McIlvane, 2014). Children with and without disabili-
ties have consistently demonstrated bene ts of group-
ing like-colored symbols, as measured by faster reaction
times locating a target symbol within an array. However,
in one study with children with autism, identi cation
and generalization for the learning of color symbols was
compared to the learning of grey-scale symbols (Het-
zroni & Ne ’ eman, 2013). In an alternating treatment
design study, all four children successfully learned and
maintained recognition of the new vocabulary, regard-
less of the level of color included in the symbols. Fur-
ther research is necessary, but the results reported by
Hetzroni and Ne ’ eman provide evidence that, although
pervasive and easily incorporated, symbols may not need
to have color to be learned and used.
Another consistent response was in relation to the
use of color in the background of symbols. Although
clinicians reported multiple reasons for using back-
ground color, to date, research related to the use of
background color has been limited to its use as a cue
for organizing vocabulary on the display. Thistle and
Wilkinson (2009) compared the response time of
children with typical development in locating sym-
bols across several conditions, including variations
of background color. The purpose of the background
color was to add a secondary cue that the symbols with
similar background color were within the same group
(e.g., orange background behind green vegetables,
pink background behind yellow fruits and vegetables).
Wilkinson and Snell (2011) used background color
as a cue to the meaning of the symbol by having PCS
emotion symbols of similar category (e.g., happy, sad,
angry) share background color. In both studies, the pres-
ence of background color detracted from performance
of participants under the age of 4 years. One hypothesis
is that the background color attracts too much attention
and distracted participants from the critical information:
the symbol content. These results suggest that caution
is warranted when deciding on the use of background
color for a speci c individual.
One third of the respondents independently men-
tioned consistency as an important principle to follow
when designing a display. Speci cally, they suggested
that organizing the symbols on the display in a consis-
tent manner may support motor planning. The effect of
motor learning can be observed in daily activities such
as typing on a keyboard or playing an instrument. With
practice, the effort involved becomes more automatic.
Motor learning theory posits that practice leads to
changes in motor patterns that in turn result in changes
in the cognitive resources required to complete the
motor movement (Fitts & Posner, 1967; Rosenbaum,
2009). However sound the theory, evidence speci c
within AAC has so far been limited to case studies and
vendor-developed strategies targeted toward individu-
als with autism spectrum disorders (Ca ero & Delsack,
2007; Stuart & Ritthaler, 2008). Suggestions for future
research are offered in an upcoming section.
Finally, although the survey did not speci cally ask
about partner modeling, some participants mentioned
the importance of this technique. Research supports
the use of partner language modeling as a method of
supporting comprehension of input (Ca ero, 2001;
Drager et al., 2006; Goossens ’ et al., 1999; Romski &
Sevcik, 1996). Romski and Sevcik (1996; 2003) also
argued that by providing augmented input, partners not
only provide a visual scaffold for the verbal input but
also demonstrate both how to use the display and the
acceptability of using aided AAC as a mode of commu-
nication. The survey responses suggest that participants
recognize the potential value of partner modeling and
seek to facilitate its practice.
Factors Contributing to Differences in Decision Making
The current survey suggests differences in clinical
decision making that may be a re ection of a variety
of factors, such as years of experience, characteristics
of caseloads, or availability of relevant pre-service and
in-service training. Future research is necessary to
determine if these differences are replicated in future
studies, and if so, what factors may be contributing to
the replication. One possible explanation may be differ-
ences in training experiences. As the eld evolves, so too
does training and education, such that today ’ s students
enrolled in SLP training programs, taught under the
current ASHA scope of practice (ASHA, 2007), may
learn different content than the SLP educated 15 or
20 years ago (Koul & Lloyd, 1994; Ratcliff et al., 2008).
For instance, the results of the current study revealed
that the proportion of SLPs who rated the child ’ s prefer-
ences as highly important was much larger in the group
with 1 – 3 years of experience compared to SLPs with
13 – 20 years of experience. In 2004, the ASHA scope
of practice guidelines underwent a substantial revision
that involved signi cant shifts in emphasis with respect
to family/child-centered practices and the inclusion of
AAC as a service area (ASHA, 2007). In the current
study, if the majority of clinicians with fewer years of
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132 J. J. Thistle & K. M. Wilkinson
Augmentative and Alternative Communication
experience in AAC service provision received their
training after 2004, a shift in pre-professional experi-
ences might be re ected in their decision-making.
Alternatively, regardless of training, differences in
perspectives might emerge depending on number of
years of experience with a variety of children. Consider,
for example, the responses related to the importance
of the type of symbol: Given that the range of avail-
able symbol sets has proliferated over just the last few
years, training may account for the differences between
those clinicians with the greatest and the least number
of years of experience, but only if the less experienced
clinicians were trained in the last few years and only
if their training included an introduction to the range
of technologies/symbols. These clinicians may rate
symbol type as a high priority, based on the knowledge
of a variety of symbol types. A plausible alternative
explanation is that longer experience imbues clinicians
with insights about the additional factors that may also
in uence decisions about symbol type. For instance,
perhaps these clinicians feel that the speci c representa-
tion is less important than other features of the display,
such as the organization or exibility of layouts. Deci-
sions are likely in uenced by the outcomes of previous
experiences, allowing the clinician to weigh factors that
colleagues with less experience may not consider. How-
ever, it is also quite possible that previous experiences
may unduly in uence current decision-making, ulti-
mately undermining the best course for the current case.
Future Research Directions
The results of this study highlight that a great deal
remains unknown about how to support SLPs in con-
tributing to the development of effective AAC displays.
What are best practices? What education, tools, and
training experiences support developing these best
practices? How does experience and caseload in uence
decision-making? The following are suggested areas for
future research that may help to answer these questions.
Identifying Best Practices. This survey sought to deter-
mine current practices, as a rst step toward identifying
display design decisions that were and were not common
across clinicians. Additionally, the decisions were exam-
ined within the context of available evidence. Decisions
regarding the type of layout, use of background color,
and support for the development of motor planning are
three areas in which future research is needed.
Type of Layout. The great majority of the SLPs in
this study reported that they typically make use of a
traditional grid display. Although research with young
children without disabilities suggests VSDs may be
an appropriate layout for beginning communicators
(Drager et al., 2003, 2004; Light & Drager, 2007;
Olin et al., 2010), this type of display was not consid-
ered to be a rst choice by clinicians in this sample.
Grid-based layouts have been available for far longer,
thus a greater research base exists concerning interven-
tions in which these layouts are used. However, the lim-
ited consideration of emerging evidence-based practices
suggests additional research is needed that addresses
both practices and outcomes related to implementing
VSDs. In relation to the practices, one line of research
could identify the pitfalls and challenges that practitio-
ners face when implementing VSDs; another could focus
on determining the ef cacy of this layout for individuals
with various etiologies and communication goals. Such
studies could seek to illustrate individual characteristics
or communication situations that are best served by
each type of display layout.
Use of Background Color. Using background color to sup-
port sentence structure is a common clinical recommen-
dation reported by SLPs, yet this practice has not been
explored in the literature. Future research could ask what
effect background color cues have on the pro ciency of
constructing a grammatical sentence. Using background
color as a cue to word class category requires the child to
understand and apply multiple concepts, that is, he or she
must understand that words belong to different word class
categories and that the color behind the symbol denotes
that category. Research is needed to determine the effect
of background color on the visual processing of the display
and how this may vary given individual characteristics.
Supporting the Development of Motor Planning. Future
research is needed to examine the impact of support-
ing motor planning. The Language Acquisition through
Motor Planning (LAMP; The Center for AAC and
Autism, 2009) intervention combines principles of
neurological and motor learning to teach language.
The motor planning aspect stresses the importance of
maintaining consistent locations of symbols. Rather
than learning the meaning of the symbol representation,
the child learns the locations that result in the desired
communication. For instance, rather than learning the
speci c characteristics of the symbol representing HUG
through repeated practice in visually searching for and
locating the symbol, the child learns the speci c motor
movements required to access that symbol.
One potential challenge of this approach occurs if an
individual is ever required to deconstruct the learned
motor pattern (cf. Light & Lindsay, 1991). Once com-
ponent skills are learned as one motion, it is effortful to
then break the group process back into its component
parts (Fitts & Posner, 1967). Thus, if sentence construc-
tion is based solely on a motor plan, rather than knowl-
edge of language structure, a transition to a new system
would require starting over and learning new patterns.
Empirical research is needed to determine how the act
of learning the motor patterns in uences learning and
using language in the act of communicating. Addition-
ally, the use of LAMP intervention has been focused on
individuals with autism spectrum disorders. Research
should seek to identify the bene ts and challenges of
this intervention across etiologies.
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AAC Display Design Decisions 133
© 2015 International Society for Augmentative and Alternative Communication
Tools to Support Decision-making. Future research that
identi es a comprehensive framework to support clini-
cal decision-making would have clinical utility. Such an
approach has been suggested in relation to complet-
ing an assessment (a) to aid in device selection (Dietz,
Quach, Lund, & McKelvey, 2012), (b) to assess dys-
arthria and the potential for AAC for individuals with
amyotrophic lateral sclerosis (Hanson, Yorkston, &
Britton, 2011), and (c) to determine functional seating
and positioning for children with cerebral palsy (Costigan
& Light, 2011). A checklist or owchart could support
practitioners as they consider various features related to
selection and representation of vocabulary, and arrange-
ment and visual features of associated symbols. This tool
may offer a double-check mechanism for clinicians who
regularly support children who use AAC, perhaps limit-
ing the danger of decision making that over-emphasizes
previous success with another child rather than a clear
focus on the needs of the current child. Additionally,
clinicians who have a more varied caseload and support
only a small number of children who use AAC could
bene t from a checklist guiding them through the com-
ponents associated with designing a display. Through a
comprehensive consideration of the critical features of
a display in relation to the child ’ s needs and abilities,
this tool may help clinicians demonstrate decisions that
balance experience with empirical evidence. Creation of
such a tool requires research that identi es the features
that are important and the factors that may in uence
the relative importance of any one feature.
Education and Experiences of Clinicians. Replication and
expansion of the current survey is needed in order to
fully characterize practices at different levels of experi-
ence and geographic location. A more in-depth explo-
ration of the training and clinical practice across years
of experience may provide insight into factors that
in uence display decisions. With only two individuals
outside of the United States providing responses, it was
not possible to report on international practices. Fur-
ther research is needed to identify practices and chal-
lenges that may differ as a result of geographical factors
(e.g., policies, training, resources). Additionally, future
research should seek to validate that reported practices
are, in actual fact, those that practitioners follow. For
example, a qualitative study using in-depth interviews
that focus on speci c children within a practitioner ’ s
caseload could offer a description of actual display
designs created that includes practitioner rationales,
as well as outcomes related to both the child and the
display designs.
Limitations of the Study
Perhaps the most critical limitation of this study is the
small number of participants who completed the full
survey. A true response rate cannot be calculated due
to the recruitment method of posting the notice on list
serves; it can be reported that 192 individuals initially
accessed the survey. The survey was very detailed, ask-
ing participants to respond to multiple open-ended
questions. This may have contributed to attrition of par-
ticipants, resulting in only 77 who completed the entire
survey. However, analysis showed that the responses of
those who did not complete the full survey were quite
similar to the responses of the 77 who did.
It is possible that those who took the survey are
not representative of all SLPs who work with children
under 10 who use AAC, as they may have had a par-
ticular interest in modi cations that go into designing
AAC displays. For instance, participants were primarily
located through postings to list serves associated with
AAC and other assistive technology. It is possible the
SLPs who were members of those list serves were more
interested in display design, or simply discussing their
practices. Additionally, although the inclusion criteria
required a minimum of 1 year of experience providing
services to children who use AAC, individual experi-
ences could be vastly different. It is possible that one
participant ’ s caseload included only a handful of chil-
dren who use AAC, while another practitioner with the
same years of experience may have worked exclusively
with children who use AAC. Other unknowns include
pre-service education, formal/informal in-service train-
ings, and extent and type of teaming, all of which may
contribute to the ways in which a practitioner designs
an AAC display. On the one hand, such different experi-
ences could contribute to different responses provided
by participants in the current study. On the other hand,
if this was the case, the similarities and differences seen
across these participants particularly illuminates the
challenges of display design. This small sample of par-
ticipants recognized the need to individualize displays,
but demonstrated a variety of approaches and rationales
for the designs they create.
Finally, in the section of the survey described here,
participants were asked to describe their decisions
when designing displays in general. They could have
been thinking of one child or several children as they
completed the survey. Responses may be based on
some memory of related display design issues, but it is
impossible to determine how accurate those memories
were. Furthermore, participants might have felt that
this task was asking them to justify their professional
actions, introducing the possibility of social desirability
bias (Podsakoff, MacKenzie, Lee, & Podsakoff, 2003;
Nederhof, 1985), which occurs when participants
provide responses that re ect their belief in the desir-
ability of a particular response rather than their true
feelings. It is dif cult to know if a response is truly
re ective of what a participant believes is the best
practice. Survey design methods and statistical analy-
ses can be utilized to reduce the in uence of social
desirability bias (Nederhof, 1985; Podsakoff et al.,
2003). Although responses in the current survey
may have re ected a social desirability bias, the self-
administered and anonymous nature of the survey may
have reduced the likelihood of such bias.
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134 J. J. Thistle & K. M. Wilkinson
Augmentative and Alternative Communication
Conclusion
The survey results indicate that the majority of SLPs
are modifying and individualizing aided AAC displays
for children under 10 years of age. Furthermore,
clinical practices related to supporting a range of com-
municative functions, making vocabulary selection
decisions, and collaborating with team members,
including supporting partner modeling, appear to be
practices commonly utilized by clinicians. Many of
these practices have an existing research evidence base.
However, other practices represent areas in which
future research is needed such as creating VSDs, utiliz-
ing symbol background color, and supporting motor
planning. Research examining the effect of such design
decisions may strengthen an evidence-based approach
by adding empirical support to commonly observed
clinical recommendations. Speci cally, research should
answer the question of what advantage the feature in
question offers, and to whom? Addressing this ques-
tion could help identify best practices toward design-
ing AAC displays. Once best practices are identi ed,
a next step may be to determine how best to support
clinicians ’ application of those best practices (e.g., what
training, tools, and supports are needed to increase the
use of desired practices?).
Notes
1. Qualtrics and all other Qualtrics product or service
names are registered trademarks or trademarks of
Qualtrics, Provo, UT, USA. http://www.qualtrics.com
2. The complete survey included ve sections; the
broad design questions were asked within Sections
1 and 2; the demographics questions were asked
within Section 5. The case study speci c questions
asked in Sections 3 and 4 will be reported in another
paper.
Acknowledgements
This research was conducted in partial ful llment of the
rst author ’ s doctoral training.
The authors would like to thank student researchers
Lauren Cherry, Marni Gruber, Samantha McDonald,
and Paige McManus for their assistance on this
project.
Funding
The rst author received funding from the U.S.
Department of Education, doctoral training grant
[#H325D110008].
Declaration of interest: The authors report no con-
icts of interest. The authors alone are responsible for
the content and writing of the paper.
References
Adamson , L. B. , Romski , M. A. , Deffebach , K. , & Sevcik , R. A . (1992) .
Symbol vocabulary and the focus of conversations: Augmenting
language development for youth with mental retardation . Journal
of Speech Hearing Research , 35 , 1333 – 1343 . doi:10.1044/
jshr.3506.1333
American Speech-Language-Hearing Association (2007) . Scope of
practice in speech-language pathology . Retrieved from http://www.
asha.org/policy/SP2007-00283/
American Speech-Language-Hearing Association (2014) . 2014
Schools survey report: SLP caseload characteristics . Retrieved from
www.asha.org/research/memberdata/schoolsurvey/
Angelo , D . (2000) . Impact of augmentative and alternative
communication devices on families . Augmentative and Alternative
Communication , 16 , 37 – 47 . doi:10.1080/07434610012331278894
Ball , L. , Marvin , C. , Beukelman , D. , Lasker , J. ,
& Rupp , D . (1999) .
Generic talk use by preschool children . Augmentative and
Alternative Communication , 15 , 145 – 155 . doi:10.1080/0743461
9912331278685
Banajee , M. , Dicarlo , C. , & Stricklin , S. B . (2003) . Core vocabulary
determination for toddlers . Augmentative and Alternative
Communication , 19 , 67 – 73 . doi:10.1080/0743461031000112034
Beukelman , D . (1991) . Magic and cost of communicative competence .
Augmentative and Alternative Communication , 7 , 2 – 10 . doi:10.1080/
07434619112331275633
Beukelman , D. , & Mirenda , P . (2013) . Augmentative and alternative
communication: Supporting children & adults with complex
communication needs (4th ed.) . Baltimore: Paul H. Brookes
Publishing Co .
Beukelman , D. , Jones , R. , & Rowan , M . (1989) . Frequency of word
usage by nondisabled peers in integrated preschool classrooms .
Augmentative and Alternative Communication , 5 , 243 – 248 . doi:10
.1080/07434618912331275296
Beukelman , D. , McGinnis , J. , & Morrow , D . (1991) . Vocabulary
selection in augmentative and alternative communication .
Augmentative and Alternative Communication , 7 , 171 – 185 . doi:
10.1080/07434619112331275883
Binger , C. , & Light , J . (2007) . The effect of aided AAC modeling
on the expression of multi-symbol messages by preschoolers
who use AAC . Augmentative and Alternative Communication , 23 ,
30 – 43 . doi:10.1080/07434610600807470
Ca ero , J. M . (2001) . The effect of an augmentative communication
intervention on the communication, behavior, and
academic program of an adolescent with autism . Focus on
Autism and Other Developmental Disabilities , 16 , 179 – 189 .
doi:10.1177/108835760101600306
Ca ero , J. M. , & Delsack , B. S . (2007) . AAC and autism: Compelling
issues, promising practices and future directions . Perspectives
on Augmentative and Alternative Communication , 16 , 23 – 26 .
doi:10.1044/aac16.2.23
Costigan , F. A. , & Light , J . (2010) . A review of preservice training
in augmentative and alternative communication for speech-
language pathologists, special education teachers, and
occupational therapists . Assistive Technology , 22 , 200 – 212 .
doi:10.1080/10400435.2010.492774
Costigan , F. A. , & Light , J . (2011) . Functional seating for school-
age children with cerebral palsy: An evidence-based tutorial .
Language, Speech, and Hearing Services in Schools , 42 , 223 – 236 .
doi:10.1044/0161-1461(2010/10-0001)
Dietz , A. , Quach , W. , Lund , S. K. , & McKelvey , M . (2012) . AAC
assessment and clinical-decision making: The impact of
experience . Augmentative and Alternative Communication , 28 ,
148 – 159 . doi:10.3109/07434618.2012.704521
Dillman , D. A. , Smyth , J. D. , & Christian , L. M . (2009) . Internet, mail,
and mixed-mode surveys: The tailored design method . Hoboken, NJ:
John Wiley & Sons .
Drager , K. D. , Light , J. C. , Carlson , R. , D ’ Silva , K. , Larsson , B. ,
Pitkin , L. , & Stopper , G . (2004) . Learning of dynamic display
AAC technologies by typically developing 3-year-olds:
Effect of different layouts and menu approaches . Journal
Augment Altern Commun Downloaded from informahealthcare.com by University of Winsconsin on 06/29/15
For personal use only.
AAC Display Design Decisions 135
© 2015 International Society for Augmentative and Alternative Communication
of Speech, Language, and Hearing Research , 47 , 1133 – 1148 .
doi:10.1044/1092-4388(2004/084)
Drager , K. D. , Light , J. C. , Speltz , J. C. , Fallon , K. A. , & Jeffries , L.
Z . (2003) . The performance of typically developing 2 ½-year-
olds on dynamic display AAC technologies with different
system layouts and language organizations . Journal of Speech,
Language, and Hearing Research , 46 , 298 – 312 . doi:10.1044/1092-
4388(2003/024)
Drager , K. D. , Postal , V. J. , Carrolus , L. , Castellano , M. , Gagliano ,
C. , & Glynn , J . (2006) . The effect of aided language modeling
on symbol comprehension and production in 2 preschoolers
with autism . American Jour nal of Speech-Language Pathology , 15 ,
112 – 125 . doi:10.1044/1058-0360(2006/012)
Fallon , K. A. , Light , J. C. , & Achenbach , A . (2003) . The semantic
organization patterns of young children: Implications for augmentative
and alternative communication . Augmentative and Alternative
Communication , 19 , 74 – 85 . doi:10.1080/0743461031000112061
Fitts , P. M. , & Posner , M. I . (1967) . Human perfor mance . Belmont,
CA: Brooks/Cole Publishing Co.
Fleiss , J. L. , Levin , B. , & Paik , M. C . (2003) . Statistical methods for rates
and proportions . Hoboken, NJ: John Wiley & Sons, Inc .
Fraenkel , P . (2006) . Engaging families as experts: Collaborative family
program development . Family Process , 45 , 237 – 257 . doi:10.1111/
j.1545-5300.2006.00093.x
Fuller , D. & Lloyd , L . (1991) . Toward a common usage of iconicity
terminology . Augmentative and Alternative Communication , 7 ,
215 – 220 . doi:10.1080/07434619112331275913
Gegenfurtner , K. R. , & Rieger , J . (2000) . Sensory and cognitive
contributions of color to the recognition of natural scenes . Current
Biology , 10 , 805 – 808 . doi:10.1016/S0960-9822(00)00563-7
Goossens ’ , C. , Crain , S. S. , & Elder , P. S . (1999) . Engineering the
preschool environment for interactive symbolic communication: 18
months to 5 years developmentally (4th ed.) . Birmingham, AL:
Southeast Augmentative Communication .
Groves , R. M. , Fowler , F. J. , Couper , M. P. , Lepkowski , J. M. , Singer ,
E. , & Tourangeau , R . (2009) . Survey methodology (2nd ed.) .
Hoboken, NJ: John Wiley & Sons .
Hanson , E. , Yorkston , K. M. , & Britton , D . (2011) . Dysarthria in
amyotrophic lateral sclerosis: A systematic review of speech
characteristics, speech treatment and AAC options . Journal of
Medical Speech-Language Pathology , 19 , 12 – 30 .
Hetzroni , O. E. , & Ne ’ eman , A . (2013) . In uence of colour on
acquisition and generalisation of graphic symbols. Journal of
Intellectual Disability Research , 57 , 669 – 680 . doi:10.1111/j.1365-
2788.2012.01584.x
Hunt , P. , Soto , G. , Maier , J. , M ü ller , E. , & Goetz , L . (2002) .
Collaborative teaming to support students with augmentative
and alternative communication needs in general education
classrooms . Augmentative and Alternative Communication , 18 ,
20 – 35 . doi:10.1080/aac.18.1.20.35
Johnson , J. M. , Inglebret , E. , Jones , C. , & Ray , J . (2006) .
Perspectives of speech language pathologists regarding success
versus abandonment of AAC . Augmentative and Alternative
Communication , 22 , 85 – 99 . doi:10.1080/07434610500483588
Johnston , S. S. , McDonnell , A. P. , Nelson , C. , & Magnavito , A . (2003) .
Teaching functional communication skills using augmentative and
alternative communication in inclusive settings . Jour nal of Early
Intervention , 25 , 263 – 280 . doi:10.1177/105381510302500403
Jones , S. D. , Angelo , D. H. , & Kokoska , S. M . (1999) . Stressors and
family supports: Families with children using augmentative &
alternative communication technology . Communication Disorders
Quarterly , 20 , 37 – 44 . doi:10.1177/152574019902000205
Kent-Walsh , J. , & Binger , C . (2009) . Addressing the communication
demands of the classroom for beginning communicators and
early language users . In G. Soto & C. Zangari (Eds.) , Practically
speaking: Language, literacy, and academic development for students
with AAC needs (pp . 143 – 172) . Baltimore, MD: Paul H. Brookes
Publishing Co .
Koppenhaver , D. A. , & Erickson , K. A . (2003) . Natural emergent
literacy supports for preschoolers with autism and severe
communication impairments . Topics in Language Disorders , 23 ,
283 – 292 . doi:10.1097/00011363-200310000-00004
Koul , R. , & Lloyd , L . (1994) . Survey of professional preparation
in augmentative and alternative communication (AAC) in
speech-language pathology and special education programs .
American Jour nal of Speech-Language Pathology , 3 , 13 – 22 . doi:
10.1044/1058-0360.0303.13
Kovach , T. M. , & Kenyon , P. B . (2003) . Visual issues and access to AAC .
In J. Light , D. Beukelman , & J. Reichle (Eds.) , Communicative
competence for individuals who use AAC: From research to effective
practice (pp . 277 – 319) . Baltimore, MD: Brookes Publishing Co .
Light , J. , & Drager , K. (2005, November) . Maximizing language
development with young children who require AAC . Presented at
the American Speech-Language-Hearing Association annual
convention, San Diego, CA.
Light , J. , & Drager , K . (2007) . AAC technologies for young children with
complex communication needs: State of the science and future
research directions . Augmentative and Alternative Communication ,
23 , 204 – 216 . doi:10.1080/07434610701553635
Light , J. , Drager , K. D. , & Nemser , J. G . (2004) . Enhancing the appeal
of AAC technologies for young children: Lessons from the toy
manufacturers . Augmentative and Alternative Communication , 20 ,
137 – 149 . doi:10.1080/07434610410001699735
Light , J. , & Lindsay , P . (1991) . Cognitive science and augmentative
and alternative communication . Augmentative and Alternative
Communication , 7 , 186 – 203 . doi:10.1080/07434619112331275
893
Light , J. , & McNaughton , D . (2013a) . Putting people rst: Re-thinking
the role of technology in augmentative and alternative
communication intervention . Augmentative and Alternative
Communication , 29 , 299 – 309 . doi:10.3109/07434618.2013.
848935
Light , J. , & McNaughton , D . (2013b) . Literacy intervention for
individuals with complex communication needs . In D. Beukelman
& P. Mirenda (Eds.) , Augmentative and alternative communication:
Supporting children and adults with complex communication needs
(4th ed., pp. 309 – 351) . Baltimore, MD: Paul H Brookes Pub
Co .
Light , J. , Page , R. , Curran , J. , & Pitkin , L . (2007) . Children ’ s ideas for
the design of AAC assistive technologies for young children with
complex communication needs . Augmentative and Alternative
Communication , 23 , 274 – 287 . doi:10.1080/07434610701390475
Marvin , L. A. , Montano , J. J. , Fusco , L. M. , & Gould , E. P . (2003) .
Speech-language pathologists ’ perceptions of their training and
experience in using alternative and augmentative communication .
Contemporary Issues in Communication Science and Disorders , 30 ,
76 – 83 .
Mayer-Johnson , R . (1992) . The picture communication symbols . Solana
Beach, CA: Mayer-Johnson .
McFadd , E. , & Wilkinson , K . (2010) . Qualitative analysis of decision
making by speech-language pathologists in the design of aided
visual displays . Augmentative and Alternative Communication , 26 ,
136 – 147 . doi:10.3109/07434618.2010.481089
Mizuko , M. , & Reichle , J . (1989) . Transparency and recall of symbols
among intellectually handicapped adults . Journal of Speech and
Hearing Disorders , 54 , 627 – 633 . doi: 10.1044/jshd.5404.627
Murphy , J. , Markova , I. , Collins , S. , & Moodie , E . (1996) .
AAC systems: Obstacles to effective use . Inter national
Journal of Language & Communication Disorders , 31 , 31 – 44 .
doi:10.3109/13682829609033150
Nederhof , A. J . (1985) . Methods of coping with social desirability
bias: A review . European Journal of Social Psychology , 15 , 263 –
280 . doi:10.1002/ejsp.2420150303
Ogletree , B. T . (2012) . Stakeholders as par tners: Making AAC work
better . Perspectives on Augmentative and Alternative Communication ,
21 , 151 – 158 . doi:10.1044/aac21.4.151
Olin , A. R. , Reichle , J. , Johnson , L. , & Monn , E . (2010) . Examining
dynamic visual scene displays: Implications for arranging and
teaching symbol selection . American Journal of Speech-Language
Pathology , 19 , 284 – 297 . doi:10.1044/1058-0360(2010/09-0001)
Augment Altern Commun Downloaded from informahealthcare.com by University of Winsconsin on 06/29/15
For personal use only.
136 J. J. Thistle & K. M. Wilkinson
Augmentative and Alternative Communication
Podsakoff , P. M. , MacKenzie , S. B. , Lee , J.-Y. , & Podsakoff , N. P .
(2003) . Common method biases in behavioral research: A critical
review of the literature and recommended remedies . Journal of
Applied Psychology , 88 , 879 . doi:10.1037/0021-9010.88.5.879
Ratcliff , A. , Koul , R. , & Lloyd , L. L . (2008) . Preparation in
augmentative and alternative communication: An update
for speech-language pathology training . American Jour nal of
Speech-Language Pathology , 17 , 48 – 59 . doi: 10.1044/1058-
0360(2008/005)
Romski , M. A. , & Sevcik , R. A . (1996) . Breaking the speech barr ier:
Language development through augmented means . Baltimore, MD:
Paul H. Brookes Publishing Co .
Romski , M. A. , & Sevcik ,
R. A . (2003) . Augmented input . In J. C. Light ,
D. R. Beukelman , & J. Reichle (Eds.) , Communicative competence
for individuals who use AAC: From research to effective practice ( pp.
147 – 162) . Baltimore, MD: Paul H. Brookes Publishing Co .
Rosenbaum , D. A . (2009) . Psychological foundations . In D.
Rosenbaum (Ed.) , Human motor control (2nd ed., pp. 93 – 134) .
Amsterdam; Boston, MA: Elsevier Inc .
Ryan , G. W. , & Ber nard , H. R . (2003) . Techniques to identify themes .
Field Methods , 15 , 85 – 109 . doi:10.1177/1525822X02239569
Schlosser , R.W. , & Sigafoos , J . (2002) . Selecting graphic symbols for an
initial request lexicon: Integrative review . Augmentative and Alternative
Communication , 18 , 102 – 123 . doi:10.1080/07434610212331281201
Shane , H. C . (2006) . Using visual scene displays to improve
communication and communication instruction in persons with
autism spectrum disorders . Perspectives on Augmentative and
Alternative Communication , 15 , 8 – 13 . doi:10.1044/aac15.1.8
Snell , M. E. , Brady , N. , McLean , L. , Ogletree , B. T. , Siegel ,
E. , Sylvester , L. , … & Sevcik , R . (2010) . Twenty years of
communication intervention research with individuals who
have severe intellectual and developmental disabilities . American
Journal on Intellectual and Developmental Disabilities , 115 , 364 –
380 . doi:10.1352/1944-7558-115-5.364
Stuart , S. , & Ritthaler , C . (2008) . Case studies of intermediate steps
between AAC evaluations and implementation . Perspectives
on Augmentative and Alternative Communication , 17 , 150 – 155 .
doi:10.1044/aac17.4.150
Sutherland , D. E. , Gillon , G. G. , & Yoder , D. E . (2005) . AAC use
and service provision: A survey of New Zealand speech-language
therapists . Augmentative and Alternative Communication , 21 ,
295 – 307 . doi:10.1080/07434610500103483
The Center for AAC and Autism . (2009) . What is LAMP? Retrieved
from http://www.aacandautism.com/lamp
Thistle , J. J. , & Wilkinson , K . (2009) . The effects of color cues on typically
developing preschoolers ’ speed of locating a target line drawing:
Implications for augmentative and alternative communication
display design . American Journal of Speech-Language Pathology ,
18 , 231 – 240 . doi:10.1044/1058-0360(2009/08-0029)
Wilkinson , K. M , Carlin , M. , & Jagaroo , V . (2006) . Preschoolers ’ speed
of locating a target symbol under different color conditions .
Augmentative and Alternative Communication , 22 , 123 – 133 .
doi:10.1080/07434610500483620
Wilkinson , K. M. , Carlin , M. , & Thistle , J . (2008) . The role of color
cues in facilitating accurate and rapid location of aided symbols
by children with and without Down syndrome . American Jour nal
of Speech-Language Pathology , 17 , 179 – 193 . doi:10.1044/1058-
3060(2008/018)
Wilkinson , K. M. , & Light , J . (2011) . Preliminary investigation of
visual attention to human gures in photographs: Potential
considerations for the design of aided AAC visual scene displays .
Journal of Speech Language Hearing Research , 54 , 1644 – 1657 .
doi:10.1044/1092-4388(2011/10-0098)
Wilkinson , K. M. , & Snell , J . (2011) . Facilitating children ’ s ability
to distinguish symbols for emotions: The effects of background
color cues and spatial arrangement of symbols on accuracy and
speed of search . American Journal of Speech-Language Pathology ,
20 , 288 – 301 . doi:10.1044/1058-0360(2011/10-0065)
Wilkinson , K. M. , O ’ Neill , T. , & McIlvane , W. J . (2013) . Eye-tracking
measures reveal how changes in the design of aided AAC displays
in uence the ef ciency of locating symbols by school-aged children
without disabilities . Journal of Speech, Language, and Hearing
Research , 57 , 455 – 466 . doi:10.1044/2013_JSLHR-L-12-0159
Williams , M. B. , Krezman , C. , & McNaughton , D . (2008) . “ Reach
for the stars ” : Five principles for the next 25 years of AAC .
Augmentative and Alternative Communication , 24 , 194 – 206 .
doi:10.1080/08990220802387851
Wormn æ s , S. , & Abdel Malek , Y . (2004) . Egyptian speech therapists
want more knowledge about augmentative and alternative
communication . Augmentative and Alternative Communication ,
20 , 30 – 41 . doi:10.1080/07434610310001629571
Wu rm , L. H. , Legge , G. E. , Isenberg , L. M. , & Luebker , A .
(1993) . Color improves object recognition in normal
and low vision . Journal of Exper imental Psychology: Human
Perception and Performance , 19 , 899 – 911 . doi:10.1037//0096-
1523.19.4.899
Xu , Y . (2002) . Limitations of object-based feature encoding in visual
short-term memory . Journal of Experimental Psychology: Human
Perception and Performance , 28 , 458 – 468 . doi:http://dx.doi.org.
ezaccess.libraries.psu.edu/10.1037/0096-1523.28.2.458
Yorkston , K. , Honsinger , M. , Dowden , P. , & Marriner , N .
(1989) . Vocabulary selection: A case report . Augmentative and
Alternative Communication , 5 , 101 – 108 . doi:10.1080/07434618
912331275076
Zangari , C. , Lloyd , L. , & Vicker , B . (1994) . Augmentative
and alternative communication: An historic perspective .
Augmentative and Alternative Communication , 10 , 27 – 59 .
doi: 10.1080/07434619412331276740
Supplementary material available online
Supplementary Appendix A and B to be found online at
http://informahealthcare.com/doi/abs/10.3109/07434618.
2015.1035798
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