Krista M. Wilkinson

Purpose: Speech-language pathologists report a desire for guidance to develop and maintain augmentative and alternative communication (AAC) supports that are customized and visually accessible for individuals with cortical visual impairment (CVI; Boster et al., 2021). In 2023, Wilkinson et al. introduced the “CVI/AAC Framework” that offered initial evidence-based considerations and data collection prompts to address this clinical challenge. The current article was written to illustrate the process of the clinical application of the CVI/AAC Framework for a young child with cerebral palsy and concomitant CVI. By demonstrating the team efforts to build a developmentally appropriate aided AAC system that was responsive to the child's CVI and motor support needs, we hope to demonstrate the utility of the framework and promote clinical uptake for decision making. Method: The team, which included clinicians, other professionals, and the child's mother, implemented an iterative approach to AAC assessment and implementation based on ongoing discussions surrounding the CVI/AAC Framework domains and the child's progress. The relative frequency of different topics of discussion and the subsequent types of decisions made were quantified to illustrate the clinical process. Furthermore, a detailed case analysis of the contents of the discussion were extracted from the transcripts. Results: The team met collaboratively for 8 months, resulting in 13 meetings. A total of 97 topics were discussed and coded related to the CVI/AAC Framework or general AAC assessment. Of the topics related to the framework, Domain 1 (characteristics of the individual) accounted for the most discussions followed by Domain 3 (AAC system design choices). Meeting documentation and screen captures of the child's AAC system across time demonstrated changes in the child's linguistic and visual functioning. Conclusions: This clinical focus article illustrates a starting point for implementation of the CVI/AAC Framework as a complementary approach to typical AAC assessment procedures. This approach should prompt clinicians to make individualized AAC changes that support meaningful communication and participation and provide a basis for future systematic research. Supplemental Material: https://doi.org/10.23641/asha.33283830

Purpose of Review: Children with motor and speech disabilities represent a heterogeneous group who can benefit substantially from augmentative and alternative communication (AAC). AAC technologies have been shown to support spoken language and communication development for individuals across a wide range of cognitive, linguistic, motor, and sensory profiles when appropriate access methods and intervention strategies are matched to individual abilities. This article reviews the current state of research related to AAC access and intervention. Recent Findings: Existing and emerging access methods, including advances in alternative access technologies are discussed. In addition, current research addressing intervention approaches for this population is examined, including literacy development and communication partner training. Summary: Despite promising advances, children with motor and speech disabilities have received comparatively limited focused attention in the literature and significant gaps remain in the evidence base. The article concludes with a call for targeted research to better understand effective AAC access solutions and intervention strategies for children with motor and speech disabilities to maximize outcomes and ensure opportunities for communication participation and development.

Purpose: This article describes practical strategies for enhancing swallow assessments for individuals with intellectual or cognitive disabilities through the inclusion of visual communication supports (known as augmentative and alternative communication [AAC]). These strategies were developed to support understanding and self-expression during the swallow assessments for individuals with Down syndrome, as part of a large research study. Over the last 2 years, these supports have been integrated into swallow assessments with 14 adults with Down syndrome. Method: Clinicians and researchers with expertise in swallowing and AAC collaboratively designed and refined visual communication aids to enhance understanding and task completion of swallowing-related assessments, including the Mann Assessment of Swallowing Ability, Iowa Oral Performance Instrument, spontaneous swallowing frequency, food avoidance inquiries, and lingual somatosensation testing. A summary table of assessments and suggested strategies is provided. All study procedures were approved by the Institutional Review Board (IRB #00022372) at The Pennsylvania State University. Results: Our observations suggest the integration of AAC enhances the accessibility of swallow assessments for individuals with intellectual disabilities, supporting their participation in these assessments. Many participants referenced the visual aids, such as videos, as key to their understanding of what to expect and what to do during assessments. These observations are consistent with research showing that multisensory modalities and adaptations can improve functional outcomes for people with Down syndrome. Conclusions: Incorporation of visual supports may be useful for clinicians and researchers seeking to improve accessibility in swallow assessments for diverse populations. Clearly, dedicated research is necessary to examine these observations systematically.

Families engaging with AAC bring diverse cultural and linguistic backgrounds that influence how services and systems are experienced. In the United States, Hispanic families constitute a rapidly growing population whose voices and experiences are still rarely reflected in AAC research. The present work explored the perspectives of six Hispanic mothers regarding their children's AAC services and system design. A phenomenological approach was used to capture mothers' lived experiences. Semi-structured interviews were conducted in English or Spanish, depending on the participant's preference, and then transcribed, translated, and thematically analyzed using the Braun & Clarke thematic analysis. Three overarching themes were identified. Navigating AAC services irrespective of cultural responsiveness described systemic challenges such as limited provider training, financial barriers, and families managing AAC independently. The role of culture in service delivery reflected how values such as familismo, personalismo, and respeto shaped mothers' perspectives. Cultural and linguistic considerations in AAC system design addressed visual representation, voice output, unique vocabulary, and dual-language navigation. The findings of the study contribute to conversations regarding AAC service delivery by documenting how cultural values and linguistic diversity shape family engagement with services and design features of communication systems.

Individuals with Down syndrome often have speech and language impairments that interfere with their ability to use speech to meet their full range of communication needs. Visual communication supports in the form of augmentative and alternative communication (AAC) are often a solution for individuals who require support to their own natural speech, including those with Down syndrome. Messages are produced via touch or reach to communication symbols presented on these AAC displays. While a line of past research has detailed the influence of AAC display design on the efficiency with which individuals with and without disabilities can find target symbols within an array, few studies have examined how different AAC displays might influence touch/reaching. Yet critical clinical implications arise if display design is resulting in inefficient (and fatiguing) motor/reaching behavior. This pilot study evaluated how visual-perceptual characteristics of AAC displays affected the efficiency and quality of reaches by six individuals with Down syndrome and six individuals without disabilities matched on age, gender, and hand preference.

Purpose: Although not often used in the area of speech and language instruction, performing arts (such as improvisation, instrumental, vocal, and dance performance) provide a context for self-expression that involves both structure and opportunities for self-expression and can offer an opportunity to contribute to a motivating activity in individual, unique ways. Method: We describe a semester-long performing arts class in which students from various majors and with and without developmental disabilities together learn various performing art forms (specifically, improvisation, vocal performance, and diverse forms of dance) for the first half of the semester. The students work together the second half of the semester to create a final performance. Student reflections that were gathered during one semester (with approval from the institutional review board) were examined descriptively to provide student perspectives into the program and to help understand how the structure supported interpersonal relations. Results: Student reflections suggested that the structure of learning the various performing arts resulted in establishment of authentic peer relationships through three pillars of friendship proposed by Finke (2016): (a) the opportunity to engage in fun and motivating activities, (b) the presence of repeated/multiple opportunities to engage in the activities together, and (c) the establishment of a safe environment where each individual's contribution added something of value to the activity. Conclusion: This descriptive analysis identified mechanisms by which performing arts can be a valuable context for supporting important social and communication goals in individuals with and without developmental disabilities.

Eye tracking research technologies are often used to study how individuals attend visually to different types of AAC displays (e.g. visual scene displays, grid displays). The assumption is that efficiency of visual search may relate to efficiency of motor selection necessary for communication via aided AAC; however, this assumption has not received direct empirical study. We examined the relation between speed of visual search and speed of motor selection of symbols. Ten individuals on the autism spectrum (AS; Study 1) and nine with Down syndrome (DS; Study 2) participated in a search task using simulated AAC displays with a main visual scene display (VSD) and a navigation bar of thumbnail VSDs. Participants were given an auditory prompt to find one of four thumbnail VSDs in the navigation bar. Eye tracking technologies measured how long it took participants to fixate visually on the thumbnail VSD, and recorded how long it took participants to select the thumbnail VSD with a finger. A statistically significant relationship emerged between visual fixation and selection latencies, confirming the positive relationship between visual processing and motor selection for both groups of participants. Eye tracking data may serve as a useful proxy measure for evaluating how display design influences selection of AAC symbols, especially when individuals are unwilling or unable to comply with traditional behaviorally-based assessment tasks.

Purpose: This study examined the processes that speech-language pathologists (SLPs) use during an augmentative and alternative communication (AAC) assessment with children with motor impairments to determine alternative access solutions. These children often are the most vulnerable to a poor fit of their AAC system, which alternative access is an integral part. Although there is an abundance of information as to what types of considerations should be made during these assessments, there is no guidance as to how the assessment is completed. The goal of this study is to build evidence about the process. Method: A collective case design was used to gain detailed insights into the decision-making process. Interviews and vignette responses were two components of the data collection. Each of the five SLPs, or cases, who participated in the study transcripts was analyzed in isolation as part of a within-case analysis. Once each SLP's process was understood, a cross-case comparison was completed to ascertain similarities or differences across the five. Results: The cross-case assertions are presented in this article. Although the SLPs individually reported a lack of defined process, a clear systemization became evident when considered collectively. The SLPs all focused on the child, isolated motor access skills, and used a process of experimentation over time to build their final recommendations. Conclusions: These results have implications for SLPs working with children with motor impairments who may benefit from AAC intervention. The shared framework can serve as a roadmap to other SLPs, especially those with less experience with these types of complex cases. The varying teaming approaches to support these cases are also discussed.

Purpose: The purpose of this project was to determine the feasibility of employing a functional magnetic resonance imaging (fMRI) task that captured activation associated with overt, unscripted (or free) discourse of people with aphasia (PWA), using a continuous scan paradigm. Method: Seven participants (six females, ages 48-70 years) with chronic poststroke aphasia underwent two fMRI scanning sessions that included a discourse fMRI paradigm that consisted of five 1-min picture description tasks, using personally relevant photographs, interspersed with two 30-s control periods where participants looked at a fixation cross. Audio during the continuous fMRI scan was collected and marked with speaking times and coded for correct information units. Activation maps from the fMRI data were generated for the contrast between speaking and control conditions. In order to show the effects of the multi-echo data analysis, we compared it to a single-echo analysis by using only the middle echo (echo time of 30 ms). Results: Through the implementation of the free discourse fMRI task, we were able to elicit activation that included bilateral regions in the planum polare, central opercular cortex, precentral gyrus, superior temporal gyrus, middle temporal gyrus, superior temporal gyrus, Crus I of the cerebellum, as well as bilateral occipital regions Conclusions: We describe a new tool for assessing discourse recovery in PWA. By demonstrating the feasibility of a natural language paradigm in patients with chronic, poststroke aphasia, we open a new area for future research.

Purpose: This article highlights the contributions of three pillars of an evidence-based practice approach (service providers, researchers, and families/clients) in the development of a framework to offer a way forward for professionals, families, and technology companies to support optimal visual and communication outcomes of individuals with cortical visual impairment (CVI) who use augmentative and alternative communication (AAC). By providing available research findings as well as practical information and lived experiences, the article offers clinical considerations and design features that can lead to addressing the unique needs of these individuals. Method: This article reviews literature concerning what is known about CVI and describes in detail and from multiple viewpoints important features required in AAC systems to support individuals with CVI and enable them to communicate effectively. Results: Components necessary for teams, communication partners, and AAC designers to optimize AAC system design in CVI are presented using external research evidence as internal evidence from lived experience to support their importance. Conclusions: An AAC system design that is tailored to the unique visual processing characteristics in CVI is likely to promote positive communication outcomes. The presentation of the lived experience of an individual who has CVI themselves illustrates the need for individualized assessments and interventions that incorporate and reflect the research presented here. Supplemental Material: https://doi.org/10.23641/asha.23902239