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Key principles underlying research and practice in AAC

Article in Augmentative and alternative communication (Baltimore, Md.: 1985) · October 2007
DOI: 10.1080/07434610701553684 · Source: PubMed

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 Augmentative and Alternative Communication, September 2007 VOL. 23 (3), pp. 191 – 203

Key Principles Underlying Research and Practice in AAC

SARAH W. BLACKSTONEa*, MICHAEL B. WILLIAMSa and DAVID P. WILKINSb

a
Augmentative Communication, Inc., Monterey, CA, USA, bUniversity of Sydney, Sydney, Australia

Six principles of AAC research and practice are offered for consideration and discussion
within the AAC community. Principle 1 requires the active participation of individuals with
complex communication needs (CCN) in all AAC activities. Principle 2 seeks to ensure that
theoretical constructs underlying research and development in AAC are grounded, widely
accepted, and clearly defined. Principle 3 underscores the need to use ergonomics in
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the design and development of AAC technologies and instructional strategies. Principle
4 highlights communication partners and the unique roles they play in AAC. Principle
5 accentuates the need to focus on societal roles, relationships, and opportunities
made possible by AAC technologies and services. Finally, principle 6 draws attention to
the importance of measuring a broad range of AAC outcomes, especially those most
significant to primary AAC stakeholders.

Keywords: Augmentative and Alternative Communication; AAC; AAC/AT Technologies;

Complex Communication Needs; Theoretical Constructs; Ergonomics; Communication
Partners; Outcomes
For personal use only.

INTRODUCTION sites in the United States, these principles were

further discussed by a group of 70 participants at
Principles are basic assumptions about an ideal the AAC-RERC sponsored 2006 State of the
state (rather than truths or laws of nature). As Science in AAC conference in Los Angeles,
such, principles serve as goals or standards, and California. Conference participants, who included
provide a framework within which to construct individuals who rely on AAC, family members,
and evaluate various activities. Principles have researchers, practitioners, university faculty, pol-
an inherent stability; i.e., they represent charac- icy makers, manufacturers and developers, agreed
teristics that are considered essential and that while other AAC principles certainly exist,
unchangeable. Thus, they can be both a guide these six principles are key to ongoing work
for day-to-day work, and a way to evaluate the within the field of augmentative and alternative
degree to which a program is ‘‘measuring up.’’ As communication (AAC).
manifested over time, the understanding and
implementation of a principle can evolve, broad-
Basic Assumptions Underlying the Principles
en, deepen, and even narrow on the way to
becoming more clearly defined and more com- There are some basic assumptions underlying the
pletely realized. six AAC principles highlighted in this paper. To
The six principles set forth in this paper rep- begin with, communication is seen as a dynamic,
resent a current, collective standard toward which transactional process that involves at least two
the partners of the Rehabilitation Engineering people. Components of the communication pro-
Research Center in Communication Enhance- cess include the (a) physical and cognitive
ment (known as the AAC-RERC) aspire.1 characteristics of the interactants (persons who
Derived over a decade, during collaborations are deaf, blind, have cerebral palsy, aphasia,
among researchers and practitioners from seven autism, etc.); (b) propositional content of

*Corresponding author. Sarah W. Blackstone, One Surf Way #237, Monterey, CA 93940, USA. Tel: þ1 831 649 3050.
Fax: þ1 831 646 5428. E-mail: [email protected]

ISSN 0743-4618 print/ISSN 1477-3848 online Ó 2007 International Society for Augmentative and Alternative Communication
DOI: 10.1080/07434610701553684
 192 S. W. BLACKSTONE et al.

messages and how they are represented and technological education, instructional strategies,
conveyed (face-to-face, by phone, over the and AAC technologies and strategies. A holistic
Internet, etc.); (c) situations in which messages communication perspective is central to the
are transmitted and understood (noisy environ- principles set forth in this article.
ment, home, school, at a movie, etc.); (d) social Finally, it is important to note that the practice
relationships of the interactants (familiar, unfa- of AAC today has broadened to extend well
miliar communication partners, boss, parent, beyond the traditional focuses on face-to-face
etc.); and (e) specific purposes of each interaction interactions, writing, and making telephone calls.
(sharing information, expressing feelings, social As society has embraced computers and tele-
closeness, etc.). In addition, communication communications, there has been a radical reorga-
partners are often noted to be uniquely engaged nization and re-conceptualization of interactive
during AAC interactions, in that meaning is communication. The who, what, why, when,
jointly established or co-constructed, often using where and how of everyday communication has
a variety of strategies, including the simultaneous certainly changed, and communication is far less
use of multiple channels or modes (speech, constrained today by temporal and spatial
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gestures, manual signs, facial expressions, electro- factors. Access to a broader range of social con-
nic and nonelectronic technologies, etc.). texts and communication partners and ways of
AAC, as an area of practice, has a growing interacting and learning offers exciting opportu-
evidence base that demonstrates the effectiveness nities as well as challenges in AAC. Children and
of AAC technologies and strategies across a adults with complex communication needs want
broad spectrum of individuals with CCN who to be, need to be, and should be participating in
are widely diverse in age, disability type, socio- these changes, which are being fashioned largely
economic status, ethnicity, culture, language, and by generic technologies and the mainstream
so forth. AAC systems are not seen as synon- marketplace.
ymous with speech generating devices (SGDs) or
even with AAC technologies (high- and low-tech),
For personal use only.

but rather are a broad, integrated group of THE SIX PRINCIPLES

strategies, tools, and techniques from which
an individual with CCN may choose when Others have written about principles in the area
communicating anywhere, any time, and with of AAC and assistive technology (Cook &
anyone. Hussey, 2001; Lloyd, Fuller, & Arvidson, 1998).
Research and development activities in the area Likewise, clinical programs often describe princi-
of AAC must account for a multiplicity of ples underlying their AAC practices. As noted,
variables to achieve outcomes that advance and the six principles set forth in Table 1 are not the
improve the lives of people with CCN. Thus, in only principles relevant to AAC research and
AAC research and practice, the end goal is not practice, but rather have determined, to a great
just the design and recommendation of AAC extent, the policies, modes of action, and deci-
devices, access methods, or outputs. Rather, AAC sions taken within the AAC-RERC; and helped
requires the concomitant attention to commu- us to define priorities for research, development,
nication content, communicative goals, enhancing training, and knowledge transfer. As such, they
social participation and social networks, commu- have provided us with a standard against which to
nicative self-management and self-determination, measure the impact of our work.

TABLE 1 Six AAC principles.

1 People who rely on AAC participate actively in AAC research and practice.
2 Widely accepted theoretical constructs are specifically addressed in the design and development of AAC technologies and
instructional strategies.
3 AAC technologies and instructional strategies are designed to support and foster the abilities, preferences, and priorities of
individuals with complex communication needs, taking into account motor, sensory, cognitive, psychological, linguistic, and
behavioral skills, strengths, and challenges.
4 AAC technologies and instructional strategies are designed so as to recognize the unique roles communication partners play
during interactions.
5 AAC technologies and instructional strategies enable individuals with complex communication needs to maintain, expand, and
strengthen existing social networks and relationships and to fulfill societal roles.
6 AAC outcomes are realized in practical forms, such as guidelines for clinical practice, design specifications, and commercial
products. The social validity of these outcomes is determined by individuals with complex communication needs, their family
members, AAC manufacturers, and the broader AAC community.
 KEY PRINCIPLES IN AAC RESEARCH 193

TABLE 2 Participants and roles in the AAC-RERC: 1998 – 2006.

Principle 1: People who Rely on AAC Participate
Actively in AAC Research and Practice Persons with Family
Types of roles CCN members
While there are multiple stakeholder groups in
AAC, the primary stakeholders are a diverse Advisory board of Center 3 3
Project advisory boards 19 15
group of individuals with complex communica- Staff 17 1
tion needs. Without them, the area of AAC would Consultants 39 7
not exist. Of course, family members, clinicians, Authored/co-authored articles 17 4
teachers, educators, researchers, developers, care- Presented at conferences 21 15
givers, friends, funders, advocates, and manu- Taught/co-taught courses 19 14
Project manager, co-investigator 4 2
facturers are also key AAC stakeholders. Thus, Subject participants 240 111
when thinking about designing and improving
AAC technologies and instructional strategies, it TOTAL NUMBER 376 170
is important to seek input from all relevant stake-
holder groups, knowing that they will not all view
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the world in the same way. The most important

Supporting Participation
voices are often the hardest to hear. In fact, indi-
viduals with complex communication needs have Individuals with complex communication needs
found it difficult to influence AAC research, come from various ethnic, racial, cultural, and
technology development, clinical practice, educa- linguistic groups; have a variety of disabling con-
tion, dissemination strategies and government ditions; and represent lifespans that range from
policy. They have been disenfranchised from the birth to death. Thus, their participation requires
decision-making, design, and development pro- different types and degrees of support. Research
cesses that, in the end, primarily affect their well- shows that individuals who rely on AAC often
being (Rackensperger, Krezman, McNaughton, face barriers to active, ongoing employment and
Williams, & D’Silva, 2005). participation in the community (McNaughton &
For personal use only.

This principle is presented first because it must Bryen, 2002, 2007; McNaughton, Light, &
inform all other AAC principles. Individuals with Grozyk, 2001; McNaughton, Light, & Arnold,
complex communication needs hold an intensely 2002; Williams, 1994). Telework, online focus
personal stake in AAC research and clinical groups, and other Internet strategies have proven
practice; hence the slogan, ‘‘Nothing about us, effective in addressing some of these challenges.
without us’’ (Charlton, 1998). Key sources of For example, Beukelman and colleagues at the
evidence about effective AAC strategies and University of Nebraska introduced prototype
technologies (high- and low-tech) are the people AAC equipment to adults who relied on AAC
who rely on them to communicate. Their char- and solicited their evaluative input using a
acteristics, experiences, preferences, priorities, questionnaire on a website using a Virtual Net-
opinions, suggestions, and expertise must be work Computing application2 (Beukelman et al.,
sought, respected, attended to, understood, and 2001). Participants in the study could work at
employed in the design, development, delivery, and their convenience and prepare responses using
evaluation of AAC systems and services. Partici- their own computers and AAC technologies. An
patory action research, a sociology methodology, additional benefit was that the research team
recognizes people with disabilities as key co- could analyze and catalogue their responses
participants in the research process (Whyte, electronically without data entry.
1991). It is widely recommended as a way to in- Another example is the Tech 2010 project
volve individuals with complex communication (Rackensperger et al., 2005). Adapting focus
needs in developing research questions, designing group methodology to the Internet, the research
methods, and analyzing and interpreting data team interviewed a group of individuals with
(Blackstone, Williams, & Joyce, 2002; Krogh & complex communication needs about their stra-
Lindsay, 1999; Iacono, Balandin, Cupples, 2001; tegies and preferences for learning to use AAC
O’Keefe, Kozak, & Schuller, 2007). The AAC- technologies. In addition, the AAC-RERC
RERC has invited many individuals with complex Writers Brigade, which employs and mentors
communication needs to its virtual table, and then individuals with complex communication needs
aggressively and respectfully sought ways to sup- to produce articles about AAC-RERC research
port their active participation and leadership. As and development projects, is demonstrating that
seen in Table 2, individuals with complex com- telework is a reasonable and productive emp-
munication needs and family members can fulfill a loyment and skill development alternative
number of roles in ongoing research, development, (Schwartz, McLeod & Blackstone, 2007). In
training and knowledge transfer activities. short, Principle 1 underlines the importance of
 194 S. W. BLACKSTONE et al.

taking the necessary steps so that, individually language development, which focuses on lan-
and collectively, the people most directly im- guage structures and is based on the early study
pacted by the outcomes of AAC-related activities of just three articulate, middle class, American
can influence the direction of research and English-speaking children, is still being used
development projects in the field and, ultimately, despite the emergence of a more multimodal,
the AAC products and instructional strategies social, and semantically and pragmatically based
that become available to them. understanding of Language and language acqui-
sition (Bates & Dick, 2002; Bowerman, 2000;
Slobin, 2003; Tomasello, 2003a). Further, other
Principle 2: Widely Accepted Theoretical
modalities, such as gesture, are now shown to be
Constructs are Specifically Addressed in the Design
critical both to linguistic and to cognitive devel-
and Development of AAC Technologies and
opment (Goldin-Meadows, 2003; Volterra,
Instructional Strategies
Caselli, Capirci, & Pizzuto, 2004). One of the
Effective design and development of new AAC most prominent accounts of language acquisition
technologies and instructional strategies cannot today, for example, is Tomasello’s ‘‘usage-based’’
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happen in scientific or social isolation. Individuals theory of acquisition (Tomasello, 2003a,b). In

with complex communication needs are best short, the current theoretical construct of Lan-
served when the process of AAC research and guage is highly relevant to AAC research and
practice is guided by clearly articulated appro- development activities, as well as to AAC clinical
aches to empirical observations and assessments practice.
and when the design and development of AAC Because theoretical constructs (whether expli-
technologies and instructional strategies are citly stated or not) impact modes of operation in
grounded in widely accepted theoretical con- research, development, and practice, they often
structs. Principle 2 reflects the need to ground determine what constitutes relevant human fac-
AAC research and practice in theoretical con- tors, what is considered relevant evidence, and
structs that help define appropriate ways to how that evidence will be interpreted. For
For personal use only.

gather information, including stakeholder input, example, the earlier sender – receiver definition
and determine relevant empirical evidence and of Communication may limit human factors
how that evidence is to be interpreted. considerations to the interface between the user
and the device. On the other hand, the construct
of Communication as the joint establishment of
The Use of Theoretical Constructs in AAC
meaning necessitates consideration beyond fac-
Research and Practice
tors that relate to the individual using an AAC
Theoretical constructs are concepts that are system, and requires taking into account key
invented for scientific and research purposes. aspects of the environment and people around the
They are not, in themselves, observable, but are individual with complex communication needs.
inferred from observations. Language and Com- An example is seen in the familiar notion of
munication are examples of important theoretical communication rate. If rate is understood as a
constructs in the area of AAC. Certainly, one matter of the successful joint establishment of
does not observe all components of language or meaning rather than as words/keystrokes per
communication directly, however it is possible to minute, then measuring how quickly information
ascertain characteristic features of each from is successfully shared and grounded rather than
repeated observations over different contexts of how quickly it is produced becomes important.
language and communication use and then to This is not to say that the speed of message
make generalizations from particulars. transmission and other access issues (e.g., auto-
Over time, theoretical constructs may change as maticity, cognitive load, etc.) are not important,
new particulars are observed or new general- only that they suddenly take a very different
izations made; i.e., they evolve. Also, a change in position within the matrix of factors that need to
one theoretical construct often requires a change be attended to and considered in AAC research,
in our understanding of other constructs. For product development, and in clinical practice.
example, with a change in our understanding of (Higginbotham, Shane, Russell & Caves, 2007).
Language has come a change in the view of how
language is acquired and what constitutes rele-
Acceptance and Consistency of Theoretical
vant stages in language acquisition and literacy
Constructs
development. Not all fields that rely on Language
as a construct will incorporate observational and While different research groups may use the
theoretical changes at the same rate. For instance, same terms to label theoretical constructs (e.g.,
Brown’s (1973) description of the stages of language, communication, learning, interaction),
 KEY PRINCIPLES IN AAC RESEARCH 195

what matters most is how clearly a construct is capacity of newer technologies and the resultant
defined, how widely that definition is accepted, change in observed social behaviors across the
and how consistently the definition is used. A globe. As AAC researchers and developers seek to
well-grounded construct means that sufficient understand interactions as they occur across
prior work has demonstrated to respected re- environments, tasks, technologies, and various
searchers that the definition provides important interactants, characteristics of the interaction
and usable insights and results. For instance, as move toward the foreground and technology
noted previously, many current researchers slides into the background. In other words, while
within and outside the area of AAC now steer the commitment to connectivity persists, its
away from a sender – receiver definition of definition has evolved in parallel with expanding
Communication, toward a definition that recog- notions of connectivity now held outside and
nizes human communication as a joint action within the field of AAC.
(negotiation) between individuals for the pur- Another way theoretical constructs can evolve
poses of jointly establishing meaning (von is through listening closely to people who use
Tetzchner & Martinsen, 2000; von Tetzchner & AAC. Their input can help ground existing
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Grove, 2003). This widely accepted view of theoretical constructs, and can also lead to
Communication guides researchers, developers, consideration of new theoretical constructs or
and practitioners in formulating and interpreting new ways of applying or defining constructs.
information. Consider the following observations by Williams
To consider a construct to be widely accepted (2004):
necessitates taking into consideration the work
and related theoretical constructs of relevant No one communication mode, no AAC
neighboring disciplines. For example, the under- device, no low-tech board, no gestures,
standing of human communication as an inter- signs, or speech could possibly meet all my
active social process with the goal of jointly communication needs all of the time. I use
establishing meaning emerges out of current multiple communication modes. I commu-
For personal use only.

psycholinguistic research (Clark, 1996, 2004, nicate in many ways. I select the best mode
2005), and is a natural extension of the notions depending on the location, with whom I am
of distributed cognition and distributed represen- communicating, and the purpose and con-
tation that have been used profitably in cognitive tent of the communication . . . I suggest that
science (Hutchins, 2001; Goodwin, 2003). everyone needs more than one way to
Furthermore, the theoretical construct of communicate. We all need access to multiple
Communication closely fits with the construct communication modes to be able to say
of social network as employed in sociology everything we need and want to say, when-
(Degenee & Forsé, 1999). Thus, the joint estab- ever and wherever we happen to be, and to
lishment of meaning view of Communication is whomever we choose.
widely supported by research in fields outside of
AAC and also links easily to other theoretical William’s personal observations suggest an
constructs employed both within and outside the important theoretical view that could be labeled
field of AAC (e.g., social networks). contextual determination of mode selection.
Obviously, certain communication modes have
unique constraints as well as capabilities, making
The Evolution and Grounding of Theoretical
them more or less suitable in certain situations.
Constructs
For example, a university student attending a
As suggested earlier, theoretical constructs tend lecture would demonstrate context-based mode
to evolve and, as they do, the focus of AAC selection by using the speech function of her SGD
research and development often shifts. For to answer a question from her professor, but
example, DeRuyter, McNaughton, and Caves turning the voice off and pointing to the message
(2007) note that connectivity (the notion that screen (while smirking) when making a snide
individuals who rely on AAC want and need to comment about the professor to a classmate.
connect to their environment and the world Viewed carefully, one realizes that Williams’
through their AAC devices), initially was ex- descriptive remarks have theoretical import, and
plored from the point of view of the device as a show how important it is to examine the
tool used for connection. Today’s focus in AAC contributions of people who rely on AAC with
has shifted to what various connections can an eye towards discovering new theoretical
provide for an individual and his or her commu- constructs or experientially relevant new twists
nication partner(s) and how can these be prior- on old theoretical constructs (in keeping with
itized?, which reflects the ‘interconnectivity’ Principle 1.)
 196 S. W. BLACKSTONE et al.

During the AAC-RERC 2006 State of the

Principle 3: AAC Technologies and Instructional
Science Conference, participants (especially indi-
Strategies are Designed to Support and Foster the
viduals with complex communication needs)
Abilities, Preferences and Priorities of Individuals
continued to call for the redesign of AAC
with Complex Communication needs, Taking into
technologies. Two common requests were: (a)
Account Motor, Sensory, Cognitive, Psychological,
make SGDs easier for individuals with CCN and
Linguistic, and Behavioral Skills, Strengths, and
their primary communication partners to learn
Challenges
and use, and (b) enable them to connect more
While this principle may seem obvious, the AAC seamlessly with mainstream technologies and
industry is small and lacks the resources of reflect contemporary design and fashion sense.
mainstream technology companies that system- It appears that to improve the cognitive and
atically assess and delineate the abilities of linguistic features and usability factors of AAC
individuals in targeted user groups, ask for and technologies and strategies, the research and
understand their preferences and priorities, and development work will necessarily come from
then respond by modifying features of existing within the field. However, advancements in
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technologies or developing new ones. The field of features such as batteries, displays, naturalness
human factors, or ergonomics, applies scientific of speech, and access to phones, wireless inter-
information concerning humans to the design of faces, advanced processing, storage, and privacy/
objects, systems, and environments for human use security, are more likely to come from main-
and can be applied to the design and development stream technology companies. Once they are
of AAC technologies. available and affordable, AAC manufacturers
can then incorporate them into AAC techno-
logies (DeRuyter, McNaughton, Caves, Bryen, &
Ergonomics
Williams, 2007).
Ergonomic designs take human capabilities,
limitations, and preferences into account in
Ergonomic studies in AAC
For personal use only.

ways that are meant to insure that a particular

product is a good fit for a targeted set of users Given the limited resources of the AAC manu-
(Kondraske, 2000). One would expect, therefore, facturing industry and the AAC research com-
that the best designed AAC technologies (high- munity, systematic ergonomic studies addressing
and low-tech) and AAC instructional strategies the abilities, preferences, and priorities of indivi-
would combine features that reflect a thorough duals who rely on AAC technologies are rarely
knowledge of the unique characteristics of the conducted. Rather, decisions about desirable
individuals who are meant to benefit from them. product features are often based on what
In fact, however, it is exceedingly difficult to technologies are available and affordable, the
ascertain and define characteristics of indivi- beliefs of people in a company, and the experi-
duals with complex communication needs ences and opinions of AAC practitioners and
because of their diversity, as well as the multi- individuals who rely on AAC as reported to
plicity of possible daily interactions they may corporate design teams. Overall, design, develop-
have (face-to-face, talking on a phone, com- ment, and manufacturing decisions in the AAC
municating while playing, emailing, lecturing, industry are not systematically based on scientific
etc.). ergonomic studies.
Three types of ergonomics are often described: A major contribution of the AAC-RERC has
(a) physical,3 (b) cognitive,4 and (c) macro- been to conduct seminal studies defining the
ergonomics.5 All are relevant to the design of abilities, preferences, and priorities of specific
AAC technologies and instructional strategies. In groups who benefit from AAC technologies, while
the area of AAC, attention originally focused on simultaneously taking into account the unique
physical ergonomics, with concerns such as how roles that familiar communication partners and
to access AAC devices and other technologies, facilitators fulfill during the communication
enhance rate, and determine preferences for process. For example, researchers at Pennsylvania
speech synthesizers (Blackstone et al., 2002). Of State University have studied characteristics and
course, communication devices are not just about preferences of young children with CCN for AAC
providing physical controls, keystrokes, rate, and technologies, and are now developing and testing
quality speech output. Cognitive and linguistic new AAC technologies and instructional strate-
issues, usability, interconnectivity, and environ- gies that are fostering the language, communica-
mental concerns (e.g., partner, task, and context) tion, and literacy capabilities of these children
also are key design factors (Higginbotham et al., (Light & Drager, 2007). Researchers at the
2007). University of Nebraska are demonstrating that
 KEY PRINCIPLES IN AAC RESEARCH 197

adults with severe aphasia can use visual scene of the circles of a communication partner’s
displays (personalized digital photographs of paradigm: family, friends, acquaintances, paid
activities and events) on SGDs to co-construct workers, and strangers (Blackstone, 1999;
messages during face-to-face interactions Blackstone & Hunt Berg, 2003; based on earlier
(Beukelman, Fager, Ball, & Dietz, 2007). Visual work by Falvey, Forest, Pearpoint, & Rosenberg,
scene displays provide a shared (and often 1994). Individuals with complex communication
familiar) context that interactants can use effec- needs communicate differently with different
tively (with minimal training) to tell stories and kinds of partners; i.e., the topics, strategies, and
engage in social interactions to the satisfaction of modes will vary. In addition, they often have
both communication partners. Further, Shane fewer communication partners overall and a
and colleagues at Children’s Hospital Boston are greater number of interactants who are family
finding that children with autism spectrum members and paid workers, rather than friends or
disorder (ASD) participate and stay engaged for acquaintances.
longer periods of time when instruction is deli-
vered using electronic screen media (ESM) and
AAC Facilitators
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characters referred to as ‘‘intelligent agents.’’

They are developing software aimed at teaching Primary communication partners often engage in
language, communication and educational con- a variety of roles in the communication lives of
cepts, via ESM and intelligent agents (Shane & individuals who use AAC. In addition to con-
Albert, 2005). versational partners, they may be AAC facilita-
In summary, the third principle includes a tors, trainers of new communication partners,
complex range of factors that, when considered advocates, and technicians. Beukelman et al.
in the design process, can improve the likelihood (2007) note that individuals with acquired neuro-
that AAC technologies and instructional strate- logical conditions typically do not have the same
gies will meet the daily communication needs of level of consistent support from outside agencies
the individuals for whom they are designed, as do children. A major consequence is that the
For personal use only.

by taking into account their abilities, skills, and role of the AAC facilitator often falls to a primary
strengths, as well as their preferences and communication partner, typically a family mem-
priorities. ber. This means that, in designing AAC strategies
and technologies, there is a need to account for
the physical and cognitive demands on facilitators
Principle 4: AAC Technologies and Instructional
and primary communication partners. For exam-
Strategies are Designed so as to Recognize the
ple, Beukelman et al. (2007) note that for indi-
Important and Sometimes Unique Roles
viduals who reside in long-term care facilities,
Communication Partners Play During Interactions
there is a need for technology that does not
with Individuals with Complex Communication
require optimal setup to be functional because
Needs
a range of different staff members will share
As the saying goes, ‘‘It takes two to tango.’’ responsibility. In addition, one needs to consider
Individuals who rely on AAC recount that with the abilities, interests, and preferences of the
some partners communicative interaction is won- co-residents.
derful, and with others it is hell. Following from Partner roles and characteristics are also
this view, and in keeping with the theoretical relevant for children and youth with complex
construct of Communication as we have defined communication needs. For example, the quality
it, a useful beginning point is to view interactions, and quantity of support that communication
rather than the individuals involved, as being partners provide during interactions with young
either successful or impaired. Thus, by looking at children matters for both their linguistic and
communicative interactions between dyads (or a cognitive development. Unfortunately, children
variety of other configurations) as they strive to with complex communication needs tend to
establish meaning, one is more likely to see how receive less and poorer quality input than other
AAC technologies and instructional strategies children in the same community (Light & Drager,
might support the communication process. 2007; Smith, 2006; von Tetzchner, Brekke,
Because of this perspective, the range of actual Sjothun, & Grindheim, 2005).
and potential communication partners is a key
consideration in the design and development of
Communication Modes
AAC systems and interventions (Kent-Walsh &
McNaughton, 2005; Murphy, 2004). There are multiple aspects that determine mode
One way to think about the different types of selection, and one important consideration is
communication partners is within the context the selection of mode based on communication
 198 S. W. BLACKSTONE et al.

partner. For example, Higginbotham and Wilkins (and asymmetry), on the other hand, is deter-
(1999) explored the various contextual factors mined through direct observation and assessment
that determined whether Denton chose to use a of an interaction (e.g., Do both communication
word board, gesture, vocalization, email, or an partners display comparable attention, time use,
SGD to communicate, and found that her choice and patterns of time deployment? Do they use the
was influenced by communication partner con- same or comparable range and types of commu-
siderations. While her preferred mode was email, nication tools? Do they display a comparable
and she would have rather used a word board in range of expressive resources, such as variations
face-to-face interactions, at the time of the study in utterance type, illocutionary forces and lan-
Denton had three friends with multiple sclerosis guage play?) (Wilkins & Higginbotham, 2005).
and visual problems who could not see the board. Designing AAC technologies and strategies to
Thus, her SGD allowed her to maintain social support parity may require increasing the degree
contact with these individuals. In an email she of symmetry between individuals who rely on
wrote: AAC and their communication partners. As
previously discussed, one example is visual scene
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. . . ptL & thank U, Jesus for my dvx! with- displays that seek to provide a shared observa-
out it I wudnt be abl to com w/my 3 best tional field so that both communication partners
frends her at th hom. al 3 r mal, in mid 50s & can share a topic using the same or similar tools.
sufr frm m s, whch hs lft thm unabl to red As noted by Williams and Denton, e-mail can
my com brd . . . ablty t sav selectd wrds & ‘‘level the playing field.’’ This sense of parity
letrs [to mk up wrds] on scren – so it cn b sen comes from ‘‘symmetry’’ of time (both partners
by thos wh hv difclty rembrng begng o wrd can readily conform to the same time constraints
or msge . . . ablty t convrs w/kids – tis sur- provided by asynchrony of the medium), and
prisingly ezy fr thm t undrstnd cuz thy hv bn symmetry of technological and linguistic re-
broat up w/cmptrs & cn hr synthtc voc sources (both had access to standard e-mail, and
clrer . . . (Higginbotham & Wilkins, 1999) time to compose allowed access to the same
For personal use only.

linguistic resources).
Williams’ (2004) noted that his most preferred
communication mode also was email. ‘‘My
Cultural and Social Factors
favorite communication mode is email. Email
really levels the social playing field for me. It lets One cannot underestimate the social and cultural
me present who I really am without the annoying factors that lead a well-intentioned communica-
visual distraction of the in-person Michael tion partner to give up on interacting with some-
Williams.’’ Denton similarly indicates that it is one who relies on AAC. For example, Robillard
only in email that she can fully articulate her (1999), the sociologist and ethnomethodologist,
thoughts and gain her genuine voice. While discusses the nature and quality of his commu-
participants in synchronous face-to-face interac- nicative interactions with hospital staff during an
tion are bound by what Clark (1996, p. 267) extended hospitalization in an intensive care unit
calls the temporal imperative (i.e., the requirement (ICU). His primary tool for face-to-face interac-
that participants immediately interpret and tion was an alphabet board. Sometimes he would
respond in a timely and simultaneous manner), speak to staff through an intermediary, who
the asynchrony of e-mail allows individuals to would either read his lips or his alphabet board
use identical tools to read and compose in their or act as an interpreter. From Robillard’s per-
own time without any immediate temporal spective, these attempts at real-time interaction
pressure. were generally unsuccessful and unrewarding. As
a consequence, he felt disenfranchised from
having direct control over his health care and
Communication Parity and Symmetry
treatment. With a lack of any moves towards
The notions of communication parity and sym- communication symmetry, all sense of parity was
metry can further inform our understanding of lost.
the roles communication partners play in different Clearly the problem did not stem from his
kinds of AAC interactions. Communicative cognitive, linguistic, or literacy capabilities, all of
parity is the extent to which interactants them- which were highly developed and intact. Nor did
selves feel they are (a) equal partners in the it stem from a lack of AAC strategies and
interaction (as befits the context), (b) have equal technologies. Instead Robillard recognized that
access to communication time and resources, and his neuromuscular disease had imposed upon him
(c) are comfortable in presenting their authentic a different temporal order, one to which few
selves in context. Communicative symmetry people could comfortably adjust (especially given
 KEY PRINCIPLES IN AAC RESEARCH 199

the subjective time pressures of a busy ICU). As communication needs and their communication
he put it: partners (Blackstone & Hunt Berg, 2003; Carey,
Potts, Bryen, & Shankar, 2004). Research has
The institutionalized, naturalized, socially shown that robust social networks positively
consensual order of conversation has a time affect health, employment, and social inclusion
order, a rhythm that assumes an intersub- (Bryen, 2006; Robertson et al., 2001). Conversely,
jective coordination of physical human individuals who lack opportunities to build such
bodies. Having a body that could not inhabit ties develop a sense of isolation or loneliness
this time order was a breach of the normal- (Fried-Oken & Bersani, 2000; Williams &
ized conversational environment. (1999, Krezman, 2000).
p. 63) Individuals with disabilities, especially those
with complex communication needs, are at high
In summary, AAC research and practice must risk for having restricted social networks. This is
be sensitive to the important and unique roles true despite decades of inclusive policies in
that communication partners play within various schools, employment, and society in general.
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types of interactions. AAC technologies and Even individuals who use AAC technologies
intervention practices need to enable both inter- effectively and who have sufficient independent
actants to succeed in the joint establishment of communication skills to participate in social,
meaning. Only in this way can individuals with academic, and employment situations, are at risk
complex communication needs truly control their for physical and sexual abuse and depression
own affairs, project their authentic selves, and (Balandin, 2002; Bryen, Carey, & Frantz, 2003;
participate in meaningful societal roles. Collier, McGhie-Richmon, Odettte & Pyne,
2006). Researchers have documented some bar-
riers adolescents and adults with complex com-
Principle 5: AAC Technologies and Instructional
munication needs face in pursuing post-secondary
Strategies Enable Individuals with Complex
education (McNaughton & Bryen, 2007), becom-
Communication needs to Maintain, Expand and
For personal use only.

ing employed (Cohen, Bryen & Carey, 2003),

Strengthen Existing Social Networks and
living independently (Schwartz, 2005), and devel-
Relationships and to Meet Their Personal Goals
oping social networks (Carey et al., 2004).
and Fulfill Meaningful Societal Roles
This fifth principle represents the culmination of
Social Roles and Interconnectivity
the first four, in that it underscores the impor-
tance of supports that will allow individuals with There is only so much that can be done in a
complex communication needs to participate fully clinical setting. While new equipment and assess-
within the community at large – where we want to ment tools may give a more accurate picture of
be at the end of the day. clients, and better instructional methods may
teach language skills in a more efficient manner,
real life does not take place in a clinic. AAC
Social Networks and Communication
technologies and instructional strategies should
AAC technologies and instructional strategies are provide the necessary tools and skills so that
meant to enable individuals with complex com- individuals can communicate effectively and
munication needs to express who they are and to efficiently across multiple environments and with
increase their communication skills and participa- multiple partners. This includes actualizing roles
tion across social networks by providing the that can be imagined and preparing for roles that
multimodal tools and strategies that can (a) are unimagined at the time.
ameliorate and overcome existing communication
barriers, (b) eliminate stereotypes, and (c) pro-
Personal Choice and Self-Determination
mote active engagement in family, community,
and societal roles. Thus, in designing AAC Not all individuals with CCN have the same
technologies and instructional strategies, solu- abilities, expectations, or desires. Not everyone
tions need to consider variables that extend can, or wants to be, a techno-wiz with electronic
beyond individuals. It must be understood that communication technologies or engage in typical
communication is complex and multimodal, and community activities. It is, however, the ever-
that many different types of AAC technologies changing expectations of the individual (no
and strategies are needed in order to support the matter what age) – not the limits of technology,
communication process. A social networks focus the effectiveness of instructional methods, or
can inform and enhance assessment and inter- barriers in the community – that should deter-
vention planning for individuals with complex mine the potential and desires of the individual.
 200 S. W. BLACKSTONE et al.

A young child or an older person with a severe should ultimately and positively influence the
cognitive disability may not shop for groceries on interactions of individuals who rely on AAC with
his or her own, but can, with the aid of family a broad range of communication partners. AAC
members or caregivers, help decide what to eat for should enable people to communicate what, how,
dinner. Similarly, a person with autism may not and with whom they wish all day, every day, as
function well outside of a familiar environment, they fulfill their desired societal roles. If the work
but within that context can learn to function well of researchers and practitioners is successful, then
and, with appropriate technology, may be able to AAC stakeholders will value it, adopt it, use it,
venture out into the community and interact with and thus, demonstrate its social validity. In
acquaintances and even strangers; use public addressing outcomes, the viewpoints of multiple
transportation; and go to work every day. A high stakeholder groups, who have different perspec-
school student with complex communication tives and needs, are considered.
needs may want to search for relevant topics
and then load this information into an SGD for
Measuring Outcomes
use in a current events class or an exchange about
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the latest Hollywood gossip. The outcomes and impacts of research and
Individuals with complex communication needs development activities in AAC (including the
are interested in taking on a variety of societal development of AAC technologies and instruc-
roles. Like everyone else, many wish to form and tional strategies), are measured in a myriad of
maintain friendships, live independently, get ways over time. For example, existing AAC
married, change jobs, and so on. One example outcomes studies report on the use/disuse of
of expanding social networks is the international AAC devices (see DeRuyter & Kennedy, 1991),
listserv ACOLUG6 (Augmentative Communica- the current use of technology, literacy levels, the
tion Online Users Group), which enables indivi- quality of life of certain groups of individuals who
duals who rely on AAC and others in the AAC began using AAC technologies 15 years ago as
community to make connections, discuss issues, children (Hunt Berg, 2005; Lund & Light,
For personal use only.

and provide support. With 600 member subscri- 2006a,b), and other factors (see Calculator,
bers, this virtual community is unique in its ability 1999). Traditionally, outcomes research focuses
to expand and strengthen social and job-related on measures of clinical results, functional com-
networks within the AAC community, and it munication, quality of life, cost-benefit, and
encourages meta-thinking about AAC by AAC consumer satisfaction. In keeping with the six
stakeholders. principles, social validity measures are inherent to
In summary, Principle 5 expands on previous assessing the outcomes and impacts of AAC-
principles by underscoring that the key desired RERC activities, as is technology transfer and
outcomes of AAC technologies and instructional contributions to the existing evidence base in the
methods must include evidence that individuals area of AAC.
with complex communication needs have the
appropriate supports for social interaction, can
Technology Transfer
participate within their families and communities,
and can fulfill preferred societal roles. It reminds Technology transfer is a significant indicator of
us that people with complex communication success for all RERCs. The AAC-RERC uses a
needs must be able to access and use AAC multi-pronged technology transfer plan to deline-
technologies and available mainstream technolo- ate approaches to transferring research results,
gies in order to express their authentic selves and design specifications, and prototypes to AAC
take on meaningful societal roles. manufacturers. The expectation is for AAC
companies to incorporate ideas, features, or
prototypes in their products so they become
Principle 6: AAC Outcomes are Realized in
available to, and are used by, individuals with
Practical forms, such as Guidelines for Clinical
complex communication needs who, in turn, will
Practice, Design Specifications and Commercial
value them as do their communication partners
products. The Social Validity of these Outcomes is
and the clinicians who provide AAC support
Determined by Individuals with Complex
services.
communication needs, their Family Members, AAC
Collaborations with industry vary, from a
Manufacturers, and the Broader AAC Community
general sharing of results and design specifica-
Principle 6 cycles back through all of the others. tions to an exclusive partnership with one
It emphasizes, once again, that meaningful out- company to develop a product. For example,
comes resulting from AAC research, develop- AAC-RERC partner McNaughton shared results
ment, training, and dissemination activities of research about employment challenges for
 KEY PRINCIPLES IN AAC RESEARCH 201

individuals with amyotrophic lateral sclerosis, influence policy and standards include working
traumatic brain injury, and cerebral palsy who actively with groups on information technology
rely on AAC by emailing all AAC manufacturers (IT) standards to improve the interconnectivity
a summary of his findings and offering to share and interoperability of AAC technologies with
additional information. The Augmentative Com- mainstream technologies, web accessibility, and
munication Employment Training and Supports the use of cell phones. In addition, working to
(ACETS) training guide for increasing employ- expand funding for SGDs through government
ability (Cohen et al., 2003), is now widely programs and private insurance enables
available, as is the Universal Log File Protocol many more people to access communication
and ACQUA, a language activity monitor with technology.
analysis software (Lesher, Moulton, Rinkus, & To summarize, AAC research and practice
Higginbotham, 2000). At the other end of the should lead to outcomes that are ultimately
spectrum, visual scene displays for adults with valued by, and make a difference in the lives of,
aphasia (University of Nebraska) are now in- individuals with complex communication needs,
corporated in an SGD, as a result of a formal their family members, AAC manufacturers, and
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collaboration with Dynavox Technologies.7 Chil- the broader AAC community.

dren’s Hospital Boston8 is supporting the devel-
opment of visual scene displays that take
advantage of the interest of individuals with SUMMARY
autism in electronic screen media and ‘‘intelligent
agents’’ to support learning and communication. The six principles delineated in this article serve
to guide the work of the AAC-RERC and are
offered here for consideration to the broader
Evidence-Based Practice
AAC community. Encouraging the active parti-
Another area receiving considerable attention in cipation of individuals with complex communi-
today’s climate of accountability is known as cation needs in all AAC-related endeavors is
For personal use only.

evidence-based practice. For example, an expand- inherent to the AAC-RERC. Being clear about
ing evidence base demonstrates that AAC tech- theoretical constructs by carefully defining them
nologies (high- and low-tech) and instructional will serve to improve communication among
strategies are indeed viable treatment approaches researchers and practitioners, and guide the field
for both children and adults with complex of AAC in directions that are firmly grounded by
communication needs. AAC-RERC partners are widely accepted theories, both from within and
contributing to the AAC evidence base by outside the area of AAC. Having a commitment
designing and developing technologies, materials, to systematically account for the abilities, pre-
and instructional strategies and then evaluating ferences, and priorities of individuals with com-
their effectiveness so that they become more plex communication needs is a requisite for
readily available to, and useable by, a greater better, more usable AAC technologies and
number and a broader range of people with instructional strategies. In addition, fully con-
complex communication needs. Research results sidering the actual and potential roles of commu-
are published in peer-reviewed journals – a crucial nication partners, and the possible nature of
step in establishing high levels of evidence. In various types of interactions in AAC research and
addition, because research that informs practice development and clinical practice, will surely
must also impact it, evidence is shared through a result in better outcomes. It is important to
webcast series, articles in newsletters, conference imagine, in concert with individuals with complex
presentations, classroom lecturers, case examples, communication needs, how AAC and mainstream
and so on. technologies can make possible a variety of
societal roles, relationships, and opportunities
that are unreachable, and sometimes unimagin-
Influencing Policy and Standards
able, without them.
Policies and standards that positively influence
the lives of individuals with complex communica-
tion needs are also key components of positive Notes
outcomes. Activities that affect policy at the local, 1 The AAC-RERC is a virtual center with seven sites (Duke
regional, and national levels and increase the University, Augmentative Communication Inc., Chil-
awareness of opportunities and barriers that dren’s Hospital-Boston, Pennsylvania State University,
Temple University, University of Buffalo-New York and
affect individuals with complex communication University of Nebraska) and ten partners (David R.
needs, service providers, and the AAC industry, Beukelman, Sarah W. Blackstone, Diane N. Bryen, Kevin
will influence outcomes. Examples of efforts to Caves, Frank DeRuyter, Jeff Higginbotham, Janice Light,
 202 S. W. BLACKSTONE et al.

David McNaughton, Howard Shane, Michael B. Carey, A.C., Potts, B. B., Bryen, D. N., & Shankar, J. A.
Williams). (2004). Networking towards employment: Experiences of
2 Virtual network computing (VNC) software makes it people who use augmentative and alternative commu-
possible to view and fully interact with one computer from nication. Research and Practice for Persons with Severe
any other computer or mobile device. Disabilities, 28(1), 22 – 34.
3 Physical ergonomics (anthropometrics, biomechanics, Charlton, J. I. (1998). Nothing about us without us: Disability
health and safety) asks the following questions: How are oppression and empowerment. Berkeley CA: University of
people physically part of a system? How can systems be California Press.
better designed to interact physically with people? Clark, H. H. (1996). Using language. Cambridge: Cambridge
4 Macroergonomics (systems theory, organizational psy- University Press.
chology) asks the following questions: What factors come Clark, Herbert H. (2004). Pragmatics of language per-
into play during interactions among people? How do formance. In L. R. Horn & G. Ward (Eds.), Handbook of
environmental constraints affect human-machine systems? pragmatics (pp. 365 – 382). Oxford: Blackwell Publishing.
5 Macroergonomics (systems theory, organizational psy- Clark, Herbert H. (2005). ‘‘Coordinating with each other
chology) asks the following questions: what factors come in a material world’’ Discourse Studies, 7(4 – 5), 507 – 525.
into play during interactions among people? How do Cohen, K., Bryen, D., & Carey, A. (2003). Augmentative
environmental constraints affect human-machine systems? communication employment training and supports
6 http://www.temple.edu/instituteondisabilities/programs/ (ACETS). Augmentative and Alternative Communication,
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assistive/acolug/ 19, 199 – 206.

7 DynaVox Technologies, 2100 Wharton Street. Suite 400, Collier, B., McGhie-Richmond, D., Odette, F., & Pyne, J.
Pittsburgh, PA 15203, USA. (2006). Reducing the risk of sexual abuse for people who
8 Children’s Hospital Boston, 300 Longwood Ave #517, use augmentative and alternative communication. Augmen-
Boston, 02115, USA. tative and Alternative Communication, 22(1), 62 – 75.
Cook, A. M., & Hussey, S. (2001). Assistive technologies:
Principles and practice (2nd ed.). St. Louis, MO: Elsevier
Science.
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