Still having his say: David Yoder's legacy in AAC.

On February 2 2023, one of the guiding lights in the field of augmentative and alternative communication (AAC) for more than four decades, David E. Yoder, passed away at the age of 90. A voracious reader and gifted storyteller, David was particularly fond of a quote from George Bernard Shaw's Back to Methuselah, "You see things; and you say 'Why?' but I dream things that never were; and I say 'Why not?'" That vision led him to take on multiple leadership roles and influence the field of AAC in multiple ways. He played a pivotal role in establishing both the International Society for Augmentative and Alternative Communication (ISAAC) and the United States Society for Augmentative and Alternative Communication (USSAAC). Additionally, he chaired the panel for the National Institute on Disability and Rehabilitation Research (NIDRR)'s inaugural Consensus Validation Conference on AAC, advocated for the American Speech-Language-Hearing Association to recognize AAC within the profession's scope of practice, and served as the first editor for the Augmentative and Alternative Communication journal. In this tribute, we describe David's diverse and unique contributions to improving the lives of people with communication challenges with a focus on some of his central insights and actions.

The Utah Gender Presentation Scale for Communication: Development and Validation of a Measure of Voice-Related Gender Incongruence.

PURPOSE: The aim of the present study was to develop and validate a patient-reported outcome measure for gender incongruence specific to voice and communication parameters, including pitch, intonation, resonance, loudness, speech smoothness, speech clarity, word choice, facial expression, gesture, and posture. METHOD: The Utah Gender Presentation Scale for Communication (U-GPS) includes 10 items, each on a 10-point scale from masculine to feminine. Items were selected based on literature review and patient focus groups. During test administration, respondents provide their current rating and goal rating for each item. The difference between these scores is used to calculate an overall incongruence score. Prospective data from transgender and gender-diverse (n = 155) and cisgender (n = 69) individuals were then used for a multiparametric psychometric evaluation of the measure. RESULTS: Findings demonstrate excellent levels of internal consistency (Cronbach's alpha for current scores: α = .943; Cronbach's alpha for goal scores: α = .970), test-retest reliability (intraclass correlation coefficient = .905), longitudinal validity (improvement in therapy for trans women: F = 293.0, p < .001; nonbinary folx: F = 80.9, p < .001), concurrent validity (correlation with the Trans Woman Voice Questionnaire: r = .51, p < .001), and known-group expectations (differences among five gender groups: F = 82.7, p < .001). CONCLUSION: The U-GPS is a meaningful measure of voice-related gender incongruence, which is clinically relevant for assessing goals in gender-affirming voice and communication therapy for individuals across the gender spectrum.

Behavioral Treatment Approaches to Lowering Pitch in the Female Voice.

PURPOSE: To assess the outcomes of three voice therapy treatment approaches with an emphasis on lowering speaking pitch. Transmasculine and cisgender individuals may desire to lower their speaking pitch, yet there has not been a method described in the literature to do this effectively using only behavioral techniques. METHOD: To investigate these approaches, we enrolled 32 adult cisgender females and randomly assigned them to one of four treatment groups: vocal function exercises (VFE), resonant voice therapy (RVT), lip-rounding therapy (LRT), and a control group. Participants received individual instruction and feedback on the given exercise program, and they continued to practice daily for 4 weeks. RESULTS: Acoustic recordings were collected before treatment, immediately after the first session, and after 4 weeks of treatment. Results showed a lower minimum pitch in the physiological range, lower speaking fundamental frequency (SFF) in reading, and lower SFF in spontaneous speech-with treatment groups performing better than the control group. Additionally, participants' self-rating of the vocal effort expended to speak in a low pitch decreased over the treatment period. CONCLUSIONS: Each treatment approach (VFE, RVT, and LRT) was successful in lowering the speaking pitch of cisgender females. These methods would likely be useful for clients seeking to speak in a lower pitch. Future research may expand results to include clinical populations, such as transmasculine individuals.

Comparison of driving capacity among patients with amyotrophic lateral sclerosis and healthy controls using the lane change task.

OBJECTIVE: Compare driving capacity of individuals with Amyotrophic Lateral Sclerosis (ALS) and healthy controls (HC) using a driving simulation program. METHODS: A prospective study was performed on individuals with ALS who reported they were still driving, and a group of HCs. Demographic data included age and gender. Assessment included cognitive assessments (Montreal cognitive assessment [MoCA] and ALS Cognitive Behavioral Scale [ALS-CBS]); gait speed (m/s); ALS Functional Rating Scale-revised total score (ALSFRS-R); and simulated driving assessment (Lane Change Task [LCT]). The LCT is a simple assessment tool which simulates the visual, cognitive, and motor demands of driving to detect at-risk drivers and uses distractions (secondary tasks) to quantify the performance loss on the primary task (lane changes). RESULTS: Twenty-eight individuals with ALS (22 males, mean age 64 years) and 20 HCs (7 males, mean age 59 years) were studied. Individuals with mild to moderate ALS (ALSFRS-R mean 36.2) were older, had mild cognitive difficulty (MoCA 24 vs 27; ALS-CBS 14.19 [SD 3.85]) and mobility decline (gait speed 1.1 vs 1.4 m/s) compared to HC. Driving assessment using the LCT found no differences in baseline scores or during motor, cognitive, or visually distracting conditions. CONCLUSIONS: Individuals with ALS with mild to moderate disease progression, with cognitive and motor weakness still demonstrate similar driving capacity to HCs using a driving simulation task. Driving assessment needs to be expanded longitudinally and perhaps with more robust measures to more precisely identify types of driving challenges that lead to cessation of driving in individuals with ALS.

Longitudinal Effects of Adaptive Interventions With a Speech-Generating Device in Minimally Verbal Children With ASD.

There are limited data on the effects of adaptive social communication interventions with a speech-generating device in autism. This study is the first to compare growth in communications outcomes among three adaptive interventions in school-age children with autism spectrum disorder (ASD) who are minimally verbal. Sixty-one children, ages 5-8 years, participated in a sequential, multiple-assignment randomized trial (SMART). All children received a developmental behavioral communication intervention: joint attention, symbolic play, engagement and regulation (JASP) with enhanced milieu teaching (EMT). The SMART included three 2-stage, 24-week adaptive interventions with different provisions of a speech-generating device (SGD) in the context of JASP+EMT. The first adaptive intervention, with no SGD, initially assigned JASP+EMT alone, then intensified JASP+EMT for slow responders. In the second adaptive intervention, slow responders to JASP+EMT were assigned JASP+EMT+SGD. The third adaptive intervention initially assigned JASP+EMT+SGD; then intensified JASP+EMT+SGD for slow responders. Analyses examined between-group differences in change in outcomes from baseline to Week 36. Verbal outcomes included spontaneous communicative utterances and novel words. Nonlinguistic communication outcomes included initiating joint attention and behavior regulation, and play. The adaptive intervention beginning with JASP+EMT+SGD was estimated as superior. There were significant (p < .05) between-group differences in change in spontaneous communicative utterances and initiating joint attention. School-age children with ASD who are minimally verbal make significant gains in communication outcomes with an adaptive intervention beginning with JASP+EMT+SGD. Future research should explore mediators and moderators of the adaptive intervention effects and second-stage intervention options that further capitalize on early gains in treatment.

Parents' Adoption of Social Communication Intervention Strategies: Families Including Children with Autism Spectrum Disorder Who are Minimally Verbal.

Notably absent from the intervention literature are parent training programs targeting school-aged children with autism who have limited communication skills (Tager-Flusberg and Kasari in Autism Res 6:468-478, 2013). Sixty-one children with autism age 5-8 with minimal spontaneous communication received a 6-month social communication intervention including parent training. Parent-child play interactions were coded for parents' strategy implementation and children's time jointly engaged (Adamson et al. in J Autism Dev Disord 39:84-96, 2009). Parents mastered an average of 70% of the strategies. Further analyses indicated some gains in implementation occurred from mere observation of sessions, while the greatest gains occurred in the first month of active coaching and workshops. Children's joint engagement was associated with parents' implementation success across time demonstrating parents' implementation was relevant to children's social engagement.

Communication interventions for minimally verbal children with autism: a sequential multiple assignment randomized trial.

OBJECTIVE: This study tested the effect of beginning treatment with a speech-generating device (SGD) in the context of a blended, adaptive treatment design for improving spontaneous, communicative utterances in school-aged, minimally verbal children with autism. METHOD: A total of 61 minimally verbal children with autism, aged 5 to 8 years, were randomized to a blended developmental/behavioral intervention (JASP+EMT) with or without the augmentation of a SGD for 6 months with a 3-month follow-up. The intervention consisted of 2 stages. In stage 1, all children received 2 sessions per week for 3 months. Stage 2 intervention was adapted (by increased sessions or adding the SGD) based on the child's early response. The primary outcome was the total number of spontaneous communicative utterances; secondary measures were the total number of novel words and total comments from a natural language sample. RESULTS: Primary aim results found improvements in spontaneous communicative utterances, novel words, and comments that all favored the blended behavioral intervention that began by including an SGD (JASP+EMT+SGD) as opposed to spoken words alone (JASP+EMT). Secondary aim results suggest that the adaptive intervention beginning with JASP+EMT+SGD and intensifying JASP+EMT+SGD for children who were slow responders led to better posttreatment outcomes. CONCLUSION: Minimally verbal school-aged children can make significant and rapid gains in spoken spontaneous language with a novel, blended intervention that focuses on joint engagement and play skills and incorporates an SGD. Future studies should further explore the tailoring design used in this study to better understand children's response to treatment. Clinical trial registration information-Developmental and Augmented Intervention for Facilitating Expressive Language (CCNIA); http://clinicaltrials.gov/; NCT01013545.

Predictors of phrase and fluent speech in children with autism and severe language delay.

OBJECTIVE: To examine the prevalence and predictors of language attainment in children with autism spectrum disorder (ASD) and severe language delay. We hypothesized greater autism symptomatology and lower intelligence among children who do not attain phrase/fluent speech, with nonverbal intelligence and social engagement emerging as the strongest predictors of outcome. METHODS: Data used for the current study were from 535 children with ASD who were at least 8 years of age (mean = 11.6 years, SD = 2.73 years) and who did not acquire phrase speech before age 4. Logistic and Cox proportionate hazards regression analyses examined predictors of phrase and fluent speech attainment and age at acquisition, respectively. RESULTS: A total of 372 children (70%) attained phrase speech and 253 children (47%) attained fluent speech at or after age 4. No demographic or child psychiatric characteristics were associated with phrase speech attainment after age 4, whereas slightly older age and increased internalizing symptoms were associated with fluent speech. In the multivariate analyses, higher nonverbal IQ and less social impairment were both independently associated with the acquisition of phrase and fluent speech, as well as earlier age at acquisition. Stereotyped behavior/repetitive interests and sensory interests were not associated with delayed speech acquisition. CONCLUSIONS: This study highlights that many severely language-delayed children in the present sample attained phrase or fluent speech at or after age 4 years. These data also implicate the importance of evaluating and considering nonverbal skills, both cognitive and social, when developing interventions and setting goals for language development.

Evidence of cue use and performance differences in deciphering dysarthric speech.

There is substantial performance variability among listeners who transcribe degraded speech. Error patterns from 88 listeners who transcribed dysarthric speech were examined to identify differential use of syllabic strength cues for lexical segmentation. Transcripts from listeners were divided into four groups (ranging from Better- to Poorer- performing). Phrases classified as Higher- and Lower-intelligibility were analyzed separately for each performance group to assess the independent variable of severity. Results revealed that all four listener groups used syllabic strength cues for lexical segmentation of Higher-intelligibility speech, but only the Poorer listeners persisted with this strategy for the Lower-intelligibility phrases. This finding and additional analyses suggest testable hypotheses to address the role of cue-use and performance patterns.

The development of an automated method for analyzing communication rate in augmentative and alternative communication.

A significant barrier to evidence-based practice in Augmentative and Alternative Communication (AAC) is the lack of validated performance measures that can be used by speech-language pathologists and rehabilitation engineers to evaluate the communication and device use of AAC consumers. Recently an effort has been made to develop automated data-logging techniques to facilitate the transcription and analysis of the AAC speaker's device use. A major source of error for the automated measurement of communication rate is the presence of excessive Inter-Selection Intervals (ISIs) (i.e., pause times), for which no communicative activity is occurring. The goal of this study was to develop an automated technique to filter out extreme ISIs, while preserving true communication rate performance. AAC data log files were obtained from seven individuals participating in a 1-month field trial of an AAC technology. Two temporal filtering techniques (arbitrary and individual) were compared for their ability to eliminate excessive ISIs. Results indicated that use of an individualized temporal filter was more sensitive to performance variability than use of an arbitrary temporal filter. Further, the individualized temporal filter elevated the participants' communication rate (measured by words per minute) by a factor of 1.8 to 34.5 greater than that of the unfiltered communication rate estimate. In addition, the first AAC communication rate performance estimates taken from the field are presented. Implications for further research and the valid use of automated data logging and analysis are discussed.