Augmentative and alternative communication (AAC) is communication for those with

impairments or restrictions on the production or comprehension of spoken or written language.[1]

Augmentative and alternative communication is any method that supplements or replaces speech
and writing when these are temporarily or permanently impaired and inadequate to meet all or
some of a person's communication needs.[1] Use of AAC involves selecting messages or codes
from a set of possibilities. The user can use these elements alone or in combination in order to
communicate a variety of messages.[2] AAC may be unaided, or aided, involving high and low
technology.

Contents
[hide]

 1 Unaided AAC
 2 Aided AAC
o 2.1 Low-tech
o 2.2 High-tech
 3 Symbols
 4 Organization of symbols
 5 Access
 6 Rate enhancement strategies
 7 Team
 8 Specific groups of AAC users
o 8.1 Cerebral palsy
o 8.2 Intellectual impairment
o 8.3 Autism
o 8.4 Developmental dyspraxia
o 8.5 Visual impairment
o 8.6 Aphasia
o 8.7 Brainstem stroke
o 8.8 Amyotrophic lateral sclerosis
o 8.9 Parkinson's disease
o 8.10 Multiple sclerosis
o 8.11 Dementia
o 8.12 Traumatic brain injury
 9 Effect on speech
 10 Multicultural aspects
 11 Language and Literacy
 12 History of AAC
 13 Outcomes
o 13.1 Employment
o 13.2 Quality of life
 14 See also
 15 References
  16 External links

[edit] Unaided AAC

Unaided AAC systems are those that do not require any external device for their use, and include
facial expression, vocalizations, gestures, and signed languages and systems.[3][4] Informal
vocalizations and gestures such as body movements, facial expressions, and body postures are
part of natural communication, and such signals may be used by those to profound disabilities.[5]
More formalized gestural codes exist that lack a base in a naturally occurring language; an
example is the Amer-Ind code based on American Indian Hand Talk, and has been used with
children with severe-profound disabilities, and adults with a variety of diagnoses including
dementia, aphasia and dysarthria.[6] The benefits of such gestures and pantomime are that they
are always available to the user, usually understood by the listener, and are efficient means of
communicating.[7]

As forms of AAC, manual signs, such as manually coded language (such as Signing Exact
English) and signed languages (such as American Sign Language and British Sign Language)
have been used alone or in conjunction with speech.[8] Formal gesture and sign systems require
adequate memory and fine-motor skills to be able to remember and physically make the signs
and gestures, as well as for communication partners to understand the symbols made.[9][10]
Manual signs in particular are less transparent in meaning than gestural codes and require more
fine-motor coordination to execute.[11] In sign systems, the symbols are hand signals which can
be iconic (they resemble the word they represent) or more abstract.[7] With signs, the
communication partners need to understand the signs for successful communication. As well, the
user's ability to control gross and fine motor movements needs to be considered with these
approaches.[7]

[edit] Aided AAC

An AAC aid is any "device, either electronic or non-electronic, that is used to transmit or receive
messages",[12] such as communication books or voice output devices using symbols such as
photographs, line drawings, words or letters.[4] Since the skills, areas of difficulty and
communication requirements of AAC users vary greatly, and so an equally diverse range of
communication aids and devices exists to meet these demands.

[edit] Low-tech
An AAC user uses number coding on an eye gaze communication board

Low-tech communication aids are defined as those that do not need batteries, electricity or
electronics to meet the user's communication needs. These are often very simple aids created by
placing letters, words, phrases, pictures and/or symbols on a board or in a book, which may be
accessed[13] Depending on physical abilities and limitations, users might indicate the appropriate
message with a body part, a head or mouth stick or light pointer. Alternatively, they might
indicate yes or no as a listener scans through the possible options.[14]

[edit] High-tech

High-tech AAC aids are electronic devices that permit the storage and retrieval of messages,
with most allowing the user to communicate with others using speech output.[15] Such devices
can also be referred to as Speech Generating Devices (SGDs) or Voice Output Communication
Aids (VOCAs).[16] High-tech systems can be divided into dedicated devices developed solely for
the purpose of communication and AAC, and non-dedicated devices, such as computers, which
have been adapted for use as communication tool, but which can also be used for other functions.
[15][17]
On static display devices, all the symbols are constantly displayed on the device. On
dynamic AAC devices, multiple pages of symbols are possible, and thus only a portion of the
symbols available are visible at any one time, with the communicator navigating the various
pages.[18]

High-tech devices vary in size and weight, as well as the amount of information they can store
and the way it is stored.[15] They vary in the user can access their messages, including the use of
direct selection of a screen or keyboard with a body part or pointer, adapted mice or joysticks, or
indirect selection using switches and scanning. The specific access method will depend on the
skills and abilities of the communicator.[15][17] Since electronic devices operate on batteries that
need to be frequently changed or charged, and may breakdown, users usually also require access
to a low-tech communication system.[13][17]

[edit] Symbols
The representation system or symbols used in AAC include gestures, hand signal, photographs,
pictures, line drawings, words and letters.[4] The choice of symbol system will depend on the
AAC user's abilities; many will use different symbol systems at different times.[citation needed] It is
important to consider the individual user's preference, visual acuity, and visual processing of
information when establishing which type of pictures are appropriate for their communication
system.[7]

Picture symbols are used with those who cannot read or write. Some picture systems, such as
Blissymbols have linguistic characteristics, while others such as the Picture Communication
System (PCS) do not.[19] Symbols can be realistic pictures in color or in black and white, or
simple line drawings. Some users understand the line drawings better than detailed colorful
pictures or vice versa.[7] Symbols can be strictly visual when located on boards or screen displays
or they can be tactile such as with the Picture Exchange Communication System (PECS).[7] With
this system, the pictures are on cards for the user to move around to form a message. Tangible
items can also be part of symbol systems, such as miniature objects representing their real
counterpart, or small items as abstract representations.[20]

The user's visual acuity and visual-perceptual discrimination skills will affect the presentation of
the symbol system on the AAC device (e.g. determining the size of the graphic symbols or the
background-figure contrast).[21]

Both low and high tech devices may use alphabet-based symbols including individual letters,
whole words, or parts thereof.[20] Literacy is required for these symbols. In low-tech devices, the
communication partner may see the symbols, such as with an alphabet board. In high tech
devices such as Voice Output Communication Aids (VOCAs), the device will read the message
put together with symbols out loud.[20]

[edit] Organization of symbols

Vocabulary organization refers to the way pictures, words, phrases, and sentences are displayed.
[22]
In an AAC system, symbols must be organized to facilitate efficient and effective
communication. This is especially important when the individual has a large number of symbols
in an AAC system.[23]

On static systems, symbols are placed in certain fixed positions; the number of symbols that can
be included in a fixed display is limited and in order to compensate the device may be set up on
multiple levels, or an encoding strategy used, in which a person can express multiple messages
by combining one to three (or more) symbols on a fixed display.[23] On a "dynamic display", a
computer screen can display linking symbols that, when activated, automatically change the
selection set on the screen to a new set of symbols.[23]
Individual pages of a communication book or device may presented into several ways. In grid
displays, individual symbols, words, phrases, or pictures are combined in a grid format.[23] The
grids may be organized in a variety of ways, including by spoken word order or frequency of
usage, for example the Fitzgerald Key organization in which symbols are placed from left to
right into categories labelled who, doing, what, where, and when, with frequently used phrases
and letters clustered along the top or bottom of the display.[24][25] The use of these displays has
been shown to facilitate language and literacy skills in children.[26] Core vocabulary, the words
and messages that are communicated most frequently appears on a "main page". A user's fringe
vocabulary, including words and messages that are specific to an individual appear on other,
pages.[23] Research has shown that both children and adults use a small core vocabulary and a
large fringe vocabulary.[27][28]

Large symbols vocabularies may also be organized by category, by grouping people, places,
feelings, foods, drinks, and action words together.[23] Research conducted with typically
developing children found that this type of organizational strategy is not useful until they reach
at least the age of 6 or 7.[29]

Another form of grid organization groups vocabulary according to specific activities.[23] These
can include items that are related to an activity (i.e. going grocery shopping) or routines within
that activity (i.e. making a list, paying for items at the cash register).[30] Each display contains
symbols for the people, places, objects, feelings, actions, and other relevant vocabulary items for
a specific activity or routine.

Visual scene displays represent a different method of organizing and presenting symbols. These
are depictions of events, people, objects, and related actions in a picture, photograph, or virtual
environment representing a situation, place, or specific experience[23][31] They are similar to
activity displays, as they contain vocabulary that is associated with specific activities or routines.
For example, a photo of a child's room could be included in the child's AAC system. Objects and
events within the photograph could then be used as symbols for communication. For example,
the symbol for "play" could be accessed by selecting the toy box, whereas selecting an individual
toy would access the name of the toy.[30] Research suggests that visual scene displays are easier
for young, typically developing children to learn and use, when compared grid displays.[32][33][34]
Symbols can also be presented in a hybrid display, in which both the grid and visual scene
displays appear together.[23]

[edit] Access
Access using eye gaze on a transparent communication board

Access to AAC entails a complex interrelationship between the features of the AAC technology,
the individual's physical abilities (e.g. motor, sensory, perceptual, cognitive and linguistic skills),
and the device users' and their communication partner's abilities to interact.[34] Technological
development in direct selection and scanning have dramatically increased access to AAC
technologies for individuals with a wide range of communications needs.[34] Some people with
severe communication impairments can use their hands to use AAC; others who cannot do so use
alternatives such as mouth sticks, head sticks, switches or eye pointing. In this "direct Selection"
a selection is made by pointing to the desired symbol using a finger or an alternative pointing
technique (i.e., head pointer, eye gaze, joystick, mouse). In order to accommodate motor control
difficulties some users use alternative activation strategies; for example in "timed activation"
must maintain contact with the aid for a predetermined period of time for the selection to be
recognized by the system. With the "release activation", the selection of the item is only made
when the person releases contact from the display.[23] Direct access is generally the first choice
for AAC users as it is cognitively easier and faster to use.[21]

Whenever AAC users are unable to choose items directly, usually due to lack of motor control,
they use an indirect selection technique called scanning, whereby items displayed for selection
are scanned visually by an indicator (such as small lights, highlighting, or contrasting borders) or
auditorily by the communication partner or by the device. When the desired message is reached,
the AAC user indicates his or her choice by using an alternative selection technique (i.e. switch
access, head nodding) to confirm the choice.[23] Several different scanning patterns are available:
in "Circular scanning", the least complex pattern, the items are displayed in a circle and then
scanned them one at a time, until the user selects a desired item. As it the easiest to understand, it
is often introduced first to children or beginning AAC users.[23] In "Linear scanning", items are
organized in rows and are scanned one at a time until a choice is made. Although more
demanding than circular scanning, it is still easy to learn.[23] Finally, in "group-item scanning"
first a group of items is selected; this group is then scanned, eliminating options until a final
selection is made. One of the most common group-item strategies is row-column scanning in
which rows of items are first scanned and selected, and the items in the resulting row scanned
one at a time until a choice is made.[23]

There are three main selection control techniques in scanning: in "Automatic scanning", the scan
proceeds at a pre-determined speed and pattern; when the desired item or group is reached the
individual makes the choice using a control interface such as switch.[23] In inverse scanning, the
switch is held down to advance the scan, and released to choose the desired item. In "step
scanning", the AAC user activates one switch to move the indicator through the items, and
another switch to select the item.[23]

[edit] Rate enhancement strategies

Augmentative and alternative communication is generally slower than speech.[35] Rate
enhancement strategies increase the user's rate of output, and as a result enhance the efficiency of
communication. There are two main options for increasing the rate of communication for AAC
devices: encoding and prediction.[35] Encoding is a technique permitting an AAC user to produce
an entire word, sentence or phrase using only one or two activations of their AAC system.[35] In
iconic encoding strategies such Semantic compaction as sequences of icons (picture symbols) are
combined to produce words or phrases.[36] In numeric, alpha-numeric, and letter encoding (also
known as Abbreviation-Expansion), words and sentences are coded as sequences of letters and
numbers. For example, typing "HH" or "G1" (for Greeting 1) may retrieve "Hello, how are
you?".[36]

Keyboard text-to-speech generating device

Prediction is a rate enhancement strategy in which the AAC device attempt to predict the letter,
word or phrase being written by the user. The user can then select the correct prediction without
needing to write the entire word. Word prediction software may determine the choices to be
offered based on their frequency in language, association with other words, past choices of the
user, or grammatical suitability.[35][36][37]

[edit] Team
A comprehensive evaluation of a user's unique abilities and requirements is necessary in order to
implement appropriate intervention and match the user with the most appropriate AAC device.
AAC evaluations are conducted by specialized multidisciplinary teams consisting of a speech-
language pathologist, occupational therapist, physiotherapist, social worker and a physician.[21][38]
The assessment team conducts interviews with the user, family members, caregivers and/or
teachers in order to obtain additional information about the user's behaviour and skills in
different settings. The team also assesses the user's motor abilities, communication skills,
cognition and vision.[38]

During the intervention process, the occupational therapist assists with the positioning and
seating adaptations so that the individual can have the best access to the AAC system. For
example, an individual with spastic arm movements might need a key guard on top of a keyboard
or touch screen to minimize the chance of selecting a wrong button. The physiotherapist works
on motor development training. The speech-language pathologist's role is to teach the user and
their communication partners how to use the AAC device, encouraging the use of natural speech
when possible. In selecting and adapting the AAC device for the user's individual needs, the
speech-language pathologist's goal is to ensure that the AAC device can be used in different
contexts and with different communication partners.[21]

[edit] Specific groups of AAC users

[edit] Cerebral palsy

Cerebral palsy is a developmental neuromotor disorder that is the result of a non-progressive

abnormality of the developing brain.[21] The motor deficits associated with cerebral palsy (CP)
cause speech disorders in 31% to 88% of CP patients, and may required AAC support for
communication.[21] Gross and fine motor challenges may be of particular concern in accessing the
AAC device.[21]

Simple switch-operated speech generating device

This population often faces an additional communication challenge, in which family members
and peers tend to direct and control conversations. Consequently, children with CP may not use
their AAC aids as often. This has the potential to lead to delays or failure to develop the full
range of communication skills such as initiating or taking the lead in conversation, using
complex syntax, asking questions, making commands, or adding new information.[39][40] Training
of communication partners may prevent the development of learned helplessness in children with
CP that can result from being passive communicators,[21] and training of the AAC user about how
to communicate effectively with others, to control their environment through communication,
and using their AAC system to make choices, decisions and mistakes.[21]

[edit] Intellectual impairment

Prior to the mid 1980s, individuals with Intellectual impairment (also known as mental
retardation) were often not provided with AAC devices as it was believed that they did not
demonstrate prerequisite skills for AAC or because of the notion that AAC would interfere with
speech development.[41] Both notions have been disabused,[42] and the use of AAC devices for this
population has been substantiated in the research literature. From simple single-switch VOCAs
to dynamic displays with visual scenes, studies have shown that appropriate use of AAC devices
can modify classroom, home, and social environments for children and adults with intellectual
impairments to increase participation,[41] make choices,[43] enhance communication skills,[44][45][46]
and even influence the perceptions and stereotypes of communication partners.[41]

A great diversity of diagnoses result in intellectual impairments, that result in varying degrees of
communication impairments. AAC interventions in this population are highly individualized,
taking into account specific abilities of language comprehension, social-relational characteristics,
learning strengths and weaknesses, and developmental patterns for specific types of intellectual
disabilities.[47]

While most individuals with intellectual disabilities do not have concomitant behavioural
problems, it is known that behavioural problems are typically more prevalent in this population
than others.[48] In the past, strategies to "manage" behavioural problems included incarceration,
medication and aversive behaviour modification techniques.[47] Since the mid 1980s, greater
emphasis has been placed on teaching functional communication skills to individuals as an
alternative to "acting out" for the purpose of exerting independence, taking control, or informing
preferences. This paradigm shift in the management of behavioural problems for this population
has placed new emphasis on AAC because many of these individuals do not have functional
speech for communication.[47]

Individuals with intellectual impairments face challenges in developing communication skills,

including problems with generalization (the transfer of learned skills into daily activities).[47]
They also often lack naturally occurring communication opportunities and responsive
communicators with whom they can interact in the home, school and community environments.
[23]
As a result, AAC intervention for this population emphasizes partner training as well as
opportunities for integrated, natural communication.[23]

[edit] Autism

Autism is a disorder distinguished by qualitative impairments in communication and social

interactions and typically have more difficulty acquiring expressive skills.[49][50] Children with
autism have been found to have strong visual-processing skills, making them good candidates for
an AAC device.[51]
Speech generating device

AAC intervention in this population is directed towards the linguistic and social abilities of the
child,[23] including providing the child with a concrete means of communication, as well as
facilitating the development of interaction skills.[49][51] Existing functional communication skills,
such as joint attention, predict better use of AAC.[51][52]

AAC systems for this population will generally begin with communication boards as well as with
object or picture exchanges such as the Picture Exchange Communication System.[49] A 2009
descriptive review provides preliminary evidence that PECS is easily learned by most individuals
and provides communication to individuals with little or no functional speech, and some limited
positive impact on social communication and challenging behaviours.[53] However, a study that
compared the use of a voice-output communication aid (VOCA) to a picture-exchange system
found that each were plausible options for children with autism, as the ease and speed of
acquisition of both systems was similar among all participants.[54]

[edit] Developmental dyspraxia

Developmental dyspraxia is a childhood motor speech disorder involving impairments in the

motor control of speech production, typically causing impairments in motor programming and
execution.[55] The speech of a child with developmental dyspraxia may be unintelligible to the
point that daily communication needs cannot be met and that the child experiences great amounts
of frustration. AAC can be a strategy to support communication, with the hope that speech will
improve with time and eventually be able to meet daily communication needs. Research
indicates that AAC use with this clientele does not impede speech development, and that it
facilitate speech development.[47] AAC interventions in this population are made alongside more
traditional speech therapy to improve natural speech production.[47]

A wide variety of AAC systems have been used with children with developmental dyspraxia.[56]
Manual signs or gestures are the most frequent unaided AAC system introduced to these
children, and can include signing unintelligible target phonemes (using fingerspelling) alongside
speech. Manual signs have been shown to decrease articulation and speech sequencing errors.[47]
Communication book

Aided systems used with children with developmental dyspraxia typically include
communication boards or books using graphic symbols, and voice output devices.[56] While these
are portable and tailored to child's communicative needs, they limit the user's ability to
communicate to the topics on the board.[57] Voice output devices provide the user with a much
greater vocabulary, access to a wider range of topics, and the ability to generate grammatical
sentences.[47]

A multimodal approach is often chosen, such that more than one AAC option is introduced to the
child. This way, the child is not only given the opportunity to experiment with various aided and
unaided AAC systems, but can also take advantage of certain systems that may be better than
others in certain contexts.[47]

[edit] Visual impairment

High and low tech AAC systems require modification in order to make them accessible to AAC
users who are blind or who have visual impairments. Modified visual output that includes large
print and/or clear simple graphics can be of benefit to AAC users with some residual vision.[58]
Tactile/tangible symbols are textured objects, real objects or parts of real objects that may be
included on an AAC device for individuals with visual impairment.[59] Braille is further an
example of a tactile/tangible reading and writing system.[citation needed] Tactile/tangible symbols can
be used on low or high tech displays and switches.[citation needed]

Auditory symbols are those that produce a meaningful sound when activated, and are thus useful
for AAC users who have vision impairments. Morse Code is an example of an auditory symbol
system, where long and short tones represent letters, words, and phrases.[citation needed] Some AAC
devices that can convert Morse code into text or speech.[citation needed] Speech is another example of
an auditory symbol that can be integrated with assistive technology for the blind and visually
impaired.[59] Auditory scanning is an access method that utilizes speech with an AAC device. It
presents options to the user by pronouncing them out loud and allows the users to select the
desired option upon hearing it.[60]

[edit] Aphasia

Aphasia is the result of an impairment to the brain's language centers affecting production,
comprehension, or both, and can cause severe, chronic language impairment.[61] Individuals with
aphasia can use AAC to communicate using a variety of means, including a combination of
speech, gesture, or other devices,[62] which may change over time as needs and skills change.[62]

Static communication device

Those with aphasia may use low-tech AAC interventions such as communication and remnant
books, drawing, photography, written words and messages, and written choices.[61] In addition,
high-tech AAC devices such as voice output communication aids, keyboards, or pictographic
grid displays may be used for communication.[61] Visual scene displays have been used with
adults who have chronic, severe aphasia, in which photos of events or people that are meaningful
to the individual are used to give context to communicative interactions.[61] Approaches such as
"Supported Conversation for Adults with Aphasia" train the communication partners to use
resources such as writing key words, providing written choices, drawing, and using items such as
photographs and maps to help the individual with aphasia produce and comprehend
conversation.[63][64]

[edit] Brainstem stroke

Strokes that occur in the brainstem may suffer from profound deficits, including locked-in
syndrome,[65] in which cognitive, emotional and linguistic abilities remain intact but all or almost
all voluntary motor abilities is lost.[66] Most will need to rely on AAC strategies to communicate,
since few recover intelligible speech or functional voice.[67] The AAC strategy used varies
depending on the time post-stroke, the residual motor capabilities and individual preference. Eye
blinks are frequently used for communication, as vertical and/or horizontal eye movements may
be preserved.[66] Low-tech alphabet boards are often introduced immediately in order to provide
the individual with basic communication. Listener assisted scanning may be used, in which the
alphabet is read out by the communication partner, and AAC user signals the desired letter is
reached. When vertical and horizontal eye movements are functional, a transparent alphabet
board may be used, in which the AAC user looks at the desired letter and this is acknowledged
by the communication partner.[66] These methods can be very slow and require intense
concentration, patience and good memory on the part of the communication partner.

Speech generating device accessed using a head mouse

The use of high-tech AAC device with individuals with locked-in syndrome may be difficult due
to the problems with voluntary muscle activity, visual focusing, memory, alertness and/or
linguistic ability.[66] A voluntary, reliable and easily controlled muscle movement is necessary to
access such as a device, though can be the slightest movement of a finger, wrist or chin, a
frowning of the forehead or biting.[66] If the patient has good head control, a head mouse activates
the computer.[66] Those who do not have stable head movement require extensive practice to
control the AAC device accurately. Laser pointers paired with laser-sensing surfaces have been
shown to increase the accuracy and consistency of head movements.[67] Examples of assistive
hardware and software used with this population include word prediction programs which reduce
the effort required to write; speech synthesizer programs which convert written text into speech;
or replacing a regular keyboard with an on-screen keyboard layout activated by a switch or head-
mouse.[66]

[edit] Amyotrophic lateral sclerosis

Amyotrophic Lateral Sclerosis (ALS) or Motor Neurone Disease (MND) is a progressive

condition in which the motor neurones required for movement break down, leading to weakness
and eventual paralysis. Approximately 75% of people with ALS are unable to speak by the time
of their death.[68] Generally, AAC is necessary when speech intelligibility becomes inconsistent,
especially in adverse listening conditions (i.e.: a noisy restaurant).[68] In most cases, this happens
when speaking rate drops to 100 words per minute.[69] In the early stages of ALS, AAC may only
be necessary to augment natural speech with unfamiliar partners (e.g. using an alphabet board to
cue the listener to the first letter of the word being spoken). In the later stages of ALS, AAC
often becomes the main communicative method, although familiar conversation partners may
still understand specific spoken words.[70] Since ALS is degenerative in nature, the choice of
device has to take into account both present and future needs.[68]
Stephen Hawking, physicist, person with ALS and AAC user

The chosen AAC system will depend on severity of speech impairment, functional status, and
communication needs in particular environments.[70] These include issues of portability,
durability and powered mobility.[70] As cognition and vision are unaffected in ALS, writing and
typing systems tend to be the most recommended and preferred devices because they allow
unlimited expression.[70] The access to the device depends on the type and severity of the disease.
In the spinal form of ALS, the limbs are affected from the onset of the disease. In these cases a
high-tech device using a head mouse or eye tracking access may be used.[71] Low-tech systems,
such as eye gazing or partner assisted scanning may be used in situations when electronic
devices are unavailable (i.e.: during bathing).[70] In the bulbar form of ALS, speech is affected
before the limbs. As a result, handwriting is often the first course of AAC. As the disease
progresses and starts affecting hand movement, writing or typing VOCA devices may be
optimal, as these require less manual dexterity, while still offering full freedom of expression. In
the final stages of the disease, eye gaze and partner assisted scanning are preferred as they carry
the added benefit of promoting social closeness.[70]

[edit] Parkinson's disease

Parkinson's disease is a progressive neurological condition in which initially no speech disorder

may be present.[23][72] However, hypokinetic dysarthria may develop later in the disease
progression,[69] and some individuals eventually lose all functional speech.[23] Factors affecting
AAC use in Parkinson's disease include the motor deficits, and cognitive changes including lack
of insight into the extent of their communication difficulties.[23][72][73] Since most individuals with
Parkinson's disease are able to communicate using natural speech, AAC devices are generally
used to supplement speech.[23] A portable amplifier, for example, increases the volume of a
person's voice and thus intelligibility. In addition the person may be taught to point to the first
letter of each word on an alphabet board supplementation; this results in a reduced speech rate
and visual information for the listener to compensate for impaired articulation. Entire words can
be spelled out if necessary.[23] Since Parkinson's disease is associated with reduced range and
speed of movement, a small-sized board may be preferred.[23] High-tech AAC keyboard speech-
generating devices are also used; keyguards may be required to prevent accidental keystrokes
caused by tremor.[23]

[edit] Multiple sclerosis

Dysarthria is the most common communication problem in individuals with multiple sclerosis
(MS); significant difficulties with speech and intelligibility are uncommon.[23][74] Individuals with
MS vary widely in their motor control capacity and the presence of intention tremor, and
methods of access to AAC technology are adapted accordingly. Visual impairments are common
in MS, and 35% of people with MS experience optic neuritis as the first symptom. AAC users
with visual impairments may require devices that allow auditory scanning systems, large-print
text, or synthetic speech feedback that plays back words and letters as they are typed.[23]

[edit] Dementia

Dementia is an acquired, chronic, cognitive impairment characterized by deficits in memory and

in at least one additional cognitive domain, such as language, visuospatial function, apraxia
(movement), judgment or executive functions.[61][75] Its most common form is Alzheimer's
disease.[47] Communication impairments are partly attributed to memory deficits.[75] AAC
intervention for individuals with dementia is relatively new.[61] Its goal is to compensate for
deficits and to capitalize on the person's strengths, focussing on recognition rather than recall.[47]
Low tech devices, such as memory books, including autobiographical information and daily
schedules, small wallets with photographs, and communication cards acting as reminders or
labels are generally preferred,[47] and several studies have shown positive outcomes in the amount
of on-topic conversation and the length of interaction with their use.[76][77][78] In addition, training
designed to teach individuals with dementia to use such memory aids, was found to be
maintained four months after intervention.[78] High-tech devices with voice output have been
found to be less effective: in one study such devices resulted in limited topic
elaboration/initiation, reduced output and heightened distraction.[75] AAC is also used to enhance
the comprehension of those with dementia. The use of augmented listening strategies, such as
identifying topics of conversation with pictures improves the conversational skills of individuals
with dementia.[47]

[edit] Traumatic brain injury

Traumatic brain injury (TBI) results in severe motor speech disorders—particularly dysarthria, in
roughly a third of cases.[79] Depending on the stage of recovery, AAC intervention may involve
the establishment of consistent responses, the facilitation of reliable yes/no responses and the
ability to express basic needs and to answer questions, and later, if necessary, more longer term
AAC, including high-tech systems. Individuals who do not recover natural speech to a degree
sufficient to meet their communication needs typically suffer from severe impairments related to
cognition.[80] Memory impairments and difficulties with new learning may influence AAC
choices, since individuals with TBI may have difficulty recalling where information has been
stored. As a result, overlearned techniques such as spelling may be more effective than AAC
systems which require navigation through multiple pages to access information.[80] Problems with
initiation and generalization of new skills may influence the extent to which the AAC system is
used in daily life; thus the training and involvement of communication partners is generally
necessary.[80]

[edit] Effect on speech

In contrast to fears expressed by family members and clinicians, a 2008 systematic review found
that AAC use does not impede the development of speech, and may result in increased speech
production, with modest gains observed.[81] A 2009 descriptive review that looked specifically at
PECS intervention studies, and found inconsistent and unclear data on whether PECS led to
increased speech; several studies reported an increase in speech, often during later phases, while
one noted little or no effect.[53]

Researchers hypothesize that using an AAC device relieves the pressure of having to speak,
allowing the individual to focus on communication, and that the reduction in psychological stress
making speech production easier.[82] Others speculate that, in the case of speech generating
devices, a model of spoken output is provided which may lead to an increase in speech
production.[83]

[edit] Multicultural aspects

Cross cultural differences should be taken into account when assessing and planning for AAC
intervention.[84] Ethnic awareness helps professionals determine which AAC system is best suited
for their client.[85][86] Providing AAC services requires the input of family, particularly for early
intervention. Respecting ethnicity and family beliefs are key to a family-centered and ethnically
competent approach.[87] AAC service providers may face challenges due to their lack of
information about other cultures, due to families' attitudes about their own involvement in their
child's care or their loved one, and culturally specific views about disabilities in general.[citation
needed]
From the team's perspective, respect and understanding of cultural diversity can help prevent
family alienation,[88] contribute to the selection of the right AAC system for the user,[89][90][91] and
to the family wanting to continue collaborating with the AAC team.[92]

Professionals must consider the "visibility" of the device.[93] Some cultures do not want the AAC
to attract attention to the user; the need for an AAC is a private matter and they will not want to
attend training sessions. These priorities may differ considerably from the AAC team's views,
but they require consideration to promote cultural respect.[94]

Culturally diverse child rearing practices influence AAC intervention.[23] Accepting a

communication aid and being labeled with a disability may be easier for some cultures which
promote accessibility.[23] Other cultures may place greater value on hierarchical family structures,
politeness, indirect communication, and respect toward authority figures.[23] Disability may also
be viewed with a stigma; thus, folk, spiritual, and natural interventions may be preferred over
modern technology.[23] Other cultures may expect an AAC device will immediately reduce the
visibility of the disability, while other cultures may prefer not to have an AAC device at all in
order to reduce stigma.[95]

When attempting to match the AAC system to the user, professionals consider several factors,
including the need for the communication device to help promote self-determination, i.e., the
ability to make one's own decisions and choices about one's life.[96][97] Some cultural groups
consider a child's independence as a rebellion, and do not believe children should be allowed to
have greater control of their own lives.[98] Thus, an AAC device may not be considered necessary
if the goal is to increase the user's independence and promote individualism.

Cultural sensitivity may require avoiding stereotyping color and symbols, such as using black to
denote "wrong" or "bad" and using culturally specific symbols and colors.[87]

[edit] Language and Literacy

Children who use AAC often experience developmental delays in vocabulary knowledge, length
of sentences, syntax, and impaired pragmatic skills.[99] Many of those whose disabilities require
AAC have difficulties learning to read and write due to a variety of impairments that can affect
emergent literacy. Most children who use AAC do not achieve literacy skills beyond a second
grade level.[100] These cognitive, language and learning delays contribute to difficulty with
literacy development,[23][99] since these children may fall behind their typically developing peers
in regular classrooms that assume a certain level of language mastery.[99] Literate AAC users
often report having access to abundant reading and writing material at home as well as in school
during childhood.[101] Engaging in rich language and literacy experiences before entering school
fosters vocabulary development, discourse skills, and phonological awareness, all of which
supports successful literacy learning.[99] In addition, reduced expectations of teachers and parents
mean that AAC users are often given fewer opportunities to engage in reading and writing
activities in and outside of the classroom, which limits the amount of time, range, and quality of
experience.[102][103][104] However, current research suggests that with explicit reading instruction,
AAC users can better develop good literacy skills.[105][106] Language and literacy delay have far
reaching effects as they facilitate self-expression and social interaction in face-to-face
conversation and provide opportunities to participate in home, work, school, and social settings.
[107]
The limited experience/exposure to print, also leads to weaker knowledge about the world
and vocabulary.[108] Furthermore, literacy fosters independence by providing access to
educational and vocational opportunities.[109]

[edit] History of AAC

Although AAC can trace its roots back to the early days of Ancient Rome, with the first use of
augmentative strategies with the deaf, its modern inception began in the 1950s. At this time,
AAC devices were mainly implemented for those whose oral and laryngeal anatomy was
damaged by surgical procedures such as laryngectomies and glossectomies.[110] During the 1960s
in the United States, the Civil Rights Movement, as well as the deaf community's pursuit of the
right to be educated using American Sign Language (ASL), helped increase public and
governmental awareness of the issues related to AAC.[110]

During the late 1960s, manual sign languages were used with individuals who had both hearing
and cognitive impairments. AAC devices were also used with individuals where intelligible
speech would likely never be possible, including those with severe dysarthrias, cerebral palsy
and amyotrophic lateral sclerosis. However, in most cases AAC strategies were only employed
after traditional speech therapy had failed, as many felt hesitant to provide non-speech
intervention to those who might be able to learn to communicate verbally.[110][111]

This view continued to dominate the field until the 1970s, legislation began requiring that all
children received educational services. As a result, many children with disabilities entered the
school system, compelling classroom teachers to find ways in which to assist communicative
exchanges.[110][111]

During the beginning of the 1980s, AAC became an area of professional specialization. Articles,
newsletters, and textbooks on the matter were published as well as the first international
conferences. The American Speech-Language-Hearing Association published a position paper
regarding AAC as a field of practice for speech-language pathologists in 1981, and in 1983, the
International Society for Alternative and Augmentative Communication (ISAAC) was founded.
[110]
In 1992, the Communication Bill of Rights, set forth by the National Joint Committee for the
Communication Needs of Persons with Severe Disabilities, stated that all individuals with severe
communication disabilities have a right to use AAC devices at all times as well as a right to
information and the opportunity to have and make choices.[110][111]

Since the 1990s, there has been an increase in in-class and natural education techniques, as
opposed to traditional pull-out methods, which has led professionals to seek ways for children
with disabilities to participate more comprehensively and successfully in classroom activities.
This inclusion model promotes the enrichment of functional skills taught within a natural
context.[110][111]

[edit] Outcomes
[edit] Employment

Physical disability may reduce the ability to work and individuals with severe physical
disabilities are often forced to discontinue their employment. According to U.S. Census Bureau
(1997), among severely disabled individuals, less than 10% were employed. Despite the various
barriers to employment, it is possible for AAC users to achieve success in educational endeavors
and employment.[112] Although they are frequently limited to low wage jobs,[113] some AAC users
also maintain higher-skilled jobs. Individuals with a severe disability such as ALS using AAC
may continue working.[114] Better work experiences were related to a positive and supportive
work environment. Access to AAC, determination and a positive attitude helped the individuals
in this study to participate in society and have a good quality of life.[114] Personality factors that
have been found to be related to employment are a strong work ethic and access to AAC
technology. Family and friend support, education and work skills are also related to positive
employment outcomes.[115]

[edit] Quality of life

AAC users generally have satisfying relationships with family and friends, and engage in
pleasurable and interesting life activities, remaining optimistic even when unemployed.[112] There
may, however be more negative post-school quality of life outcomes,[112] especially when post-
secondary education or employment are not pursued. The negative outcomes are related to
dissatisfaction with the service delivery and AAC supports, which results in communication
barriers for AAC users. These issues reflect issues with policy barriers, lack of resources, and
dissatisfaction with communication devices that exist for AAC users.[112]