AAC Technologies for Young Children with Complex

Communication Needs: State of the Science and Future

Research Directions

JANICE LIGHT* and KATHRYN DRAGER

The Pennsylvania State University, University Park, PA 16802, USA

Augmentative and alternative communication (AAC) technologies offer the potential toprovide children who have complex communication needs with access to the magic andpower of communication. This paper is intended to (a) summarize the research related toAAC technologies for young children who have complex communication needs; and (b)define priorities for future research to improve AAC technologies and interventions forchildren with complex communication needs. With the realization of improved AACtechnologies, young children with complex communication needs will have better tools tomaximize their development of communication, language, and literacy skills, and attain theirfull potential.

Keywords: Aided communication; Assistive technology; Augmentative and alternativecommunication (AAC); Children; Cognitive processes; Communication; Design; Earlyintervention; Learning

INTRODUCTION

In their early years of development, most childrenrapidly acquire speech and language skills toallow them to express needs and wants, interactsocially with adults and peers, expand theirconceptual development, and develop the founda-tions for more advanced language and literacyskills (Light, 1997). However, some young chil-dren do not develop speech and language skills asexpected due to motor, language, cognitive, and/or sensory perceptual impairments that mayresult from cerebral palsy, autism, Down syn-drome, or other developmental disabilities. Thisheterogeneous group of children with complexcommunication needs typically experiences re-stricted access to the environment, limited inter-actions with their communication partners, andfew opportunities for communication (Light,1997). They are at significant risk in all aspectsof their development. The challenge is to providechildren who have complex communication needswith access to the magic and power of commu-nication at the earliest possible age to circumvent

the negative effects of communication disabilities(Light & Drager, 2002). Augmentative andalternative communication (AAC) systems1 offerpotential tools to meet this challenge. In order tobe optimally effective, AAC systems must bedesigned to meet the needs and accommodate theskills of young children (Blackstone, Williams, &Wilkins, 2007).The goals of this paper are two-fold: (a) to

summarize the research related to AAC systemsfor young children, with a particular focus on thedesign of AAC technologies; and (b) to definepriorities for future research to improve AACtechnologies and enhance outcomes for childrenwith complex communication needs. Althoughthis paper focuses on young children, many of theissues discussed also have implications for olderchildren and adults who are beginning commu-nicators. Even though this paper focuses on thedesign of AAC technologies, it is critical torecognize that these technologies are but one ofthe important components of AAC interventions.If AAC interventions are to be maximallyeffective, they should ensure not only that

*Corresponding author. Department of Communication Sciences and Disorders, 308G Ford Building, The Pennsylvania StateUniversity, University Park, PA 16802, USA. Tel: þ1 814 863 2010. Fax: þ1 814 863 3759. E-mail: JCL4@psu.edu

Augmentative and Alternative Communication, September 2007 VOL. 23 (3), pp. 204 – 216

ISSN 0743-4618 print/ISSN 1477-3848 online � 2007 International Society for Augmentative and Alternative CommunicationDOI: 10.1080/07434610701553635

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children have access to appropriate AAC systemsas a means to communicate, but also that theyreceive appropriate instruction to learn thelinguistic, operational, social, and strategic skillsrequired to communicate effectively and ensurethat children have appropriate opportunities andsupport from their partners to communicate(Light, 2003).

RESEARCH ON THE USE OF AAC

SYSTEMS BY YOUNG CHILDREN

The selection and development of appropriateAAC systems is one key component in interven-tion for young children with complex commu-nication needs to ensure that they have aneffective means to communicate. What do weknow specifically about the use of AAC systemsby young children with complex communicationneeds?

Use of Multiple Modes of Communication

One of the most robust findings in AAC researchis that individuals with complex communicationneeds typically rely on multiple modes to meettheir needs (Blackstone & Hunt Berg, 2003).Young children with a wide range of develop-mental disabilities typically use a variety of means(either simultaneously or sequentially) to com-municate with others in daily situations, includingspeech and speech approximations, signs, none-lectronic systems (e.g., communication boards),and AAC technologies (e.g., Binger & Light,2006; Light, Collier, & Parnes, 1985; Light &Drager, 2005). Choices of modes often relate tothe child’s skills as well as the communicationcontext, partners, tasks, and intent (Blackstone &Hunt Berg, 2003; Light et al., 1985).

Impact of AAC on Natural Speech Development

Despite the documented benefits of AAC inter-ventions on communication, many clinicians andparents still hesitate to adopt AAC for fear that itwill impede the development of natural speech(Romski & Sevcik, 2005). However, the evidencesuggests that this fear is unwarranted. Results of ameta-analysis by Millar, Light, and Schlosser(2006) indicated the following: (a) none of the 27cases demonstrated decreases in speech produc-tion as a result of AAC intervention; (b) the vastmajority (89%) demonstrated gains in speechafter AAC intervention. For the most part, thegains observed were modest (i.e., þ20 spokenwords or less); however, in more than half of thecases, ceiling effects were observed in the speech

measures, suggesting that these data may under-estimate the effects. The majority of the partici-pants (aged 2 – 60 years) had mental retardationor autism, and the AAC interventions involvedmanual signs or nonelectronic aided systems.Future research is required to delineate the effectsof AAC technologies on natural speech acrosschildren with a wide range of disabilities. Romski,Sevcik, Adamson, and Cheslock (2006) arecurrently engaged in such research with toddlerswith complex communication needs; results oftheir investigation will make an important con-tribution to the field.

Comparative Effectiveness of AAC Systems

There is evidence that many different types ofAAC systems can have a positive impact on thecommunication skills of young children, includingunaided systems such as signs and gestures(e.g., Bartman & Freeman, 2003; Sigafoos et al.,2004) and aided systems, both nonelectronic(e.g., Charlop-Christy, Carpenter, LeBlanc, &Kellet, 2002; Johnston, McDonnell, Nelson, &Magnavito, 2003); and electronic technologies(e.g., DiCarlo & Banajee, 2000; Romski et al.,2006).To date, there is limited evidence of the

comparative effectiveness of various types ofAAC systems. For example, Mirenda (2003,2005) conducted a narrative review of the researchto determine the comparative effectiveness ofunaided and aided AAC systems with childrenwith autism spectrum disorders and concludedthat manual signs, graphic symbols, and AACtechnologies ‘‘. . . all have potential as commu-nication aids for individuals with autism’’ (2005,p. 52). It seems doubtful that there will be aunilateral answer to the question of the compara-tive effectiveness of AAC systems. Instead it seemsthat effectiveness will be determined by a complexinteraction between various factors, includingfactors intrinsic to the child, extrinsic factorssuch as communication partners and social con-text, as well as the overall purpose of theinteraction. Mirenda (2005) concluded: ‘‘WhichAAC technique is ‘best’ for a given individualdepends on: the learning/developmental prioritiesfor the person; the person’s existing skills andabilities; the person’s and family’s preferences; theperson’s current and future communication needs;and the environments in which and the peoplewith whom the person is likely to interact’’ (p. 52).It is highly unlikely that a single system will meetthe needs of all children with complex com-munication needs across all daily interactions.Despite the limited evidence of the relative

effectiveness of different AAC systems, it seems

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that there are tendencies in practice to use certaintypes of AAC systems with young children. It isreported that most preschoolers with complexcommunication needs use gestures, nonelectroniccommunication boards, or simple AAC techno-logies with digitized speech output, with very fewchildren reported to use AAC technologies thatoffer a greater breadth of communication options(Binger & Light, 2006; Hustad et al., 2005).Unfortunately, in many cases, these most fre-quently used systems may not provide sufficientcapacity for language and communication devel-opment for young children. As a result, the child’sdevelopment may be artificially constrained, notby factors intrinsic to the child, but by externalfactors such as (a) the limited capacity of simpleAAC technologies with digitized speech to store awide range of concepts, (b) failure to addvocabulary to systems on a regular basis, and/or(c) limited knowledge/use of signs by parents andother facilitators (Light & Drager, 2005). Paul(1997) argued that young children with complexcommunication needs require access to AACsystems ‘‘. . . that can grow with them. That is,the child needs a language system that hasinherent in it the capacity to make the crucialtransitions from one level of linguistic complexityto another . . . If these transitions are not built intoan AAC system, the child is doomed to a limitedmodality of communication’’ (p. 142). Light andDrager (2005) found that young children withdevelopmental disabilities (ages 1 – 3) demon-strated substantial increases in vocabulary acqui-sition when they were provided with access todynamic display AAC technologies, vocabularywas added on a daily basis, and partners modeledfunctional use of this vocabulary in meaningfulcontexts via AAC and speech (Light & Drager,2005). They concluded that expectations are oftentoo low. It is critical to maximize opportunitiesfor language development in the early years whenchildren are neurologically primed for learning.

RESEARCH ON REDESIGNING AAC

TECHNOLOGIES TO ENHANCE THEIR

EFFECTIVENESS

Although the positive benefits of a range of AACsystems have been documented, Light and Drager(2002) argued that the full potential of AACtechnologies has not yet been realized for youngchildren with complex communication needs.Current AAC technologies tend to reflect theconceptual models and priorities of nondisabledadults. These technologies do not have strongappeal for young children and they are difficult tolearn to use. In order to enhance the positive

effects of AAC interventions for young childrenwith complex communication needs, Light andDrager (2002) proposed that AAC technologiesshould be redesigned to increase their appeal,expand their function, and reduce their learningdemands. According to Blackstone et al. (2007),AAC technologies should be designed to fosterthe capabilities, preferences, and priorities ofthose who use them, and must take into accounttheir strengths and challenges.

Enhancing the Appeal of AAC Technologies for

Young Children

Young children with complex communicationneeds and their peers may be more apt to useAAC technologies if these technologies areappealing to them. To date, there has been onlylimited research to investigate techniques toenhance the appeal of AAC technologies: Light,Drager, and Nemser (2004) compared the featuresof award winning toys to those of AAC technol-ogies; and Light, Page, Curran, and Pitkin (inpress) used a modified participatory designmethodology to investigate children’s preferencesand priorities in the design of AAC technologies.Results of these two studies suggested designspecifications that may potentially serve toincrease the appeal of AAC technologies foryoung children by integrating play and commu-nication, providing meaningful fun contexts forinteraction, expanding output options, enhancingaesthetics, and providing options for character-ization and personalization (see Table 1). Overallthe results indicated that children valued AACtechnologies that were cool and served to enhancethe user’s self esteem and social image. Futureresearch is required to determine empiricallywhether implementation of these design specifica-tions results in increased engagement and use ofAAC technologies by young children and theirpeers.

Enhancing the Functions of AAC Technologies

Traditionally, AAC technologies have been de-signed as speech prostheses that allow the user tospeak out linguistic messages; they do not provideengaging contexts for children to support socialinteraction (Light et al., in press). In contrast,when children were asked to design technologiesfor young children with disabilities, they devel-oped inventions that supported a wide range ofinteractive activities as contexts for social inter-action (e.g., playing video games, engaging inimaginative play, watching movies, doing artsand crafts activities, listening to music, surfingthe Internet, talking on the phone; Light et al.,

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in press). Their designs suggested the need forfuture research to develop AAC technologiesthat support interconnectivity to allow integra-ted access to a broad array of functions(see DeRuyter, McNaughton, Caves, Bryen, &Williams, 2007).

Reducing the Learning Demands of AAC

Technologies for Young Children

AAC technologies must not only be appealingand meet the breadth of communication needs ofyoung children, but they must also be easy tolearn and use. It is challenging for beginningcommunicators to learn to use many AACsystems because of the multi-faceted attentiondemands. The children must monitor their ownactions (communicative attempts) and they mustalso coordinate attention to at least two to threeexternal foci: the partner(s), the AAC system(s),and the ongoing shared activity (Light, Parsons, &Drager, 2002). These attention demands arecompounded because communication is notstatic; rather it is a dynamic interactive process(Blackstone et al., 2007). The child must constan-tly coordinate attention across the various foci(i.e., self, partner, AAC systems, shared activity) tomonitor and accommodate changes within thedynamic interaction. This coordination is espe-cially complex for beginning communicators

with motor or visual impairments who mayhave difficulty with gaze shifting, and for thosewho have difficulty with joint attention (e.g.,children with autism).Cress (1999) proposed two ways to reduce these

attention demands: (a) reduce the number of toolsor external foci, and/or (b) reduce the complexityof the tools. The number of tools (and thereforethe joint attention demands) can be reduced byintegrating the AAC system with the play activity.For example, Light and Drager (2005) presentedbooks, songs, and other play activities withinAAC technologies along with communicationvocabulary, thus reducing the need for the childto shift attention between the system and theactivity. In addition, individual low-tech AACsymbols (backed with Velcro) can be easilyinfused into play activities; the symbols can betaken off the communication board and broughtdirectly into the play activity, explicitly linkingthe symbol and the toy or other referent. To date,there are no controlled research studies that haveinvestigated the effects of integrating AAC withplay and other daily activities to reduce attentiondemands; future research is required to do so.Another way to reduce the cognitive demands

for young children is to re-design AAC technol-ogies. Current technologies are not transparentto young children; and which impose signifi-cant motor, cognitive, linguistic, and sensory

TABLE 1 Design features to enhance the appeal of AAC technologies for young children.

Type of feature Specific recommendation

Function . Integrate multiple functions (e.g., social interaction, communication, play, humor, entertainment,telecommunication access, companionship, artistic expression, environmental controls)

. Provide dynamic contexts to facilitate social interaction

. Incorporate motivating interactive activities (e.g., games, play activities, songs, music, books)

. Provide access to innovative functions (e.g., sound effects, virtual educational/play environments) toenhance self-esteem/image

Color/Lights . Use multiple bright colors for symbols & hardware. Provide multi-colored removable covers to allow personalization. Use color to designate different operations or functions. Use lights to provide feedback & create visual effects

Shape/appearance . Use a variety of shapes including character shapes. Incorporate transformable configurations and moveable parts. Develop modular AAC systems that can be built up and taken apart into individual units to accommodate

development. Develop light weight systems proportionate to young children. Use various materials including plastics, soft plush materials, etc.

Output . Incorporate a library of sound effects (e.g., animal sounds, car sounds, burping). Include sounds to express emotions (e.g., laughter, anger, crying). Provide access to music (e.g., songs, MP3 files, musical instruments). Include a wide range of voices that appeal to children to facilitate imaginative play (e.g., voices of popular

children’s characters). Provide access to speech sounds at phoneme level to support sound play and the development of

phonological awareness skillsPersonalization . Incorporate popular themes (e.g., sports teams, movies, books, television characters)

. Characterize the system as a companion (e.g., name, personality)

. Provide choices to allow personalization of name, voices, personality, attitude, external appearance

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perceptual demands. As a result, some youngchildren may not be able to understand and usecurrent AAC technologies; others may need manyhours of instruction to do so. AAC technologiesshould be redesigned to minimize the cost oflearning while at the same time maximizing thepower of communication (Beukelman, 1991). Inrecent years, a number of research studies haveinvestigated learning of AAC technologies byyoung children. With one notable exception(Ferrier, Fell, Mooraj, Delta, & Moscoe, 1996),most of this research has focused on children whoare symbolic. Ferrier and colleagues developedand implemented a baby babble blanket forinfants with significant disabilities who werepresymbolic. Future research is required toinvestigate technologies to maximize functionfor the youngest children and facilitate thedevelopment of symbolic communication.The research on the design of AAC technolo-

gies for children at the ‘‘first words’’ stage andbeyond has focused on the following components:representations of language concepts, organiza-tion/layout, navigation, selection, and output.

Representations of Language Concepts

What do we know about young children’sunderstanding and use of various AAC symbols?There is evidence that, over time, young childrencan learn to understand and use a variety of AACsymbols, including signs, gestures, tangible sym-bols, Picture Exchange Communication (PECs),Mayer Johnson Picture Communication Symbols(PCS), Blissymbols, and so on (e.g., Barton,Sevcik, & Romski, 2006; Bondy & Frost, 1998;Romski & Ruder, 1984; Rowland & Schweigert,2000). However, many of the current AACsymbols are not immediately transparent toyoung children (e.g., Mirenda & Locke, 1989;Mizuko, 1987; Musselwhite & Ruscello, 1984;Light, et al., 2007). Lund, Millar, Herman, Hinds,and Light (1998), and Light, et al. (2007), foundthat children’s representations of early emerginglanguage concepts differed significantly from therepresentations used in many current symbol sets;the latter may not be developmentally appro-priate for young children. These researchers askedtypically developing children to draw pictures often early emerging language concepts, thenanalyzed the children’s drawings and descrip-tions, and compared them to the representationsused in current AAC symbol sets. The children’srepresentations differed significantly from thoseused in AAC symbol sets: They were grounded incontext, typically involved familiar experiences,and used entire scenes to depict the concepts; theydid not use isolated parts of objects or events. For

the most part, results were consistent across avariety of ethnic/cultural groups, although therewere a few differences in some of the representa-tions for specific concepts (Light, et al., 2007).Redesigning AAC symbols may reduce thelearning demands; future research is required toinvestigate the most appropriate representationsfor young children.

Layout and Organization

Once a child has acquired more than oneconcept, then the challenge is to organize anddisplay these concepts appropriately within AACtechnologies. The organization and layout ofrepresentations can serve to facilitate or impedethe accuracy and efficiency with which the childis able to locate, select, and functionally use theconcepts. Until recently, little was known abouteffective layouts and organizations or about thefactors that affect the location and use of targetitems.Recently, Wilkinson and colleagues established

a line of research to investigate the effects of coloras one factor in the organization and layout ofitems. Color cues play an important role in visualprocessing and memory, but little attention hasbeen focused on the impact of color in AACsystems (Wilkinson & Jagaroo, 2004). Wilkinson,Carlin, and Jagaroo (2006) determined that colorof items in a search array influences the accuracyand efficiency with which typically developingpreschoolers (4 – 5 years old) are able to locate atarget. When the target stimulus is distinct incolor from other stimuli, children are moreaccurate and faster in locating a target item.Color is not the only variable to be consid-

ered. Other display variables that may influencelearning and use include background, borders,shape, pattern, texture, size, position, and move-ment/animation (Scally, 2001). Future research isrequired to delineate the effects of these types offeatures to optimize the design of AAC tech-nologies. This research should consider notonly the performance of children whose visionis within normal limits, but also the performanceof children with visual impairments. AidedAAC systems impose significant demands onvisual perception and processing. Many childrenwho require AAC are at risk for visual im-pairments (Kovach & Kenyon, 2003). To datethere has been little research to investigatetechniques to maximize learning and functionaluse of AAC by children with concomitant visualimpairments.Two critical aspects of layout and organization

that may have an impact on learning and useare the groupings and arrangements of the

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representations on the screen. Light, Drager, andcollegues conducted a series of experimentalresearch studies to investigate with typicallydeveloping children (ages 2 – 5) the learningdemands of different layouts and organizationsof AAC technologies, including (a) a taxonomicgrid layout (i.e., symbols organized according tohierarchical categories and displayed in a row-column layout), (b) a schematic grid layout (i.e.,symbols organized according to events or experi-ences and displayed in a row-column layout), (c) aschematic visual scene layout (i.e., a contextualscene of an event with concepts embedded underhot spots in the scene), and (d) (for the 4- and 5-year-olds only) iconic encoding (i.e., an encodingtechnique in which line drawings that are rich insemantic associations are used in combinations ascodes to retrieve single words or phrases). Drager,Light, Curran-Speltz, Fallon, and Jeffries (2003)found that the youngest children (age 2.5 years)were most accurate locating vocabulary using thevisual scene displays compared to the gridlayouts, even though the displays were notpersonalized to the experiences of the childrenin this study. Light, Drager, McCarthy et al.(2004) found that, by ages 4 and 5, the childrenwere able to locate vocabulary with the visualscene displays and the grid layouts with similarlevels of accuracy, but they had significantdifficulty learning to use iconic encoding.More recently, Light and Drager (2005) eval-

uated the effects of AAC intervention that usedvisual scene displays with young children withdevelopmental disabilities (ages 1 – 3) and con-cluded the following: (a) all of the children wereable to use the visual scene displays to participatein social interactions, upon initial introduction inthe first session, once their use had been modeled;(b) the children demonstrated significant increasesin turn taking immediately upon introduction ofthe AAC technologies utilizing visual scenes; (c)the children sustained these gains in turn takingover the long term; and (d) all of the children alsolearned to use other types of displays over time,including traditional grid displays and hybriddisplays (i.e., displays that utilized visual scenesbut had some concepts displayed in a traditionalgrid layout). Drager et al. (2005) found similarresults in a study of preschoolers with autism(ages 3 – 5).Shane (2006) explored the implementation of

visual scene cues, utilizing a ‘‘complete visualscene that portrays, in pictorial form, a conceptor command that is being presented simulta-neously through spoken language’’ (p. 12). Heproposed that visual scene cues be used withchildren with autism spectrum disorders in twoways: either (a) as compensatory strategies where

the goal is to bypass the child’s comprehensiondeficits or auditory processing difficulties, or (b)as therapeutic tools where the goal is to buildcomprehension of the oral language input bygradually reducing dependence on scene cues.Shane (2006) reported that use of scene cues,along with speech input, resulted in significantimprovements in performance compared tospoken input alone.Visual scene displays may offer several advan-

tages for beginning communicators compared totraditional grid displays: (a) The scenes representfamiliar events or activities within the children’slives, maximizing the meaningfulness of therepresentations; (b) they present language con-cepts in context, providing support for children’sunderstanding in the early stages of languagelearning; (c) visual scene displays, by definition,organize language schematically according toevent experiences, a mapping that is congruentwith young children’s organization of languageconcepts (cf., Fallon, Light, & Achenbach, 2003);and (d) the visual scene displays preserve theconceptual and visual relationships betweensymbols that occur in life (e.g., location, propor-tionality of concepts). In contrast, traditional griddisplays decontextualize symbols and presentthem out of context; language is presented in abox, isolated from the context in which it occurs.Neither the conceptual nor visual relationshipsbetween concepts are preserved in a grid display(e.g., in a traditional grid display, the line drawingof the apple used to represent apple may be as bigas the head of the boy used to represent theconcept boy, which in turn may be as big as theentire person used to represent the concept run).Future research is required to better understandthe effects of layouts and organizations and thefactors that impact learning and use.

Navigation

One of the challenges of using AAC systems withmultiple pages or screens is the need to navigatethrough the system to find the target concept.Drager, Light, and colleagues investigated thedemands of navigating dynamic display systemsfor young children. Results indicated that typi-cally developing children (ages 2 – 5) had moredifficulty locating the correct page (from a mainmenu with a choice of four symbols/pages) thanlocating the target symbol when on the correctpage (out of a choice of 12 – 30 symbols), eventhough the probability of finding the correctpage by chance (0.25) was much greater than theprobability of finding the correct symbol bychance (0.03 – 0.08) once on the correct page(Drager et al., 2003; Light, Drager, McCarthy,

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et al. (2004)). Navigation may be particularlydifficult for young children for several reasons: (a)they must hold in mind a conceptual model of thehidden pages in the system; and (b) they mustunderstand the relationship between the represen-tations used on the menu page and the hiddenpages of vocabulary. One way to potentiallyreduce navigational demands is to utilize repre-sentations on the menu page, such as screenshots,that provide a mnemonic cue and make explicitthe relationship to the hidden vocabulary pages.Drager, Light, et al. (2004) investigated thelearning demands of different approaches to menupages and page layouts in AAC technologies withtypically developing 3-year-olds, including: (a)visual scene displays that used screen shots of thefour scenes on the menu page for navigation, (b)traditional grid displays that used screen shots ofthe four vocabulary grid pages on the menu page,and (c) traditional grid displays with a traditionalmenu page (i.e., four single symbols on the menupage used to represent navigation to the four pagesof vocabulary). Results indicated that the childrenwere more accurate locating vocabulary using thevisual scene displays with screenshots of the sceneson the menu page for navigation; they were leastaccurate using the traditional grid display with thetraditional menu design. Future research is re-quired to investigate the navigational demands ofAAC technologies as well as techniques to facil-itate learning and use.

Selection Techniques

In addition to designing AAC systems that utilizeappropriate representations, organizations, lay-outs, and navigational features, it is also criticalto consider the techniques used to select targetitems to communicate. Most young childrenhave difficulty using a standard keyboard ormouse, as use of these interfaces imposes sig-nificant motor, cognitive, linguistic, and sensoryperceptual demands. Specifically, use of theseinterfaces requires fine motor control and pre-cision of movement as well as an understandingof the relationship between the actions performedon the keyboard or with the mouse, and theresulting actions on the screen. Understandingthis relationship is cognitively complex, becausethe keyboard and mouse are displaced physicallyfrom their resulting actions on the screen.Use of touch screens integrated into the

computer display is one way to simplify accessfor young children. In this case, the child’s touchto the screen is directly related to the ensuingaction; there is no physical displacement betweenthe cause and the effect as with a traditionalkeyboard or mouse. Unfortunately touch screens

are not a viable solution for many children whohave motor impairments. Children with severemotor impairments are typically introduced toscanning as a means of alternative access.Research suggests that it is difficult for young

children to learn to scan (Mizuko & Esser,1991; Mizuko, Reichle, Ratcliff, & Esser, 1994;Petersen, Reichle, & Johnston, 2000). Perfor-mance is affected by numerous factors related tothe learner (e.g., motor, sensory perceptual,cognitive skills) as well as the scanning technique(e.g., type of scanning, scanning pattern, size ofthe array, length of wait time). Recent researchsuggests that it is possible to redesign scanning toreduce the learning demands and improve theperformance of young children. McCarthy et al.(2006) redesigned scanning to make the offer ofitems and the feedback upon selection moreexplicit through the use of animation and speechoutput with appropriate intonation. Typicallydeveloping 2-year-olds demonstrated more rapidlearning and performed more accurately with theredesigned scanning than with traditional scan-ning. Results suggest that by redesigning scanningwe can reduce the instructional time required forchildren to attain mastery.Despite the potential benefits of redesigned

scanning techniques, this access method is stillvery slow. There is an urgent need for improvedaccess techniques for young children, especiallythose with severe motor, cognitive, and/or sen-sory perceptual impairments. Light et al. (2005)reported on current research to develop andevaluate a personalized multimodal recognitioninterface to improve access to technology forpeople with disabilities. This innovative interfaceutilizes computer vision techniques to track themovements of a range of modalities (e.g., hand,head/eye, vocalizations/speech) and recognize thepatterns of movement used for intentional selec-tion, whether sequential or simultaneous (e.g., thecoordination of eye and hand movement toward atarget with vocalization used to designate actualselection of the target). The system is alsointended to identify and ignore unintentionalmovement patterns (e.g., tremor, reflexes). Re-search is urgently required to develop improvedaccess technologies (see Higginbotham, Shane,Russell, & Caves, 2007).

Output of AAC Systems

Once target items are selected by the user, theymust then be communicated to the partner. Thereare several methods for presenting the output ofAAC technologies: the screen display, printedhard copy, and speech output. To date, researchon the output of AAC technologies has focused

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primarily on the performance of adults and olderchildren with synthesized speech output. Recentresearch investigated the performance of children(age 4 – 6) and found that both monolingual andbilingual speakers of English perform less accu-rately with synthesized speech than with naturalspeech, just as adults and older children do(Axmear et al., 2005). Young children (age 3 – 5)also perform less accurately with digitized singlewords than with single words communicated vianatural speech (Drager, Ende, Harper, Iapalucci,& Rentschler, 2004). Children who are 4 and 5years old do better than younger children (3-year-olds) in intelligibility tasks, but for all childrenin this age range, the intelligibility of singlewords is very low (55 – 77%) for both synthesizedand digitized speech (Drager, Clark-Serpentine,Johnson, & Roeser, 2006). The intelligibility ofsentences is higher, but it is problematic ifchildren are constrained to the use of sentencesonly, as single words allow novel combinationsand foster language and literacy skills. Futureresearch is needed to improve the intelligibility ofspeech output at the single word and at thephoneme level in order to maximize the benefitsof speech output for language and literacydevelopment.In addition to intelligibility, another issue to

be considered is the choice of the human speakerused to make the recording of digitized speechfor storage in AAC technologies. The currentpractice is to find a close age match between thesample voice and the child using the AACsystem. To investigate the effectiveness of thispractice, Drager, Ende, et al. (2004) had collegestudents listen to words digitized by three femalechildren: a 4-, 6-, and an 8-year-old. The resultsof this pilot study indicated that the intelligibilityof the digitized speech produced by the 4-year-old speaker was significantly lower than that ofthe 6- and 8-year-olds. This study used only onespeaker of each age, and thus results arepreliminary; however, it seems that matchingthe digitized voice to the age of the child who isusing AAC may not be appropriate for theyoungest AAC users, given the low intelligibilityof young speakers.In summary, it is apparent that there have

been significant advances in the research on useof AAC systems by young children with complexcommunication needs: (a) to understand theinterplay of various modes of communication;(b) to investigate the effects of AAC on naturalspeech production; and (c) to improve thedesign of AAC technologies by beginning toinvestigate techniques to increase the appeal,enhance functions, and reduce the learningdemands.

PRIORITIES FOR FUTURE RESEARCH

Future research is urgently required to furtherunderstanding and improve the design andimplementation of AAC technologies to max-imize outcomes for young children with complexcommunication needs and older individuals whoare beginning communicators. Specifically, fu-ture research is required to investigate thefollowing: (a) preferences and priorities of youngchildren with complex communication needs andtheir families, (b) improved designs of AACtechnologies to better meet the needs of youngchildren and older beginning communicators, (c)improved designs of AAC technologies to bettersupport parents and professionals in implement-ing AAC effectively with young children andother beginning communicators, (d) effectiveinterventions to support beginning communica-tors in learning the skills to become competentcommunicators, (e) advocacy and public policyto ensure early identification of and earlyintervention for young children with complexcommunication needs, and (f) preservice andinservice training to close the gap betweenresearch and practice to improve services andresults for beginning communicators who requireAAC.

Preferences and Priorities of Young Children and

Their Families

If AAC interventions are to be effective, theymust be responsive to the needs of youngchildren with complex communication needsand their families. The early years of childhoodare times of rapid development involving bothquantitative and qualitative changes in children’sneeds and skills. These years are challengingones for families as they adjust to the changingneeds of their children and try to understandthe complexities of the service delivery system.To date, there has been only minimal researchto investigate the perspectives of parents ofchildren with complex communication needs(e.g., Angelo, Jones, & Kokoska, 1995; Bailey,Parette, Stoner, Angell, & Caroll, 2006). Futureresearch is required to better understand familypreferences and priorities to ensure that AACtechnologies and services are truly consumer-responsive.

Improved Designs for AAC Technologies for

Young Children

Future research is required to redesign AACtechnologies to better meet the needs of youngchildren, specifically to (a) enhance the appeal in

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order to increase motivation and use; (b) reducethe learning demands through utilization ofdevelopmentally appropriate representations, or-ganizations, layout, navigation, selection, andoutput; (c) support dynamic just in time program-ming to provide young children with the languagethey require to communicate in the moment as itoccurs; (d) support seamless transitions to accom-modate quantitative and qualitative developmen-tal changes; (e) serve as dynamic interactivecontexts to support young children and theirpartners (adults and peers) as they communicate(rather than as static speech prostheses alone); (f)provide integrated access to multiple functions(e.g., communication, play, social interaction,entertainment, companionship, telecommunica-tion, artistic expression); and (g) integrate devel-opmentally appropriate learning opportunities toenhance language and literacy development andsupport participation in the educational curricu-lum. Specific attention is required to meet theneeds of children at the very earliest stages ofcommunication development. ‘‘It is never tooearly to incorporate AAC into language andcommunication intervention for the young childwith a significant communication disability’’(Romski & Sevcik, 2005; p. 182).

Improved Designs for AAC Technologies for Older

Beginning Communicators

In addition to young children, beginning com-municators include older children or adults withsignificant cognitive impairments and/or multi-ple disabilities. The needs of this latter grouphave frequently been neglected. There arenumerous challenges in providing effectiveAAC services to this group, including thefollowing: (a) slow rates of learning necessitat-ing AAC systems that impose few learningdemands and that offer cognitive supports, (b)years of learned passivity or challenging beha-viors necessitating AAC technologies and inter-ventions that offer significant immediateimpacts, (c) difficulties identifying and adaptingchronologically age appropriate valued activitiesas contexts for meaningful communication, (d)negative societal and professional attitudes andlow expectations necessitating advocacy forservices and funding, and (e) large numbers ofcaregivers/partners with frequent turnover, ne-cessitating AAC systems that are easy toimplement and that provide explicit partnersupports. Future research is urgently required toinvestigate effective AAC technologies andinterventions for older children and adultswho are beginning communicators, to allowthem to attain their full potential.

Improved Designs for AAC Technologies for

Partners

Communication is a transactional interactiveprocess in which participants jointly negotiatemeaning (Blackstone et al., 2007). The successor failure of interactions involving individualswho require AAC is determined not only bytheir own actions, but also by their commu-nication partners (Light, 2003). This is espe-cially true of beginning communicators whohave yet to develop communicative competence;they require support from their partners tocommunicate successfully. In order to ensureeffective interaction, parents and other partnersrequire competence in the operation, mainte-nance, customization, and implementation ofAAC systems. Usually it takes parents andprofessionals a significant amount of time todevelop technical competence with AAC sys-tems. Current systems provide few, if any, builtin supports for partners to facilitate theirinteractions with beginning communicators.Future research is required to better supportparents and other partners in implementingAAC systems effectively with young childrenand older beginning communicators. Specifi-cally, research is required to develop a newgeneration of AAC technologies that (a) providedynamic contexts to support interaction withbeginning communicators (i.e., provide partnerswith something to do with the beginningcommunicator and something to talk about);(b) incorporate easy instruction to guide part-ners in learning how to interact effectively withthe beginning communicator (e.g., video instruc-tions, prompts, text support); (c) are easy tolearn to operate and program; (d) are fast toprogram; (e) allow just in time programmingthat can be done in real time during a dynamicinteraction; and (f) are easy to modify inresponse to quantitative and qualitative changesin the developing child. As Blackstone et al.(2007) indicated, AAC technologies mustbe designed to recognize the unique rolesthat communication partners play during inter-actions.Realizing these advances in AAC technologies

will require concerted research to better under-stand the process of language and communicationdevelopment in young children who require AACand to investigate human factors issues related tochild – technology – partner interaction. In addi-tion, there will need to be effective transfer ofthese research and development efforts to assistivetechnology manufacturers to ensure the successfulproduction of a new generation of AAC technol-ogies for young children.

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Effective AAC Interventions to Maximize

Outcomes

Although it is critically important to improve thedesign of AAC technologies for beginning com-municators and their partners, simply providingappropriate technologies will not guarantee posi-tive outcomes. Concerted intervention is requiredto ensure that beginning communicators learn thelinguistic, operational, social, and strategic skillsrequired to become competent communicators(Light, 2003). To date, the research has largelyfocused on establishing what is possible. There isevidence that AAC interventions utilizing avariety of instructional procedures can havepositive effects on the communication skills ofyoung children, including interventions that uti-lize structured behavioral methods and those thatuse child-centered, social pragmatic methods(Romski, Sevcik, Hyatt, & Cheslock, 2002).Future research is required to better delineatefactors that positively impact outcomes for begin-ning communicators, to better understand thecritical components of effective AAC interven-tions, and to investigate the relative effectivenessof different types of AAC interventions. Forexample, Romski et al. (2006) reported onthe preliminary results of a study designed toinvestigate the effects of two different parent-implemented AAC interventions and a spokencommunication intervention on the communi-cation skills of toddlers with complex commu-nication needs.Research on AAC interventions is especially

challenging given the heterogeneity and lowincidence of the population, the complexity ofAAC interventions, and the necessity to considernot only child, but also family and partnervariables. To date, most of the research hasfocused on AAC interventions with preschoolers(ages 3 – 5). With a few notable exceptions (e.g.,Arens, Cress, & Marvin, 2005; Ferrier et al., 1996;Light & Drager, 2005; Romski et al., 2006; Smidt& Cress, 2004; Wilcox, Kouri, & Caswell, 1990),there has been a paucity of research to investigateAAC interventions for children under the age of3, despite the critical importance of early inter-vention. Future research is urgently required toaddress the needs of the youngest children,including those with a wide range of disabilitiesand associated sensory impairments.

Public Policy and Advocacy

Despite the demonstrated benefits of AAC, inpractice, many children who require AAC are stillnot referred for services until they are older andhave already missed out on valuable opportunities

for learning (Hustad et al., 2005). Efforts areurgently required to (a) increase knowledge ofAAC by medical personnel, speech languagepathologists (SLPs), and early intervention profes-sionals to ensure early identification of childrenwho would benefit from AAC; and (b) increasepublic awareness in order to reduce opportunitybarriers for young children with complex commu-nication needs. Advocacy efforts are also requiredto increase expectations of professionals whowork with young children with complex com-munication needs through research to demon-strate the substantial gains in communication,language, and literacy skills that can be realizedwith appropriate AAC interventions. Efforts arerequired to ensure the efficient availability offunding for appropriate AAC technologies foryoung children, which should include not justsimple digitized systems, but also AAC technolo-gies that provide greater capacity for languagelearning and communication development.

Preservice and Inservice Training for Early

Intervention Professionals

There is a substantial gap between what theresearch suggests is possible through AAC inter-ventions and what is actual practice for mostyoung children with complex communicationneeds. Improved preservice and inservice trainingof SLPs and early intervention professionals isnecessary to enhance their knowledge of evidence-based practice in AAC and to improve servicesand results for beginning communicators. Re-search is required to investigate the best trainingapproaches to effect changes in the practices ofprofessionals and to demonstrate the impact ofthis type of preservice and inservice training onoutcomes for children with complex communica-tion needs.

CONCLUSION

This research agenda is an ambitious one. It willrequire the effective collaboration of manystakeholders: consumers who use AAC and theirfamilies, researchers well versed in a variety ofmethodological tools, educational and rehabilita-tion professionals with expertise in AAC, assistivetechnology manufacturers, and experts from awide range of related disciplines. This researchwill lead to more effective AAC systems andinterventions for young children with complexcommunication needs. With access to appropriateAAC systems and early evidence-based AACinterventions, young children with complex com-munication needs will have the opportunity to

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maximize their functional communication, lan-guage development, and literacy learning, andwill be able to attain their full potential.

Acknowledgements

This paper was completed as part of the Com-munication Enhancement Rehabilitation Engi-neering Research Center (AAC-RERC). TheAAC-RERC is a virtual research center that isfunded by the National Institute on Disabilityand Rehabilitation Research (NIDRR) of the USDepartment of Education under grant numberH133E030018. The opinions contained in thispublication are those of the grantees and do notnecessarily reflect those of the Department ofEducation. For additional information on theAAC-RERC, see http://www.aac-rerc.org/. Thispaper is based on a paper presented at the State ofthe Science Conference on Communication En-hancement, in Los Angeles, CA in March 2006.The authors are grateful to the partners of theAAC-RERC for their comments and suggestionsduring the conceptualization and writing of thispaper, specifically David Beukelman, SarahBlackstone, Diane Bryen, Kevin Caves, FrankDeRuyter, David McNaughton, Howard Shane,and Michael Williams.

Note

1 In this paper, the term AAC system is used to refer to bothunaided AAC systems (e.g., gestures, signs) and aidedAAC systems, both low tech (e.g., nonelectronic commu-nication boards and books) and high tech electronicsystems (e.g., voice output communication aids, VOCAs).The term, AAC technologies, is used to refer specifically toelectronic aided AAC systems (e.g., VOCAs or speechgenerating devices, SGDs).

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