From the Desk of Ann Kummer
Children who lack the physical ability to produce speech sounds and children who lack sufficient verbal language skills can often benefit from the use of an augmentative or alternative communication (AAC) system. Speech-language pathologists (SLPs) who work with these children are challenged to determine the most effective means of communication for each child to maximize the child’s potential and quality of life.
Because AAC systems continue to evolve, particularly with changes in technology, it is often hard to keep up with current AAC best practices. Therefore, I am happy that Drs. Kent-Walsh and Binger are providing an overview of current considerations in pediatric augmentative and alternative communication (AAC) service delivery in this 20Q article. They are uniquely qualified to do so as noted in their bios.
Jennifer Kent-Walsh, PhD, CCC-SLP, FLASHA Honoree, ASHA Fellow, is a Professor of Communication Sciences and Disorders, the Director of the Assistive Technology Demonstration Center / AAC Lab, and the Associate Dean for Research in the College of Health Professions and Sciences at the University of Central Florida (UCF). Dr. Kent-Walsh and her research collaborators, including primary research collaborator Dr. Cathy Binger, develop and evaluate interventions designed to improve language and communication outcomes for children who use augmentative and alternative communication (AAC). Dr. Kent-Walsh teaches in the areas of AAC and assistive technology at UCF and has published research findings widely in the speech-language pathology literature. She is currently a Principal Investigator for research projects and programs funded by the Chesley G. Magruder Foundation, the Florida Alliance for Assistive Technology and Services, the WITH Foundation, and the National Institutes of Health (NIDCD).
Cathy Binger, PhD, CCC-SLP, is a Professor in the Speech and Hearing Sciences Department at the University of New Mexico. She has published multiple research articles, book chapters, and books pertaining to supporting early language development for young children who require AAC. Dr. Binger teaches in the areas of language development, language disorders, and augmentative and alternative communication (AAC) at the University of New Mexico and is currently a Principal Investigator for a multi-site clinical trial investigation funded by the National Institutes of Health (NIDCD).
In this course, you will learn which pediatric populations can most benefit from the use of AAC. In addition, you will learn about AAC assessment and intervention options that are evidence-based.
Now…read on, learn, and enjoy!
Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q
20Q: Pediatric Augmentative and Alternative Communication
Service Delivery: Key Considerations
After this course, readers will be able to:
- Define augmentative and alternative communication (AAC).
- Describe pediatric populations who can benefit from the use of AAC.
- Describe the scope and purpose of AAC service delivery.
- Describe evidence-based AAC assessment and intervention options.
1. What is augmentative and alternative communication (AAC) and is it different from assistive technology (AT)?
According to the American Speech-Language-Hearing Association (ASHA; 2005), AAC involves research and clinical/educational practice focused on compensating for temporary or permanent impairments, activity limitations, and participation restrictions of individuals with severe disorders of speech-language production. Importantly, AAC includes both spoken and written communication modes. The words within the term AAC provide good insight into what is involved in this area of research and practice: “augment” implies communication supplementation, and “alternative” implies communication replacement. Even the word “and” within the term “augmentative and alternative communication” represents a noteworthy broad-based meaning; it is not “augmentative or alternative communication,” which might imply more restrictions for AAC applications. Although some individuals might have a need to completely replace natural speech through other communication modes, other persons might only need to replace natural speech in particular contexts and augment functional speech through additional communication modes in other contexts. There is no “one size fits all” approach to AAC implementation, which encompasses both technologies and other low-tech tools used for communication, as well as the interventions that support the implementation of these tools.
AAC is sometimes referred to within the category of “speech communication” assistive technology (AT). The Technology-Related Assistance to Individuals with Disabilities Act of 1988 (Tech Act) first described an AT device as "any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities." The Individuals with Disabilities Education Act (IDEA) of 2004 proceeded to use almost the same definition for AT as in the Tech Act but added an exception to exclude surgically implanted medical devices. This legislation also defined an AT service as "any service that directly assists a child with a disability in the selection, acquisition, or use of an assistive technology device." (§1401(2)).
2. Who can benefit from the use of AAC?
AAC is an area of research and practice with high relevance to both adults and children; in fact, recent estimates suggest that approximately 5 million Americans and 97 million people worldwide could benefit from AAC to increase their functional communication skills and community participation (Beukelman & Light, 2020). Recent survey findings indicate that approximately 1 in 89 school-age children have highly unintelligible speech – all of whom, no doubt, could benefit from some form of AAC (Binger, Renley, Babej, & Hahs-Vaughn, 2021). Since the scope of this article is framed around pediatric AAC applications, we will specifically review broad categories of children who can benefit from AAC.
Just as it is impossible to define a “one size fits all” approach to AAC service delivery, it is also impossible to identify a singular profile of a person who can benefit from AAC and AAC services. Individuals with complex communication needs – a term frequently used to describe individuals who can benefit from the use of AAC - have a wide range of communication needs and abilities; they also come from a full spectrum of socioeconomic, ethnic, racial, linguistic, and cultural backgrounds. The only true unifying characteristic for this group is the fact that that they require the use of adaptive supports to meet some or all of their spoken and/or written communication needs due to temporary or permanent communication impairments (Beukelman & Light, 2020).
Children can experience these temporary or ongoing communication impairments because of both developmental and acquired conditions. Many children with developmental disorders have congenital disorders; that is, whether immediately identified at birth or not – there is a condition or conditions present from the time of birth that involves persistent associated communication disorders. Examples of common developmental causes of severe communication disorders include autism spectrum disorder (ASD), cerebral palsy, developmental apraxia of speech, Down syndrome, intellectual disability, and a range of lower incidence syndromes. Children who have developmental disabilities with associated significant communication impairments can benefit from AAC supports and interventions from infancy and across the lifespan. Ideally, they learn to use AAC tools and supports while still in the process of developing their initial speech and language skills. In contrast, children who experience acquired conditions most often develop speech and language skills typically for a period prior to experiencing some type of trauma (e.g., traumatic brain injury, spinal cord injury) or medical event (e.g., stroke, brain tumor) yielding communication disorders. Additionally, children may have either “progressive” (i.e., degenerative) or “non-progressive” disorders (the vast majority are the latter), and they also may have physical and/or sensory impairments that affect communication skills and needs. The individual characteristics and needs of individual children influence the type of AAC options that will be most relevant to supporting increased functional communication in their everyday lives within their natural environments (Binger & Kent-Walsh, 2010).
3. Will using AAC with young children hinder speech development, and should clinicians, therefore, wait to introduce AAC until speech has been determined to not be an option for a child?
Neither use of AAC nor AAC introducing interventions will hinder the development of natural speech. In fact, research indicates the opposite; AAC has been found to increase natural speech when therapy includes a multimodal intervention approach to simultaneously focus on speech skills and AAC implementation (Kasari et al., 2014; Millar, Light, & Schlosser, 2006). Further, introducing AAC early has been shown to: (a) support the development of natural speech and language skills (Romski, Sevcik, Adamson, Smith, & Barker, 2010; Wright, Kaiser, Reikowsky, & Roberts, 2013); and (b) increase expressive and receptive vocabulary for toddlers and young children (Drager et al., 2006; Romski, Sevcik, Barton-Hulsey, & Whitmore, 2015). There are no prerequisites to use AAC or to begin AAC intervention. Therefore, AAC intervention should be introduced to children with complex communication needs as early as possible – ideally within their first year (Beukelman & Light, 2020).
4. When and where do children with complex communication needs require support and access to AAC?
There is a simple answer to this question: all the time and everywhere infants, toddlers, preschoolers, school-age children, and teenagers can be found! Although many early childhood clinical and/or educational service-delivery programs involve some services which are provided in more controlled clinical environments, the main focus of any AAC intervention program should be on increasing functional communication in natural settings. Therefore, children need access to AAC in all settings where they communicate and might need support in those environments to learn to use their AAC effectively across communication partners. Importantly, clinicians cannot be present in all relevant settings for a given child. As discussed in more detail later, partnering with families, caregivers, and other service providers is very important to ensure consistent access and support for AAC across environments. As reported by ASHA (n.d.), concerns about overuse of screen time do not apply to the use of screens as part of an AAC system; without ongoing access to aided AAC, children with complex communication needs will experience situations in which they have little or no “voice” or options to communicate.
5. What are common categories of AAC options that children might use?
At the broadest level, AAC options are typically divided into two categories: (a) unaided AAC options, and (b) aided AAC options. Unaided AAC requires only the person’s body to communicate. Unaided AAC, therefore, involves motor control in some form. Examples include body language, facial expressions, finger spelling, gestures, manual signs, vocalizations, and verbalizations (ASHA, n.d.). In contrast, aided AAC options involve use of some external tool, which can be either electronic or nonelectronic. Nonelectronic aided AAC options are often referred to as “light-tech” or “low-tech” (e.g., communication boards/books, visual schedules, picture cards, writing), and electronic forms are often referenced as “high-tech AAC” (e.g., speech generating devices/SGDs, tablets with AAC apps, text-to-speech devices, single message devices with recorded messages, texting). Most children with complex communication needs will use varying combinations of unaided AAC, aided AAC, and any functional speech and vocalizations. Although a comprehensive overview of all SGD and app features is beyond the scope of this resource, it is important for the reader to note that an increasing spectrum of features are available for use with children with complex communication needs, and careful consideration should be given to ensure that selected AAC options offer features that are relevant to the overall skills and communication needs of any child.
6. What is the overarching goal of pediatric AAC service delivery?
Although clinicians and stakeholders often focus on AAC technologies, the overarching goal of pediatric AAC service delivery is not to find technological solutions to address children’s communication challenges. Rather, the ultimate purpose of AAC service delivery is to enable individuals with complex communication needs (of any age) to engage in activities of choice effectively and efficiently within environments of natural relevance (Beukelman & Light, 2020). This translates to a need for AAC service providers to focus on the desired functional communication outcomes and the full spectrum of interaction purposes when designing AAC assessment and intervention programs.
Light (1988) published a practical categorization framework that included four common purposes of communicative interaction; this framework, which was more recently expanded to include a fifth purpose of communicative interaction (D. R. Beukelman & Light, 2020), can be a useful reference for clinicians as they consider priority areas for AAC supports, assessment, and intervention. Specifically, clinicians should consider whether children with complex communication needs are able to effectively communicate to meet the following purposes of interaction: (a) communication of needs and wants, (b) transfer of information, (c) fostering social closeness, (d) adhering to social etiquette norms, and (e) maintaining internal dialoguing.
7. What are some common signs of unmet communication needs for children?
Three common signs of unmet communication needs are: (a) withdrawal from participation, (b) lack of communication, and (c) the presence of challenging behaviors (e.g., crying, screaming, throwing things, actions causing injury to self or others). Challenging behaviors often are the result of an inability to communicate effectively, or of others failing to recognize communication attempts. Clinicians should consider the following to identify unmet communication needs: with whom, where, when, why, about what, and how the child needs to communicate in daily interactions (Beukelman & Light, 2020). These questions should be answered during the AAC assessment process to ensure the effectiveness and efficiency of communication options in all relevant communication contexts and across communication partners. Communication breakdowns or absence of communication in certain environments, with specific communication partners, about certain topics of relevance to same-age peers, are strong indications of unmet communication needs. For example, if a child is reported to be successfully communicating at home with family members but is observed to infrequently communicate with anyone at school, it would be important to drill down into the specifics of any barriers to functional communication in the school setting.
8. Who are common members of pediatric AAC assessment and service-delivery teams?
Completing an AAC assessment is a complex process that should involve a range of key stakeholders and professionals. Binger and colleagues (2012) published the AAC Assessment Personnel Framework to provide an overview of the roles and responsibilities of key categories of personnel commonly involved in any AAC assessment, including the following: AAC finders, general practice SLPs, AAC clinical specialists, facilitators and communication partners, collaborating professionals, AAC research and policy specialists, manufacturers and vendors, funding agencies and personnel, and AAC/assistive technology agencies and personnel. Although service-delivery models can differ across settings (e.g., schools vs. outpatient clinics), key personnel involved in the assessment process remain relatively constant and often remain engaged in the service-delivery process during intervention and as communication needs and skills evolve over time. Furthermore, it is possible for personnel across service-delivery networks to be involved in providing AAC services and supports for children. For example, a school-aged child might receive AAC services supported by a speech-language pathologist (SLP) and other school district assistive technology team members while also receiving AAC intervention from a university clinic or private practice and trialing new AAC device options in the home setting as an initial step through a Tech Act demonstration site. Coordination across team members - both within service systems and across service systems - undoubtedly will foster the most effective and efficient service-delivery outcomes for children with complex communication needs.
9. What roles do SLPs play in pediatric AAC service delivery?
The American Speech-Language-Hearing Association (n.p.) describes that SLPs play a central role in the screening, assessment, diagnosis, and treatment of persons requiring AAC intervention, including clinical/educational services (diagnosis, assessment, planning, and treatment), advocacy, education, administration, and research. Further specification on the roles and responsibilities of school-age children provide insight on the specific activities in which SLPs engage in providing pediatric AAC services – whether that be in school contexts or in the context of community-based early intervention services or other clinical settings.
- Complete a culturally and linguistically relevant, comprehensive assessment of the individual’s speech, language, and overall communication abilities.
- Consider the student’s need for AT, including AAC.
- Request, coordinate, or conduct a transdisciplinary and culturally and linguistically relevant AAC assessment within the child’s natural environment and educational setting that includes both the child and their caregiver(s).
- Provide trial periods with AAC systems and collect data on functionality, effectiveness, and efficiency of use.
- Provide a variety of multimodal AAC supports as appropriate, including no-tech, low-tech, and high-tech, to allow the child to communicate across various environments in the school setting.
- Collaboratively write and implement goals related to speech, language, literacy, participation, and use of AAC as part of the individualized education program (IEP) team and/or Individualize Family Service Plan (IFSP).
- Determine the need for further assessment and/or referral for other services.
- Refer to other professionals (rehabilitation engineer, AT professional, occupational therapist, physical therapist, music therapist, vision specialist, special educator, respite care worker) to facilitate access to comprehensive services, reduce barriers, and maximize opportunities for successful AAC use.
- Ensure that the student’s needs are met by others on the evaluation and treatment team.
- Provide initial and ongoing training for medical and allied health professionals, teachers, parents, support staff, and community members about AAC and the needs of students who use AAC.
- Participate in IEP or IFSP meetings.
- Ensure that AAC goals and AAC use are documented in a student’s IEP or IFSP.
- Provide transition support and documentation if AAC is deemed necessary for the student as they enter and exit the school system.
- Counsel persons who use AAC and their families/caregivers regarding communication-related issues and provide education aimed at preventing abandonment and other complications relating to AAC use.
- Counsel persons who use AAC and their families/caregivers regarding communication-related issues and provide education aimed at preventing abandonment and other complications relating to AAC use.
- Remain informed of research in the area of AAC and help advance the knowledge base regarding AAC assessment and intervention.
The ASHA Code of Ethics (2016) also specifies that SLPS should engage in only those aspects of the profession that are within their scope of competence, considering their level of education, training, and experience. SLPs with inadequate experience to provide AAC services are bound by the Code of Ethics to refer the child to an SLP with AAC experience, or, at minimum, to consult with a fellow SLP who has AAC experience to ensure appropriate service delivery.
10. Are AAC services always provided in person?
Telepractice service delivery has become more common in the SLP and AAC disciplines (e.g., Hall, Juengling-Sudkamp, Gutmann, & Cohn, 2020). Of course, AAC telepractice undeniably has intensified in the context of the COVID-19 pandemic. As in all areas of healthcare service delivery and education, practitioners responded essentially overnight to find ways to meet the AAC service delivery needs of individuals with complex communication needs. Technological advancements, community resources, increasing payer flexibility, and decreasing costs have provided pathways to overcome many of the barriers that previously made access to telehealth services challenging for individuals with AAC needs.
In addition to widespread informal reports of AAC services being successfully delivered during the pandemic, the research literature increasingly includes results of applications of both dedicated telehealth and combined in-person telepractice interventions (e.g., Hall, Boisvert, Jellison, & Andrianopoulos, 2014; Schlosser et al., 2020). Initial telepractice findings are encouraging, with positive communication outcomes apparent for both AAC assessment and intervention. In our own work with a hybrid intervention (that is, in-person + telepractice), we have documented positive changes in the communication supports parents provide as well as communication improvements in children receiving AAC. (e.g., Timpe et al., 2021). AAC telepractice does often require ingenuity in delivering AAC technologies to the homes and schools of children and close coordination with their caregivers and other service providers; however, these approaches can pay dividends in providing needed services to children with AAC needs.
11. How are AAC assessment and intervention typically approached?
A common framework used to guide the AAC assessment and intervention process is the “Participation Model” (Beukelman & Mirenda, 2013). This model provides a systematic process for conducting AAC intervention and assessment programs based on daily life functional participation requirements (Beukelman & Light, 2020). The process involves identifying participation supports and barriers as well as the individual’s capabilities and access barriers, which is followed by planning, implementing, and evaluating intervention outcomes meeting the child’s needs in the immediate and over time.
12. Are assessment and intervention separate processes for AAC service delivery?
Given the ongoing need to ensure that the AAC tools and supports used by children continue to meet their communication needs over time, and are well-matched to their physical and sensory needs, assessment and intervention are necessarily cyclical and interdependent processes in AAC service delivery. Regardless of the underlying conditions yielding significant speech and/or language impairments, all children undoubtedly experience changes in their communication needs, partners, and requirements over time. Further, as a child advances in their development, careful consideration of new tools or supports that can be used to advance communication effectiveness and/or efficiency is required. For example, a child might start using graphic symbols to communicate at an early stage of development. Once the child develops functional literacy skills, new AAC solutions are likely to increase communicative efficiency and effectiveness. In examples like this, implementing informal and formal assessment tasks on an ongoing basis is critical to inform ongoing adjustments in communication intervention programs. This approach aligns within the Participation Model, with AAC assessment serving as the information-gathering process required to plan effective AAC interventions (Beukelman & Light, 2020).
13. What are elements of communicative competence that should be considered when working with children using AAC?
Light and colleagues (2003, 2014) describe the following five essential elements of communicative competence for individuals using AAC:
- Linguistic competence includes the child’s knowledge of and the ability to use the language(s) spoken and written in their family and community and knowledge of and the ability to use the linguistic code (symbols, syntax, grammar) of the AAC system.
- Operational competence includes skill in the technical operation of AAC systems and techniques.
- Strategic competence is the ability to use available features to convey messages efficiently and effectively (e.g., asking for choices, using word/phrase prediction, using introductory statements, and effectively addressing communication breakdowns).
- Social competence is knowing what, where, with whom, when and when not to, and in what manner to communicate.
- Psychosocial competence is the ability to manage the demands and challenges of daily life, maintain a state of mental well-being, and demonstrate adaptive and positive behavior during communication (World Health Organization, 1997); this includes aspects of motivation, attitude, confidence, resilience, and persistence for children.
14. What roles do communication partners play in supporting effective AAC use for children with complex communication needs?
Communication partners – that is, people such as family members, educators, service providers, and peers – provide context and purpose for communicative interactions. Through dynamic interactions, communication partners continuously influence each other throughout the course of interactions (e.g., Kent-Walsh & McNaughton, 2005). This ongoing influence is high stakes for young children who are dependent on the richness of their language environments to positively influence their language learning and functional communication skill acquisition. For children using AAC, communication partners not only provide important language models but are often critical to ensuring ongoing access to aided AAC systems through operational maintenance and appropriate set-up – particularly in the case of very young children as well as those with significant motor impairments. Therefore, best practices and clinical practice guidelines indicate the importance of providing training and support for communication partners to further support children with complex communication needs (e.g., ASHA, n.d.; Kent-Walsh, Murza, Malani, & Binger, 2015).
15. What is an example of an evidence-based communication partner instructional program?
Many studies have reported success with communication partner instruction across a range of communication partners and settings (e.g., Kent-Walsh et al., 2015). Some instructional approaches reported in the literature have involved teaching communication partners to implement individual evidence-based communication skills to support the communication of children using AAC. A meta-analysis of AAC communication partner instruction investigations (Kent-Walsh et al., 2015) found that strategy instruction resulted in larger effect sizes than partner interventions that used less structured approaches. Strategy instruction focuses on teaching partners a series of predictable steps that they should follow to enhance the child’s communication skills. One of the AAC communication partner programs that employs such strategy instruction is Improving Partner Applications of Augmentative Communication Techniques (ImPAACT; Kent-Walsh, Binger, & Malani, 2010). The ImPAACT program was originally validated across a series of investigations which a range of communication partners, including family members and various educators. Some of the core instructional techniques include the use of modeling, role play, verbal rehearsal, and coached practice (Kent-Walsh et al., 2010).
16. What are examples of common evidence-based skills or techniques communication partners can be taught to support children’s functional use of AAC?
Although some variability in evidence-based instructional program content has been noted, the communication partner intervention literature has been relatively consistent in identifying effective interaction skill targets. Many investigations report various combinations of the following four interaction skills as effective intervention targets for the communication partners of children using AAC: (a) using extended wait time or expectant delay; (b) consistently responding to the child’s communicative attempts; (c) using of open-ended or WH questions (who, what, where, etc.) instead of yes/no questions; and (d) modeling AAC system use (e.g., Kent-Walsh, Binger, Murza & Malani, 2015).
17. What communication changes do children experience when their communication partners are taught to use evidence-based communication strategies?
A range of positive changes in children’s communication outcomes has been documented in the literature to date. Many studies have focused on pragmatic skills and have documented positive changes in children’s turn-taking rates and expanding their communicative functions (e.g., not just requesting but also commenting and asking questions). Additionally, children have expanded their vocabulary diversity as well as utterance length and complexity. It has been exciting to see so many different types of positive changes in children’s communication skills by working directly with communication partners, and we are looking forward to seeing this evidence base evolve into additional areas such as narrative development.
18. Is literacy instruction important for children who use AAC?
Literacy skills are critical to full participation in contemporary society for any individual. Being able to read and write effectively has been documented to influence a range of outcomes, including health, educational, vocational, and even social outcomes. One contemporary example that drives this point home is the widespread use of social networking and social media for dissemination of and engagement with a full spectrum of information and people. Without functional literacy skills, it is challenging to engage in many popular social media platforms. As important as literacy skills are to function independently in society for any individual, literacy plays an even more fundamental role for children using AAC; literacy skills afford children using AAC increased opportunities to say exactly what they want to say and how they want to say without depending on communication partners and clinicians to select vocabulary or messages for them (e.g., Beukelman & Light 2020). Therefore, supporting literacy development is crucial for many children with complex communication needs. These interventions include emergent literacy skills such as phonological awareness and print concepts as well as interventions that explicitly focus on reading and writing.
19. How can clinicians support expressive language development for children using AAC?
Typical language development offers an excellent model to guide aided expressive language development. For example, we know that children who are typically developing say approximately 50 words by the time they are 18 months old, and those 50 words consist not only of nouns (including proper nouns such as ‘Daddy’ and ‘Max’), but also other words such as adjectives (e.g., hot and big), verbs (e.g., go, help, and push), prepositions (e.g., in and on), and social words (e.g., hi and bye-bye). It is important to ensure that children who use AAC have access to the same range of vocabulary on their AAC systems as children who use spoken language to communicate. All children require variability within their word base to begin to combine words and eventually to produce sentences. Therefore, for children who are solidly in the early symbolic phase of development, providing highly restrictive vocabulary on aided AAC systems is problematic. For example, if a young pre-literate child relies on picture symbols that mainly consist of nouns, the child will lack the vocabulary to build sentences. This restricted access to vocabulary necessarily will negatively impact expressive grammar development. Another commonly used approach focuses on providing children with words that are commonly used words across many people. This ‘core vocabulary’ includes important words such as “go,” “more,” and “that.” However, a strict focus on core vocabulary restricts the development of a rich, motivating, expressive lexicon - thereby negatively impacting semantic development. Further, this approach necessarily results in the child using language in inherently different ways than children who primarily use speech to communicate; for example, using the word “go” to refer to a wide range of movements rather than having access to words such as run, drive, and ride, or using the word “that” to refer to all kinds of objects. It is important to remember that overuse of these general terms is a sign of language impairment in children who rely on speech to communicate. Of course, we recognize the inherent tension in aided AAC between providing access to hundreds and even thousands of words and a child’s ability to locate those words. Using typical language development as a model is part of this consideration, to ensure that we are allowing for an ever-expanding vocabulary whenever possible.
20. Can pre-literate children learn to use graphic symbols to generate novel phrases and sentences?
Acquisition of generative, rule-based language is just as important for children who use AAC as for typically developing children. Many young children with AAC needs have profiles that indicate the potential to use generative language, but even these children have been reported in the literature to often have poor expressive language outcomes (Binger & Light, 2008). Picture symbols can be used to represent language concepts within the AAC systems of pre-literate children who are not yet able to spell out their messages letter-by-letter. Use of such symbols offers pre-literate children the opportunity to be generative in their language expression. For example, to describe what their dog did last night, they could select the symbols DOG + ATE + MOM + ‘S + BURRITO + OFF + HER + PLATE. Teaching children to produce these kinds of generative utterances is possible for many children if they are provided with appropriate language interventions that are rooted in a typical language development framework (e.g., Binger, Kent-Walsh, Harrington, & Hollerbach, 2020; Kent-Walsh, Binger, & Buchanan, 2015).
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