Disability and Rehabilitation: Assistive Technology

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Augmentative and alternative communication

with children with severe/profound intellectual
and multiple disabilities: speech language
pathologists’ clinical practices and reasoning

Anna Rensfeld Flink, Gunilla Thunberg, Anna Nyman, Malin Broberg & Jakob
Åsberg Johnels

To cite this article: Anna Rensfeld Flink, Gunilla Thunberg, Anna Nyman, Malin Broberg & Jakob
Åsberg Johnels (03 Nov 2022): Augmentative and alternative communication with children
with severe/profound intellectual and multiple disabilities: speech language pathologists’
clinical practices and reasoning, Disability and Rehabilitation: Assistive Technology, DOI:
10.1080/17483107.2022.2137252

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DISABILITY AND REHABILITATION: ASSISTIVE TECHNOLOGY
https://doi.org/10.1080/17483107.2022.2137252

ORIGINAL RESEARCH

Augmentative and alternative communication with children with severe/profound

intellectual and multiple disabilities: speech language pathologists’ clinical
practices and reasoning
Anna Rensfeld Flinka,b , Gunilla Thunberga,c , Anna Nymand,e , Malin Brobergf and
Jakob Åsberg Johnelsa,g,h
a
Speech and Language Pathology Unit, Department of Health and Rehabilitation, University of Gothenburg, Gothenburg, Sweden; bHabilitation
& Health, Region V€astra G€otaland, V€anersborg, Sweden; cDART Centre for AAC and AT, Sahlgrenska University Hospital, Gothenburg, Sweden;
d
Division of Speech and Language Pathology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm,
Sweden; eHabilitation & Health, Stockholm, Sweden; fDepartment of Psychology, University of Gothenburg, Gothenburg, Sweden; gGillberg
Neuropsychiatry Centre, University of Gothenburg, Gothenburg, Sweden; hChild Neuropsychiatric Clinic, Sahlgrenska University Hospital,
Gothenburg, Sweden

ABSTRACT ARTICLE HISTORY

Purpose: Augmentative and alternative communication (AAC) is recommended to be included in commu- Received 25 April 2022
nication interventions directed at children/youth with severe/profound intellectual and multiple disabil- Revised 7 October 2022
ities (S/PIMD). Even so, the evidence base for AAC practices with children with S/PIMD is limited. Also, Accepted 12 October 2022
little is known about how frequently AAC is implemented with this target group, which AAC tools and
KEYWORDS
methods are applied, and the related clinical reasoning of speech-language pathologists (SLPs). This study Severe/profound intellectual
aimed to explore SLPs’ beliefs, clinical reasoning and practices in relation to AAC implementation with and multiple disability;
children/youth with S/PIMD. intellectual disability;
Materials and methods: In this sequential, mixed-methods study, 90 SLPs working with children with augmentative and
disabilities within habilitation services in Sweden participated in an online survey. The survey answers alternative communication;
were statistically analysed. Subsequently, focus group data were collected from seven SLPs and analysed AAC; speech-language
using thematic analysis. pathologists; clinical
Results and conclusions: Despite AAC being highly prioritized, SLPs found it challenging and complex reasoning; clinical
to implement with this target group. A wide variety of AAC methods and tools were considered and decision-making
implemented. Clinical decision-making was a balancing act between competing considerations and was
mainly guided by the SLPs’ individual, clinical experiences. The resources, engagement and wishes of the
social network surrounding the child were considered crucial for clinical decision-making on AAC.
Implications for research and practice are discussed.

� IMPLICATIONS FOR REHABILITATION

� Speech-language pathologists (SLPs) seemingly find a wide variety of Augmentative and Alternative
Communication (AAC), ranging from unaided methods to assistive technology of various complexity, to be
potentially suitable for children/youth with severe/profound intellectual and multiple disabilities (S/PIMD).
� The motivation and preferences of the social network surrounding the child with S/PIMD seem to
influence SLPs’ clinical decision-making on AAC to a high degree. Sometimes this may be considered
an even more important factor than the abilities of the child.
� SLPs’ clinical decision-making on AAC for children/youth is guided by their individual, clinical experi-
ence to a high degree.
� An increase in family oriented AAC intervention research targeting individuals with S/PIMD could
potentially strengthen the association between research and the current, experience-based clin-
ical practice.

Introduction Augmentative and Alternative Communication (AAC) is imple-

Communication is a basic, human need regardless of the presence mented within clinical or educational practices, with individuals
of complex disabilities. The right to communicate and to do so whose spoken and/or written communication does not meet their
through any mode of communication is protected in the needs. The goal of AAC intervention is to enable efficient and
Convention on the Rights of Persons with Disabilities [1]. effective engagement in interactions, participation in desired

CONTACT Anna Rensfeld Flink anna.rensfeldt.flink@gu.se Speech and Language Pathology Unit, Department of Health and Rehabilitation, University of
Gothenburg, Gothenburg, Sweden
Supplemental data for this article can be accessed online at https://doi.org/10.1080/17483107.2022.2137252.
� 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
2 A. RENSFELD FLINK ET AL.
activities and to enhance learning and development [2]. An AAC
system can include some type of equipment or assistive technol-
ogy (i.e., aided AAC) or build on bodily resources such as vocaliza-
tions, gestures or signs (i.e., unaided AAC). Multimodal AAC
approaches are common and encouraged [2]. The familiar com-
munication partners of the individual with disability need to be
involved in the AAC intervention process and receive instructions
on how to integrate AAC into their communication [3–5].
Children with profound intellectual and multiple disabilities
(PIMD) have significantly limited cognitive abilities combined with
severe motor disabilities [6]. Their everyday functioning is com-
monly also affected by other disabilities (e.g., visual impairment)
and medical conditions (such as epilepsy) [6–9]. In this study, the
term severe or profound intellectual and multiple disabilities (S/
PIMD) is used, to manage the clinical indistinctiveness between
severe and profound intellectual disabilities in this population, in
line with a number of previous studies [8,10,11].
Communication in children with S/PIMD is pre-symbolic and
often pre-intentional [12], meaning that the children rely on con-
crete ways of communicating and that the communication part-
ner is essential in initiating and maintaining interaction. AAC has
been suggested as having the potential to increase social partici-
pation for children with the most severe disabilities [13]. AAC,
both aided and unaided, is also argued to be useful in improving
intentionality in young children with (varied) disabilities on
pre-symbolic levels of communication [14,15], and in increasing
intentionality and enhancing use of symbols when on the devel-
opmental levels of emerging language [4,16]. In a study by
Holyfield [17] preliminary evidence was provided that school-aged
children with S/PIMD are able to increase their social gaze behav-
iour in interaction through a prelinguistic, object-based AAC inter-
vention. Studies exploring the effects of AAC on communicative
behaviours as well as development in children with specified S/
PIMD are however sparce [17,18], and there are also general
knowledge gaps when it comes to how AAC design can be devel-
opmentally sensitive to subgroups of children with atypical devel-
opment in communication, cognition, motor skills, hearing and/or
vision [19]. In a systematic review of aided AAC interventions for
individuals with S/PIMD, 25 studies with 59 participants were
included [18]. It was found that almost all included studies
described interventions targeting requests supported by simple
speech-generating devices (SGDs)/microswitches. Only one of the
studies included parents in the intervention and a total of seven
participants in included studies were under the age of six [18].
Moreover, Simacek and colleagues [18] concluded that much is
unknown with regard to intervention intensity or maintenance
and generalization of skills in relation to aided AAC interventions
with the S/PIMD population.
Knowledge on AAC use in clinical practice with children with
S/PIMD and its related clinical reasoning is limited. In general, pro-
fessionals’ decision-making in AAC practice seems to be con-
nected to a number of competing considerations regarding
patient characteristics, features of the AAC system in itself [20,21]
and sometimes also factors connected to daily communication
partners [22]. When it comes to working specifically with the
S/PIMD population, studies targeting SLPs in Australia and the
United Kingdom (UK) have reported on inclusion of AAC in com-
munication interventions with individuals with S/PIMD [23,24]. In
the UK, the most-used AAC practice with this population is report-
edly objects of reference [23]. A study exploring the use of assist-
ive technology with individuals with profound ID in several
European countries found that when assistive technology was
applied, it was commonly used with the goal of supporting
communication and interaction [25], hence being used as AAC. In
the context of Sweden, clinical use of AAC is mentioned in studies
targeting children with severe motor disabilities combined with
varied levels of intellectual disability [26,27] and Rett syndrome (a
diagnosis that for some individuals results in S/PIMD) [28]. AAC is
included in the curriculum of a Swedish, clinically spread, parent-
focused communication course, that is sometimes offered to
parents of children with S/PIMD [29].
Relationships between professionals’ attitudes or beliefs and their
actual implementation of AAC or assistive technology with individu-
als with S/PIMD have been proposed [25,30] and in a more general
patient context, AAC experience reportedly shapes decision-making
in the AAC assessment process [21]. The theory of planned behav-
iour [31] has been utilized as a theoretical model to characterize
similar relationships between professionals’ intentions to implement
specified clinical or educational practices and (I) their beliefs and
attitudes about the consequences of the practice, (II) the social sup-
port for engaging in the practice and (III) potential obstacles or ena-
bling factors for implementing the practice [e.g., 32,33].
In Sweden, AAC is provided to children with S/PIMD through
the child and youth habilitation services. The Swedish Health and
Medical Services Act (1982:763) regulates the free-of-charge avail-
ability of habilitation services and (if needed) communication aids
for individuals with intellectual disabilities. The habilitation serv-
ices aim to provide multi-professional support and interventions
to promote development, functional abilities and well-being, in
active cooperation with the parents, and preferably in coordin-
ation with other healthcare services and school/pre-school [34,35].
SLPs within habilitation services are encouraged to prioritize inter-
ventions targeting communication partner responsiveness and
multimodal AAC with young patients on pre-symbolic levels of
communication [36].
Given the relatively low level of research evidence for various
AAC interventions targeting children with S/PIMD (beyond some
use of SGDs in school contexts), it is to a large extent unknown
what beliefs SLPs hold regarding AAC and S/PIMD, how their clin-
ical decision-making is shaped, to what extent AAC is imple-
mented and which AAC tools and methods are typically
implemented. Evidence-based AAC practices most often follow
the clinician-driven practice-to-research route [37]. More know-
ledge on clinical AAC practices and clinical reasoning targeting
individuals with S/PIMD could hence guide future intervention
research in this field, which is warranted in order to strengthen
the evidence base.
The study aimed to answer the following research questions:
1) To what extent do SLPs intend to implement AAC with chil-
dren/youth with S/PIMD? 2) Which AAC tools and methods are
typically included in AAC interventions with children/youth with
S/PIMD? 3) What beliefs do the SLPs hold relating to AAC inter-
ventions with children/youth with S/PIMD and how do these
beliefs guide their clinical reasoning and decision-making? 4) Is
there a relationship between on the one hand SLPs’ clinical
experience and on the other hand their beliefs and clinical deci-
sion-making regarding AAC with children/youth with S/PIMD?
Materials and methods
Study design
The study was a mixed methods study with a sequential, explana-
tory design [38,39]. As such, the study was executed in subse-
quent phases where the first phase informed the second phase
[38–40]. First, an online survey was performed, and the data were
statistically analysed. Second, to fully answer the research
 AAC WITH CHILDREN WITH S/PIMD - SLP'S PRACTICES 3

questions and to explain and interpret statistical findings, two
complementary focus groups were carried out.
Phase 1: online survey
Participants. Eligible participants in this study were SLPs working
with children or youth with S/PIMD (up to 18 years of age) within
the habilitation services in Sweden.
Heads of habilitation services in 11 Swedish, counties were
contacted with an enquiry about recruiting participants within
their organizations. Habilitation services in nine counties (covering
approximately 73% of Sweden’s population) agreed to cooperate.
A contact in each cooperating county forwarded an email with
study information and survey invitations to all SLPs working
within the child and youth habilitation services (N ¼ 219). The sur-
vey was open for respondents for five weeks. The response rate
was 56% (123 submitted survey responses). Some responses were
excluded (a total of 33) due to the respondents not working with
patients with S/PIMD (N ¼ 28), or the respondents not consenting
to their answers being used in the research project (N ¼ 5). Thus,
the survey answers of 90 respondents constitute the data in
Phase 1 of the study. Demographic information of the respond-
ents is shown in Table 1. No information about non-responders
was available to us.
Procedure. The survey content was mainly informed by an unpub-
lished Master’s thesis by two SLP students, targeting SLPs’ experi-
ences from AAC interventions with children and youth with
S/PIMD [41]. The findings indicated that the SLPs utilized a
predominantly multimodal AAC approach and that the AAC inter-
vention processes were highly individualized and dependent on
the resources of the social network surrounding each child, the
AAC knowledge and interest of the colleagues (of varied profes-
sions) as well as the respective SLP’s clinical experience of
patients with S/PIMD [41]. Based on these results, we decided to
include a wide and detailed range of AAC characteristics in the
survey. The AAC-specific items in the survey were structured and
labelled in a way that sought to be comprehensible to the clinic-
ally-based SLPs in a habilitation services context in Sweden.
Communication passports were included in the survey despite
them not necessarily being formally classified as an AAC interven-
tion [23]. Still, communication passports are instructional resour-
ces for communication partners that aim to enhance interaction
between individuals with disability and communication partners
[42] and are reportedly used with the S/PIMD population [23,41].
The SLPs’ experiences of complexity related to AAC interven-
tions with this target group [41] prompted us to address demo-
graphic factors in connection to clinical experience. We were
guided by the theory of planned behaviour [31] when designing
survey items, to attempt to capture the social cognitive factors
that may influence the SLPs’ clinical decision-making.
The survey was divided into six sections and contained a total
of 30 items (with occasional sub-items). A description of each sec-
tion follows in Table 2. The survey in its entirety, translated into
English, can be found in a supplementary file.
Swedish University Computer Network (SUNET); a cloud-based
tool for online surveys, was utilized for running the survey. The

Table 1. Included survey respondents’ characteristics.

Survey data
Variables Sub-variables n (%) M (max–min)
Respondents/participants 90
Age (years) 41.30 (24–65)
Gender Female 80 (88.9)
Male 4 (4.4)
Prefer not to say 6 (7.8)
SLP experience (years) <5 19 (21.1)
5–10 18 (20.0)
>10 53 (58.9)
Habilitation experience (years) 10.56 (0–35)
Part of clinical workload devoted to patients with S/PIMD 31.24 (0a–100)
County V€asterbotten 7 (7.8)
G€avleborg 4 (4.4)
€
Orebro 1 (1.1)
Stockholm 18 (20.0)
€
Osterg€ otland 7 (7.8)
V€astra G€otaland 24 (26.7)
J€
onk€oping 6 (6.7)
Halland 6 (6.7)
Skåne 17 (18.9)
Expressed interest in participating in subsequent focus group Yes 53 (58.9)
No 37 (41.1)
a
Two included respondents reported to work regularly with the target group even though they currently had none on their caseload.

Table 2. Summary of survey content, section by section.

Sections of the survey Content
Introductory section A statement on the topic of the study and definitions of the terms S/PIMD and AAC.
Section for consent Items for consenting to participate in the study. Opportunity to consent to being contacted to participate in
the subsequent focus group.
Demographic section Items targeting: age; gender; workplace; percentage of S/PIMD cases in caseload; work experience (in time)
within habilitation services.
Section targeting experiences, intentions Items targeting: intention to implement AAC; the experienced value of AAC; perceived social norm in relation
and beliefs to AAC; perceived behaviour control in relation to AAC implementationa.
Section targeting AAC methods and tools The respondents were asked to estimate how often different, specified AAC methods/tools/symbols/signals
had been included in AAC interventions with children with S/PIMD over the last two yearsa.
a
A 7-step Likert scale was used, ranging from –3 to 3.
4 A. RENSFELD FLINK ET AL.
survey was accessible to the respondents through a web link that
was received by email. Respondents were not able to respond to
the survey twice from the same IP-address.
Analysis. Statistical analyses were performed using IBM SPSS sta-
tistics. Descriptive statistics were used to summarize and describe
the demographic data as well as the responses to items in the
section addressing experiences/intentions/beliefs and the section
addressing implemented AAC. Associations between items
addressing AAC methods and tools on the one hand, and work
experience on the other, were investigated using Spearman’s rho
correlations. (The data were generally not normally distributed,
and a non-parametric te). Due to the number of correlations per-
formed, the Bonferroni corrections for multiple correlations can
be considered. However, the Bonferroni correction is considered
to be overly conservative in cases such as the current one [43],
where the items concerning AAC are unlikely to be independent
from one another in relation to experience factors. Instead, we
aimed to transparently account for all performed correlations,
their strengths and to interpret patterns of associations at both
0.05 (less conservative) and 0.01 (more conservative) alpha levels,
with two-tailed tests.
Phase 2: focus groups
After completion of the statistical analysis in Phase 1, the results
were robustly discussed by the authors in relation to the research
questions. In this connecting analysis [40], we decided where
qualitative data would potentially add clarification and deeper
understanding. Focus groups were chosen because they enable
the researcher to seek patterns when a range of individuals share
and contrast opinions and ideas about a common topic [44]. The
connecting analysis guided the execution of the focus groups in
the study’s second phase.
Participants. Focus group participants were recruited from survey
respondents. Through purposive sampling we aimed to include
SLPs a) with a variety of work experience from habilitation serv-
ices b) with a varied percentage of S/PIMD cases in their caseload
c) from different counties d) who stated (in the survey) that they
prioritized other communication interventions over AAC as well as
SLPs who stated that they did not.
In the survey, 53 respondents declared an interest in partici-
pating in a focus group. We initially sorted them into a matrix,
based on their work experience (in years) from habilitation serv-
ices and the percentage of worktime devoted to S/PIMD patients.
Notes were made regarding which county they worked for, and
their survey reply regarding how they prioritized AAC interven-
tions. Based on this information and our principles for purposive
sampling, 11 respondents with long habilitation service experi-
ence and 13 respondents with shorter habilitation service experi-
ence were selected and contacted. Out of those 24 SLPs,19
replied to the invitation, but some declined participation (N ¼ 7)
or were unable to attend at designated dates (N ¼ 5). Finally,
Table 3. Demographic features of participants in the focus groups (as annotated in the survey).
Groups
Pseudonyms Anne
Age 45–54
Female (F)/male (M) F F
Habilitation service experience (years) 21
Part of workload devoted to patients with S/PIMD (%) 75%
Age is reported in spans to avoid risk of possible identification of participants.
seven SLPs working in five different counties consented to partici-
pate in one of our focus groups.
In order to avoid power differentials and hierarchies and to
create a comfortable environment for everybody to share their
views [44], we designated one of the focus groups (Group A) for
SLPs with long working experience within habilitation services
and the other focus group (Group B) to SLPs with fewer working
years within habilitation services. See Table 3 for description of
the participants.
Procedure. Focus groups were carried out online as virtual meet-
ings lasting 90 min each. On-site focus groups were deemed
unrealistic given how the participants were scattered
geographically.
Data coding and analysis. The focus group data were audio
recorded and transcribed verbatim by the first author. A reflexive,
thematic analysis was conducted on the transcribed data [45,46].
The first author performed the major part of the analysis but con-
sulted with the other authors. Both transcripts were firstly read
with the overarching research questions in mind and secondly
coded semantically [45], starting with the transcript of Group A.
After having coded both transcripts, the codes together with their
corresponding extracts were grouped into initial themes. This pro-
cess was influenced by fieldnotes and preliminary perceptions of
the patterns of the focus group discussions, as perceived by the
first author. In a gradual, reflexive process where focus shifted
between the research questions, the transcripts, coded extracts
and potential themes, the codes and themes were refined,
regrouped, and a final thematic structure was decided upon, with
one overarching theme and three sub-themes. All themes were
prevalent in both focus groups.
Ethical considerations
All included survey respondents received written information
about the study, and actively consented (within the survey) to
participate in the study. Only respondents who were interested in
participating in the focus groups disclosed their identity (by
declaring contact information of their choice). The focus group
participants received both written and oral information about the
study and consented in writing to participation. The study was
submitted to the Swedish Ethical Review Authority for assessment
(application number 2020-05228). The authority had no ethical
objections to the study protocol.
Results
Results from phase 1 (survey)
SLPs’ intention to implement AAC
The respondents were asked “When you meet a patient with S/
PIMD ( … ) and you are asked to clinically address their communi-
cation, how often do you offer any kind of AAC?”. They rated their
Focus Group A Focus Group B
Anita Alice Angelica Britt Betty Bella
45–54 45–54 35–44 35–44 25–34 <25
F F F F F
10 12 10 3 3 <1
64% 85% 8% 10% 15% 90%

answers on a scale from 3 (“never”) to 3 (“always”). Median was
at the end of the scale: 3.0 (mean: 2.5, SD 0.69, min/max: 0/3),
revealing a very high self-reported intention to implement AAC
with the target group.
SLPs’ beliefs related to AAC interventions with children/youth with
S/PIMD
In Figure 1, ratings of subjective norm (beliefs about the import-
ance and value of AAC implementation with children/youth with
S/PIMD) are visualized. As can be seen, the SLPs generally rated
highly on items addressing the importance or value of AAC.
However, there were also relatively high agreements on the item
addressing whether the SLPs rated other communication interven-
tions higher than AAC (Md:1).
The respondents were asked about the perceived expectations
from others to implement AAC with children/youth with S/PIMD.
Figure 2 shows the responses to these items. “The social network
of the child” was characterized as “family, teachers, personal assis-
tants, etc”. “Experts within the AAC field” were characterized as
“employees at regional AAC centres or colleagues with long
experience of working with AAC”. The term “co-workers” referred
to colleagues in the multi-professional habilitation team. The SLPs
generally rated highly on these items, indicating that they per-
ceived other stakeholders to value AAC interventions, and to
expect the SLPs to implement AAC with children/youth with S/
PIMD. AAC experts received particularly high ratings.
Four items addressed the respondents’ perceptions of how
easy or difficult it is for them to successfully implement AAC with
children/youth with S/PIMD. Results showed substantial variation
among respondents, yet the results revealed a low sense of
Figure 1. Stacked bar chart showing how answers to items addressing subjective norm in relation to AAC implementation were distributed. The scale ranged from -3
(equivalent to never/unimportant/do not agree at all) to 3 (equivalent to always/very important/completely agree).
Figure 2. Stacked bar chart showing how answers to items addressing social norm in relation to AAC implementation were distributed. The scale ranged from -3
(equivalent to do not agree at all) to 3 (equivalent to completely agree).
AAC WITH CHILDREN WITH S/PIMD - SLP'S PRACTICES 5
control and experienced difficulties in relation to AAC implemen-
tation with patients with S/PIMD, from most respondents. The
results are shown in Figure 3.
Types of AAC that are included in interventions
Twenty-four items addressed how often various AAC characteris-
tics had been implemented with children/youth with S/PIMD in
the last two years. Detailed descriptive results from all 24
addressed AAC characteristics are presented in Table 4. The vast
majority of the median ratings were distributed on the lower half
of the scale. The highest median values (equivalent to 1) were
obtained for items targeting the use of simple speech-generating
devices (with one message) and objects and manual signs as sym-
bols/signals.
Clinical experience in relation to decision-making and beliefs
regarding AAC
The Spearman’s Rho test was used to calculate correlations
between either experience from working within habilitation serv-
ices (number of years) or experience from working with children/
youth with S/PIMD (percentage of patient-focused work-hours
that was dedicated to the S/PIMD group) and each of the speci-
fied AAC characteristics. Results are shown in Figure 4, showing
different patterns of correlation. This means that experience from
habilitation services and experience from patients with S/PIMD
correlated with different clinical decision-making about what AAC
tools or methods to implement.
Correlations were also calculated between, on the one hand,
experience from habilitation services or experience from patients
with S/PIMD, and, on the other hand, beliefs about AAC (items
6 A. RENSFELD FLINK ET AL.

Figure 3. Stacked bar chart showing the distribution of item ratings concerning perceived control over the implementation of AAC intervention with children/youth
with S/PIMD. The scale ranged from –3 (equivalent to do not agree at all) to 3 (equivalent to completely agree).

Figure 4. Correlations (Spearman’s Rho) between frequency of implementing specified AAC with children/youth with S/PIMD and: Panel a) experience from working
within habilitation service (number of years), as well as Panel b) experience from working with children/youth with S/PIMD (percentage of total caseload).

addressing subjective norm, social norm or behaviour control). base (statement: “There is good evidence supporting AAC imple-
Only two significant correlations were found. S/PIMD experience mentation with children/youth with S/PIMD”) (Rho: 0.21, p<.05).
correlated positively with perceptions about a strong evidence Habilitation Service experience correlated positively with
 AAC WITH CHILDREN WITH S/PIMD - SLP'S PRACTICES 7

Table 4. Descriptive statistics addressing Likert ratings that referred to how complex and relies on multiple factors. “I find that there are a lot
often the specified AAC had been included in interventions with children/youth of different factors that impact my assessment” (Bella). This seemed
with S/PIMD in the last 2 years.
to refer to decisions on the choice of specific AAC as well as
Category Subcategory: rated item Md M SD Min/max where, how and in cooperation with whom it should be imple-
Aid SGDa, one message 1.0 0.4 1.8 –3/3 mented. However, the complexity rarely seemed to prompt the
Communication boards/books 0.0 –0.3 1.6 –3/3
Communication passport (book) –0.5 –0.5 1.8 –3/3
decision not to view AAC as feasible. ““It seems ethically problem-
Simple app (in digital unit) –1.0 –0.9 1.5 –3/3 atic not to offer any kind of AAC intervention” (Britt).
SGDa, multi message –1.0 –1.2 1.7 –3/3 There was no clear, paved path to follow, but rather unique
Advanced app (in digital unit) –2.0 –1.6 1.5 –3/3 decisions, relying on a number of factors that were mainly con-
Communication passport (digital) –2.0 –1.7 1.7 –3/2
nected to the child, their social environment and characteristics
Eye gaze control –2.0 –1.9 1.2 –3/1
Vocabulary size One referentb at a time 0.0 0.2 1.9 –3/3 and circumstances surrounding the SLP (elaborated further in the
10–50 words/symbols 0.0 –0.1 1.6 –3/3 sub-themes). All AAC methods seemed to be viewed as possibly
<10 words/symbols 0.0 –0.4 1.8 –3/3 appropriate for individuals with S/PIMD, depending on the cir-
>50 words/symbols –1.0 –1.1 1.8 –3/3 cumstances. Sometimes, some SLPs seemed to experience a feel-
Vocabulary Schematic/activity based 0.0 0.3 1.8 –3/3
organization ing of not living up to the standards they wished to practice by:
Syntactic –2.0 –1.2 1.9 –3/3 “There is the way that you imagine you should be working, and
Pragmatic –2.0 –1.3 1.8 –3/2 then there is the clinical reality” (Betty). The more experienced SLPs
Visual scene display –3.0 –2.4 1.2 –3/2 expressed that through experience, they had learned to juggle
Symbol/signal Manual signs 1.0 0.6 1.6 –3/3
Objects 1.0 0.6 1.7 –3/3 the complexity by being flexible when thinking of potential AAC
Photos 0.0 0.2 1.7 –3/3 solutions, setting realistic goals based on the whole situation and
Recorded speech 0.0 0.0 1.6 –3/3 expecting slow progress. This contrasted to their practice in ear-
Pictographic symbols 0.0 –0.3 2.1 –3/3 lier years of their careers:” I think back to when I was new myself,
Synthetic speech –1.0 –0.7 1.8 –3/3
Tactile signs –1.0 –0.8 1.8 –3/3 and it was easy to get started thinking ‘( … ) this family hasn’t any
Ideographic symbols –3.0 –2.4 1.0 –3/1 AAC at all, what should I do?’ and then you sort of began with too
–3 equalled not at all. 0 equalled in half of the cases and 3 equalled in all cases. much, too intensely, too quickly.” (Angelica) The younger SLPs men-
a
Speech-generating device. tioned that it was important to get clinical advice from more
b
A single object/signal/symbol. experienced colleagues or experts and thus lean on the experi-
ence of others. In line with this, experienced SLPs mentioned how
they guided young, ambitious and sometimes overwhelmed col-
leagues not to rush into too complex intervention plans with this
group of patients: “Sometimes I act as a sounding board ( … ) My
role is probably to dial down expectations ( … ) I usually say more
like: ‘start with the basics, where are the basics?’” (Anne).

Uncertainty regarding the child’s abilities and prognosis

Figure 5. Thematic structure.
perceived importance of AAC in relation to other interventions
(question: “How important do you think it is that AAC interven-
tions are given high priority in comparison with other inter-
ventions?”) (Rho: 0.23, p<.05). No correlations at the 0,01 level
were found in those correlation analyses.
Results from phase 2 (focus groups)
The focus group discussions followed a topic guide and were cen-
tred around the following topics: 1) values and beliefs related to
the wide variety of implemented AAC; 2) experienced challenges
specific to AAC implementation with the S/PIMD target group; 3)
conceptual boundaries of AAC in relation to implementation with
the S/PIMD group and 4) perceived social norm in relation to AAC
implementation with the S/PIMD group.
The thematic analysis of the focus group data resulted in one
overarching theme “clinical decision-making: leaning on experi-
ence to juggle complexity” and sub-themes (see Figure 5). The
themes are elaborated with illustrating quotes below.
Clinical decision-making: leaning on experience to jug-
gle complexity
The participants unanimously expressed that clinical decision-
making on AAC relating to children/youth with S/PIMD is very
Factors relating to the specific child seemingly guided the clinical
decision-making. On a general note, children with S/PIMD were
perceived to have more individual challenges than other patients.
The importance of finding an AAC system which could enhance
the specific individual’s quality of life was mentioned.
Children/youth with S/PIMD were experienced to develop at a
very slow and unpredictable pace and this was repeatedly men-
tioned as a challenge when planning an intervention and know-
ing what outcome to expect. Even the most experienced SLPs
found themselves having to try different intervention paths with-
out knowing beforehand if they would necessarily suit the specific
child and their developmental trajectories. “You search quite a lot,
and try many different approaches, which means that you find it to
be more difficult” (Alice). The most common way to manage this
seemed to be to set intervention goals that were quite low and
to develop a mindset where you appreciate every bit of
(small) progress.
Further, the individual child’s unique combination of abilities
and disabilities affected clinical decision-making about AAC. The
motor disabilities of the children/youth with S/PIMD seemed to
partly prompt a focus on aided AAC. This was due to an overall
focus on aids in the habilitation process with this group of
patients. Also, other aids, such as wheelchairs, created opportuni-
ties for mounting communication aids, such as screens. Presence
of sensory impairments was mentioned as a critical aspect of the
clinical decision-making regarding AAC: “There you sort of have to
consider vision, hearing, interpretation, CVI [Cerebral Visual
Impairment] ( … )” (Betty). Perceived uncertainty about the actual,
8 A. RENSFELD FLINK ET AL.
cognitive abilities of the specific child with S/PIMD was men-
tioned as a challenge in relation to clinical decision-making. ““I
also find it ( … ) very tricky with cognition when you do not know a
child’s level” (Anita).
Adjusting to the social network surrounding the child
The social context of children with S/PIMD was raised by all par-
ticipants as perhaps the most important factor for clinical deci-
sion-making. Children/youth with S/PIMD were sometimes
experienced as having more complex and multi-branched social
networks than others. At the same time, the success of any AAC
intervention was experienced to be very dependent on the per-
sons surrounding the child in his/her everyday life.” They [children
with S/PIMD] are so hugely reliant on their [social] environment that
it depends: if a parent gets sick or if good assistants are replaced by
less committed assistants or if you change teachers to someone
who does not see the point of AAC, then it sort of does not matter
how much you work with the child, because it is still the environ-
ment that carries the communication” (Britt). The parents were
most commonly mentioned as being important in relation to clin-
ical decision-making on AAC, but other parts of the child’s social
network were also mentioned and discussed.
The families of children/youth with S/PIMD were experienced
to more often than other families lack capacity in terms of time
and energy. “These parents are more often completely worn down,
the ones who have children with S/PIMD” (Alice). The SLPs reported
that they tended to lower the bar of the intervention when they
perceived that the parents had too much on their plate.
Sometimes, if the parents lacked capacity to participate in the
intervention, then the intervention could rely more heavily on
someone else, such as a personal assistant or a member of school
staff. However, this solution was vulnerable to staff turnover. If
the social network lacked someone with a strong driving force,
the SLPs found it very difficult to implement AAC and especially
so for high-tech AAC. “You can try to introduce something more
technically advanced, but the chances of it succeeding are pretty
slim if there is not a strong driving force close by. And that is sort of
the most important factor” (Britt).
The SLPs described in various ways how the expectations and
motivations of parents and others in the child’s network affected
the clinical decision-making. The expectations could relate to par-
ticular interventions or to the child’s development. The import-
ance of a motivated social network was stressed repeatedly. ““We
do want the family to be motivated. It is the family’s motivation
that matters, very much so” (Bella). Technology seemed motivating
to some stakeholders. It could prompt a sense of normality and
competence (since “all children” use tablets, for instance). Also,
parents may have seen or heard of other children use a particular
aid and hope that the same one would be beneficial to their
child. Sometimes the expectations and motivations differed
between the SLP and the child’s social network. The SLPs experi-
enced that some parents (or other stakeholders) had unrealistic
expectations on high-tech AAC as a “quick fix”, while others had
very low motivation to engage in AAC where the SLP saw that
the child had potential to benefit from it. Some social networks
needed a lot of coaching and encouragement in order to remain
motivated.” To maintain the motivation to use AAC with a patient
who may not respond for an extremely long time, if at all. ( … ) It is
very easy to give up at that point, I think. There are several conver-
sations like that too, about keeping on and sticking with it”
(Angelica). Yet other stakeholders had long-term goals for the
intervention that were far more ambitious than the SLP viewed as
realistic. The SLPs with long experience shared that over the years
they had become more inclined to listen to the stakeholders, and
particularly the parents, when they had strong opinions about
certain AAC solutions or long-term goals. “Experience also brings
some humility ( … ). When I was new, I could more clearly say: ‘this
is what’s best for you’. And now I have seen too many times that
totally different choices were the best ones” (Anne). Sometimes, to
give the parents’ wishes a fair chance, the SLPs initially went
along with them, but had a “Plan B” to suggest, should it
be needed.
The complexity of the disabilities in children with S/PIMD com-
bined with slow development was also experienced to cause
more conflicting expectations and motivations between parents
within the same family or between the school and the home,
compared with other groups of patients, in turn complicating the
clinical decision-making of the SLPs. “I talk a lot with the family,
and I try to talk to the school too but ( … ) they do not always
agree” (Betty).
The particular circumstances of implementing AAC in cooper-
ation with the school were mentioned in both focus groups. In
school, it was found that AAC needed to be functional not only in
one-on-one interaction. “[In school] they want to use things that
are usable for the whole group. They want to use the interactive
whiteboard in joint activities and communication boards, pictures
and manual signs” (Britt). When it comes to high-tech AAC devi-
ces, it was recognized that it could be very impractical for teach-
ers and other school staff to learn to use a different high-tech
device for each student in the class. The SLPs sometimes sug-
gested a method or tool that was already in use by peers in the
class, even if one could argue in favour of another solution when
only looking at the needs of the specific child. “Because if you
come to a teacher and introduce, well the fifth variant of something,
then there is a less chance of that working. If you choose something
that another child uses, well then … ” (Anne).
It was also mentioned that it usually became easier to imple-
ment AAC when the child started school since the teachers could
be expected to have some AAC knowledge.
The SLP’s internal and external resources
As described in the overarching theme the AAC practice with chil-
dren with S/PIMD seems to be experience driven. Hence, the indi-
vidual experiences of each SLP were described as shaping their
clinical decision-making. The AAC solutions of former patients
seemed to be go-to choices when faced with a new patient.
“There is a threshold to get going with, for example, Snap Core First
or PODD book or something and it, it matters quite a lot to my clin-
ical decisions which other children I have [on my caseload]. If I have
a couple who use Snap Core First, then I have wrapped my head
around that system ( … ), while I at the same time may not have
had any users of PODD books, causing me to have a high threshold
to initiate that” (Britt). Some AAC-methods cannot be imple-
mented unless the clinician takes a mandatory course. Whether or
not the SLP had taken various courses widened or limited the
AAC toolbox. On the other hand, even when accredited on a cer-
tain AAC method, the experience of practicing it still seemed like
the most important factor for whether or not it would be further
used. “Maybe not just what courses I have taken, but also what I
feel confident in and what I have seen functioning well ( … ). I may
have a course accreditation but never use it. And then perhaps
when an opportunity actually arises, I still won’t use it” (Betty).
The SLPs seemed to experience that they had to interpret and
define AAC’s conceptual boundaries for themselves. When asked
about whether it was clear which interventions with children/
youth with S/PIMD were to be classified as AAC, the answer was

unanimously “no” and the participants imagined that perceptions
of conceptual boundaries of AAC probably differed between SLPs.
Several mentioned that the concept seemed to have been grad-
ually broadened in recent years to include strategies for support-
ing interaction or cognition. The more complex the disabilities,
the more unclear it seemed whether certain interventions were in
fact AAC. “ … like interpreting reactions, I think of that as AAC. I
can write it down: ‘when the child does this, then we interpret it like
that’ and then we reinforce what the child does, and it becomes an
expression ( … ) But does that count as AAC or not?” (Anne). It was
unclear whether the confusion regarding the AAC boundaries
affected the clinical decision-making, but it did seem to compli-
cate the practice since education and communication about AAC
with persons in the child’s social network was such an important
part of the practice. “It depends on who you ask. Does the school
view that as AAC or not? Do the parents view it as AAC?” (Angelica)
A variety of factors connected to the SLPs’ organizational con-
texts were mentioned in relation to clinical decision-making.
Available resources such as sufficient time, opportunities to take
courses, clear routines for implementation of interventions, prox-
imity to experienced colleagues (both SLPs and other professions)
and available expert teams within the organization all affected
the SLPs’ practices. Organizational support was particularly helpful
when you as an SLP lacked experience, such as when being newly
employed, when implementing an AAC method for the first time
or when facing a patient with a rare condition. Also, regulations
on prescribing publicly funded aids differed slightly across the
counties, thus affecting clinical decision-making.
Discussion
In this explanatory, mixed-methods study, we explored Swedish
SLPs’ clinical decision-making regarding AAC with children and
youth with S/PIMD. The results painted the picture that AAC was
highly valued, offered to a very large extent, and that a wide var-
iety of AAC methods and tools was considered. The (perceived)
“ideal” AAC solution was balanced against the complexity of the
child’s disabilities and uncertain prognosis, the resources and
wishes of the child’s social network and the resources of the SLP
in terms of time, knowledge, clinical experience and access to
knowledgeable colleagues. More detailed conclusions to each
research question will be presented and discussed below.
Intention to implement AAC
It was concluded that the SLPs had very high intentions to imple-
ment AAC with children/youth with S/PIMD. They seemed to
(almost) always offer AAC. It was even reflected upon as an eth-
ical obligation. We are not aware of any prior studies concluding
a high intention to implement AAC with children/youth with S/
PIMD. In this context it is worth mentioning that the conceptual
boundaries between AAC and cognitive support and between
AAC and intervention strategies supporting interaction were
unclear to the SLPs. When interpreting the high intentions to
implement AAC it may hence be most accurate to cautiously
apply a wide definition of AAC.
Commonly implemented AAC
A variety of AAC tools and methods were implemented with chil-
dren/youth with S/PIMD, according to the survey results. More
concrete AAC solutions had the highest ratings, but out of 24
addressed AAC characteristics, only two (vocabulary organized as
AAC WITH CHILDREN WITH S/PIMD - SLP'S PRACTICES 9
visual scene displays and use of ideographic symbols) received
medians that were equivalent to “never”, when asked how often
the AAC method had been implemented in the last two years.
The low ratings on visual scene displays could be considered sur-
prising, given that it is recommended to use this with emerging
communicators and that it has been found to be less cognitively
demanding than other ways to organize vocabulary [19]. The the-
matic analysis confirmed that the SLPs seemed to consider the
complete AAC toolbox as potentially valid, but that the clinical
decision-making on methods and tools was a balancing act
between several factors, that were all taken into account. Similar
trade-offs between competing factors have been reported in AAC
decision-making in previous studies [20,47,48].
Beliefs about AAC intervention with children with S/PIMD
The third research question addressed beliefs and values relating
to AAC interventions and how these beliefs and values guided
the clinical decision-making in connection to AAC. The cognitive
abilities of the children were discussed in the focus groups as
being important when deciding on an AAC method, but no spe-
cific suggestions or ideas were further elaborated. For emerging
communicators, AAC systems should harmonize with the child’s
current developmental level and at the same time challenge the
child and promote growth in developmental domains [19].
However, the child’s exact level of cognitive functioning was
sometimes experienced as being under discussion and the chil-
dren were often experienced as having very uncertain trajectories
of cognitive development. This seemingly challenged the SLPs
when trying to find the best AAC fit.
Given the children’s low cognitive functioning, it may be sur-
prising that seemingly more cognitively demanding AAC solutions
with large vocabularies were considered and implemented. Less
cognitively demanding AAC solutions (such as using one referent
at a time) were indeed the most common (according to survey
results). Nevertheless, the SLPs did not think that low cognitive
functioning in the child necessarily excluded the more advanced
AAC methods. Relatedly, in a previous study on assistive technol-
ogy use with individuals with profound ID, it was found that pro-
fessionals with more knowledge on assistive technology
considered the person’s limited cognition to be less of an obs-
tacle to the implementation of assistive technology, as compared
to professionals with less assistive technology knowledge and
experience [25]. However, for the SLPs to consider more cogni-
tively demanding or more technically advanced AAC, the SLPs
carefully considered the motivation and engagement of the
child’s daily communication partners. Indeed, one of the most evi-
dent themes in the thematic analysis was the adjustment to the
resources and motivations of the child’s social network when
choosing and implementing AAC. Also, the analysis of survey data
showed that the majority rated positively on the item stating that
the actions of parents and teachers had greater impact on the
outcome of the AAC intervention than the actions of the SLP.
Some focus group participants even articulated that the social
network’s motivation and resources were the factors that most
strongly guided their clinical decision-making. Similar results have
been found in a study on SLPs’ clinical reasoning in relation to
AAC interventions targeting children with autism, where “the
communication partner’s AAC skills” and “the communication
partner’s perception of AAC outcomes” were two of the most fre-
quently mentioned factors considered to predict, moderate and
mediate AAC outcomes [22]. The highlighted importance of the
parents and other significant communication partners was
10 A. RENSFELD FLINK ET AL.
motivated by the belief that the quality of communication of chil-
dren with S/PIMD is very reliant on the interactional patterns of
the communication partner, a belief that is confirmed by literature
[49–51]. The importance of the communication partner’s involve-
ment in interventions targeting children/youth with S/PIMD is
indeed previously recognized [16,52,53] as well as the importance
of individualizing AAC interventions aimed at children with dis-
abilities and adjusting them to the parents’ knowledge, abilities
and desires [54,55]. A family centred approach for AAC services
has been proposed, where the application of family systems the-
ory and ecological systems theory guides successful, collaborative
relationships with the families in AAC intervention [56].
Research evidence was almost never mentioned in the focus
groups as a factor that strongly guided the clinical decision-mak-
ing about AAC with children/youth with S/PIMD. This resembles
the results in a British study addressing SLPs’ approaches to com-
munication interventions with individuals with PIMD [23] and
similar results have been found regarding SLPs’ clinical decision-
making on AAC for children with other, or a broader range of dis-
abilities [22,57]. In the survey results, it was however evident that
a majority of the SLPs believed that there is good research evi-
dence in support of AAC interventions with children/youth with
S/PIMD. This stands somewhat in contrast to the current research
evidence on AAC targeting this group, which is actually rather
limited [17,18,23].
Clinical experience in relation to decision-making and beliefs
about AAC
Both statistical and thematical analyses indicated relationships
between clinical experience and clinical decision-making but not
necessarily between clinical experiences and beliefs about AAC.
According to an Australian study, SLPs view their individual, clin-
ical experience from working with AAC and children with S/PIMD
as important for gaining adequate skills to implement communi-
cation intervention with this target group [24]. Our results seem
to add the notion that different clinical experience may guide dif-
ferent decision-making. Statistically, experience from the habilita-
tion service correlated significantly with implementation of certain
AAC methods, while the proportion of S/PIMD patients in the
caseload correlated with implementation of some other AAC
methods. These different relationships could possibly be
explained somewhat by the results of the thematic analysis:
Experiences from past patients and their social networks seemed
to guide clinical decision-making to a great extent. The threshold
for implementing more unusual and/or technically complex AAC
solutions, such as eye gaze control or PODD books, could report-
edly be quite high. However, once you as an SLP had already
implemented them, you were more likely to implement them
again. To have a higher proportion of complex patients on your
caseload could possibly have prompted you to cross the thresh-
old from “standard solutions” to more rare solutions, thus making
you more inclined to do so again. This kind of experience-driven
clinical choice-making could potentially explain why use of some
of the less applied AAC methods (such as visual scene displays)
correlated with the proportion of S/PIMD cases in the caseload.
On the other hand, the SLPs who had worked for several years
and had experience of following S/PIMD cases over a long time,
described in the focus groups how they over the years had
learned to “start with the basics” and not to rush too quickly into
overly ambitious plans. This could possibly explain the positive
correlation between habilitation service experience and (for
instance) using one referent (e.g., one picture or object) at a time.
Moreover, the thematic analysis implied that long experience
had nuanced some of the SLPs beliefs about their own compe-
tence in relation to the parents’ competence and made them
more inclined to listen to the parents’ convictions about what
interventions would work in the long run. The clinician’s sensitiv-
ity to parents’ wishes and acknowledgement of the parents as an
expert on their own child has been proposed as being important
for parents’ engagement in AAC intervention [54]. Also, for the
SLP to make compromises when a parent’s wishes do not match
the SLP’s suggested choice of AAC has been argued to reduce
the risk of AAC abandonment [55]. This was mentioned as a con-
scious strategy by a couple of the more experienced SLPs in the
focus groups.
Limitations
There are several potential limitations with the study. First, we
have no information about the non-responders to the survey. This
prevents us from knowing whether the non-responders and res-
ponders differed in important ways. Second, there is a risk of the
survey responses being affected by social-desirability bias, where
the SLPs overreported what they experienced as desirable AAC
practice. Third, the counties included in the study were not stra-
tegically sampled, even though a coverage of more than 70% of
Sweden’s population with diverse demography could potentially
indicate representativity. Even so, the results cannot be directly
generalized beyond the context of SLPs in Swedish habilita-
tion services.
Implications for research and clinic
The study shed light on the important and challenging task SLPs
face when working with AAC implementation and children with
S/PIMD. Restricted resources when it comes to time and further
training opportunities were mentioned in the focus groups as lim-
iting factors in the everyday work, which seemed more informed
by experience than by broader evidence. In the focus groups it
was mentioned that a vision of how one ought to work (seem-
ingly based for instance on research and case reports from clinical
conferences) stood in contrast to a complex reality where it rarely
felt possible to live up to the perceived standard. The few, avail-
able studies and their results may possibly be hard for the SLPs
to translate to their actual, clinical context. There is a shortage of
family and home oriented AAC intervention research targeting
the S/PIMD population [18] which is the primary intervention con-
text for SLPs within Swedish habilitation services. More studies in
this area of research are warranted and could potentially
strengthen the association between clinical practice and research
evidence. Some AAC characteristics that were quite commonly
implemented are, to the best of our knowledge, very under-
studied when targeting the S/PIMD group, such as use of manual
signs, tactile signs or AAC solutions with larger vocabulary sizes,
prompting intervention studies in these areas.
It seems clinically relevant to raise self-awareness about the
evidence-based relevance of the family-centredness that the SLPs
described in the focus groups. This is supported in literature as
important for avoiding AAC abandonment [55,56]. The SLPs
mainly referred to this as being learned through experience, and
it seems it would be empowering for them to learn that their clin-
ical instincts in this matter harmonize with research evidence.
Maybe especially so when there sometimes seemed to be a sense
of failure on the SLP’s part when compromising or adjusting their
initial plan for AAC to the resources and wishes of parents.

Beyond the scope of this study, but interesting for future stud-
ies, is the topic of applied intervention goals for the AAC inter-
ventions, how these are clinically evaluated and what counts as
“successful” AAC implementation with children/youth with S/
PIMD. Goal setting was touched on in the focus groups as being
challenging. When targeting the S/PIMD population with its slow
and uncertain developmental trajectories, it is reportedly very dif-
ficult to assess and track communication development in research
[9,58,59] as well as in clinical practice [60]. Hence, it is of interest
to explore how goal setting and evaluation of AAC interventions
are handled in clinical practice.
In line with other previous research exploring professional
decision-making in healthcare and education [e.g., 32,33], we
applied the theory of planned behaviour as a theoretical guide
when developing the survey [31]. We found it to be a useful
framework when characterizing potential factors associated with
clinical decision-making in AAC practice and we encourage it to
be used in further related research.
Another area for future studies is the shared interprofessional
decision-making between the healthcare setting and the school
or pre-school setting. In the focus group data, the collaboration
with teachers in schools was highlighted as important for clinical
decision-making.
Acknowledgements
The authors are very grateful to all participating SLPs who
devoted time to share their clinical insights.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
The study was financially supported by the S€avstaholm
Foundation, the Swedish state under the ALF agreement, the
Jerring Foundation, the Queen Silvia Jubilee Fund and the Linnea
and Josef Carlsson Foundation.
ORCID
Anna Rensfeld Flink http://orcid.org/0000-0002-2006-8569
Gunilla Thunberg http://orcid.org/0000-0002-9582-7814
Anna Nyman http://orcid.org/0000-0002-8553-7397
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