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.

Systematic Review of Variables Related to Instruction in Augmentative and Alternative Communication Implementation: Group and Single-Case Design.

PURPOSE: This article provides a systematic review and analysis of group and single-case studies addressing augmentative and alternative communication (AAC) intervention with school-aged persons having autism spectrum disorder (ASD) and/or intellectual/developmental disabilities resulting in complex communication needs (CCNs). Specifically, we examined participant characteristics in group-design studies reporting AAC intervention outcomes and how these compared to those reported in single-case experimental designs (SCEDs). In addition, we compared the status of intervention features reported in group and SCED studies with respect to instructional strategies utilized. PARTICIPANTS: Participants included school-aged individuals with CCNs who also experienced ASD or ASD with an intellectual delay who utilized aided or unaided AAC. METHOD: A systematic review using descriptive statistics and effect sizes was implemented. RESULTS: Findings revealed that participant features such as race, ethnicity, and home language continue to be underreported in both SCED and group-design studies. Participants in SCED investigations more frequently used multiple communication modes when compared to participants in group studies. The status of pivotal skills such as imitation was sparsely reported in both types of studies. With respect to instructional features, group-design studies were more apt to utilize clinical rather than educational or home settings when compared with SCED studies. In addition, SCED studies were more apt to utilize instructional methods that closely adhered to instructional features more typically characterized as being associated with behavioral approaches. CONCLUSION: The authors discuss future research needs, practice implications, and a more detailed specification of treatment intensity parameters for future research.

Participant characteristics predicting communication outcomes in AAC implementation for individuals with ASD and IDD: a systematic review and meta-analysis.

This meta-analysis examined communication outcomes in single-case design studies of augmentative and alternative communication (AAC) interventions and their relationship to participant characteristics. Variables addressed included chronological age, pre-intervention communication mode, productive repertoire, and pre-intervention imitation skills. Investigators identified 114 single-case design studies that implemented AAC interventions with school-aged individuals with autism spectrum disorder and/or intellectual disability. Two complementary effect size indices, Tau(AB) and the log response ratio, were applied to synthesize findings. Both indices showed positive effects on average, but also exhibited a high degree of heterogeneity. Moderator analyses detected few differences in effectiveness when comparing across diagnoses, age, the number and type of communication modes, participant's productive repertoires, and imitation skills to intervention. A PRISMA-compliant abstract is available: https://bit.ly/30BzbLv.

Advances in AAC intervention: some contributions related to applied behavior analysis.

This article extends Dr. Bob Remington's call for collaborations between those supporting behavioral approaches and those supporting more natural developmental approaches to beginning communication intervention. This article expands areas previously discussed by Dr. Remington. Topics that are addressed include pivotal behaviors that may facilitate communication acquisition, matching law and response efficiency, generalization, maintenance, and the related topics of general case instruction (which involves an understanding of stimulus and response classes). These topics reflect contemporary areas of research that could be better integrated into translational research and have not been extensively integrated into augmentative and alternative communication (AAC) practice. Dr. Remington's article discussed the value of behavioral approaches and corresponding methodology to AAC researchers and practitioners. We agree and discuss the need for greater interaction among proponents of varying approaches to intervention.

Current Trends in Telehealth Applications to Deliver Social Communication Interventions for Young Children with or at Risk for Autism Spectrum Disorder.

PURPOSE OF REVIEW: Early, intensive, and high-quality interventions can often improve social communication outcomes for children with autism spectrum disorder (ASD). Many children experience barriers to intervention, resulting in significant delays to intervention onset or missed opportunities for intervention altogether. With constant advances in technology, the field is experiencing a rapid increase in investigation of telehealth applications to intervention delivery. This article highlights the current trends in social communication intervention via telehealth used in early intervention practices for children with ASD over the past 5 years, including a brief review of studies (from 2014 to January 2020) and our team's experiences in this area. RECENT FINDINGS: Based on our experience and the 22 studies we identified in this area, we describe the current trends in telehealth applications used and how interventions were delivered. We also provide recommendations, limitations, and future directions on this topic. SUMMARY: Telehealth offers innovative intervention delivery options by increasing intervention access, overcoming barriers such as geography and costs of service delivery for young children with ASD.

Implementing Aided Augmentative Communication Systems With Persons Having Complex Communicative Needs.

Augmentative and alternative communication (AAC) systems can support communication skills for people with significant developmental disabilities who experience complex communication needs (CCNs). There is a need to tailor best practices in AAC assessment and intervention to create individualized communication systems with this population. In this article, we outline the important components of AAC systems that can be implemented in authentic settings. However, given the limited evidence on AAC interventions specific to people with CCNs, we also identify some priority areas for future inquiry. Among these involve strategies to enhance decision making regarding (a) matching communication mode(s) to learner skills and contextual demands, (b) identifying communicative opportunities and obligations, (c) individualizing aided communication display features, (d) selection of vocabulary specificity, and (e) considering dosage parameters needed to acquire and maintain a communicative repertoire. In addition, we briefly discuss the use of telehealth to enhance intervention capability.

Requests for Communication Repair Produced by Typically Developing Preschool-Age Children.

Purpose When breakdowns in communication occur, children may request a repair to increase understanding of the message. Unrepaired communication breakdowns may cause confusions, limit conversational exchanges, and restrict children's learning opportunities. Relatively little is known regarding the conditions under which children produce repair requests. Thus, this study examined the verbal communication repair requests produced by typically developing children and evaluated the relationship between children's repair requests and performance on a theory of mind task. Method Participants included 25 typically developing 4-year-old children who completed standardized, norm-referenced assessments of their expressive language, receptive language, and IQ; a theory of mind task; and a shared book reading task. In the shared book reading task, the examiner elicited child repair requests using questions and statements that contained insufficient information. Results Participants produced a statistically significant greater number of repair requests when presented with questions with insufficient information compared to statements with insufficient information ( p < .001). There were no differences in total repair requests between participants who passed or failed the theory of mind task ( p = .45). Conclusion Among preschool-age children, the shared book reading task provided a naturalistic medium that facilitated the examination of children's repair requests. Results from this study provide baseline information to which the repair requests produced by other populations, such as children with autism spectrum disorder, can be compared.

The Effect of Partner Reauditorization on Undergraduates' Attitudes Toward a Peer Who Communicates With Augmentative and Alternative Communication.

Purpose: This study compared college students' attitudes toward a peer who used a nonelectronic augmentative and alternative communication (AAC) system with and without a partner reauditorization strategy and also examined the effect of reauditorization on reported (a) ease of understanding the peer who used AAC, (b) willingness to engage in interactions with the peer who used AAC, and (c) preferences regarding AAC systems. Method: Sixty-four participants completed surveys after viewing each of 2 counterbalanced conditions involving a video of a peer who communicated using AAC. Mean survey ratings were compared between conditions. Results: Participants reported (a) more positive attitudes toward, (b) a greater ease in understanding, and (c) an increased willingness to interact with the peer who used nonelectronic AAC with partner reauditorization. Participants indicated that reauditorization contributed positively to the observed conversation. Reported preferences for nonelectronic AAC systems did not vary as a function of reauditorization, and most participants reported a preference for an electronic speech-generating device when compared with a nonelectronic system. Conclusion: Partner reauditorization may play a role in improving attitudes that individuals hold about peers who use nonelectronic AAC and may contribute to ease of understanding the aided message and increased likelihood of peer interactions.

Promoting Conditional Use of Communication Skills for Learners With Complex Communication Needs: A Tutorial.

Purpose: Conditional use of communication skills refers to the ability of a learner to appropriately generalize and discriminate when, where, and how to communicate based on constant variation and shifts in environmental cues. Method: We describe discrimination and generalization challenges encountered by learners with complex communication needs and ways in which these challenges are fostered through traditional communication intervention programming. We address arrangements in instruction that maximize the probability of learners acquiring the conditional use of new vocabulary and the modest instructional technology implemented when planning for generalization. Results: We propose establishing well-discriminated and generalized use of new vocabulary items through the application of a general case instruction framework to communication intervention programming. Conclusion: We provide intervention methodology, including intervention steps for general case instruction, a plethora of functional examples, and graphic displays to assess and intervene to promote conditional use of communication skills for learners with complex communication needs.

Playing the Long Game: Considering the Future of Augmentative and Alternative Communication Research and Service.

This article examines the growth of aided augmentative and alternative communication (AAC) in providing support to children and youth with significant communication needs. Addressing current trends and offering a discussion of needs and probable future advances is framed around five guiding principles initially introduced by Williams, Krezman, and McNaughton. These include: (1) communication is a basic right and the use of AAC, especially at a young age, can help individuals realize their communicative potential; (2) AAC, like traditional communication, requires it to be fluid with the ability to adapt to different environments and needs; (3) AAC must be individualized and appropriate for each user; (4) AAC must support full participation in society across all ages and interests; and (5) individuals who use AAC have the right to be involved in all aspects of research, development, and intervention. In each of these areas current advances, needs, and future predictions are offered and discussed in terms of researchers' and practitioners' efforts to a continued upward trajectory of research and translational service delivery.

Autism Spectrum Disorder (ASD) Prevalence in Somali and Non-Somali Children.

The current study presents results from an autism spectrum disorder (ASD) public health surveillance project conducted in Minneapolis. The study was designed to compare ASD prevalence in Somali children (ages 7-9) to that of non-Somali children. The study adapted methodology used by the Centers for Disease Control and Prevention's Autism and Developmental Disabilities Monitoring Network. Results indicated that Somali (1 in 32) and White (1 in 36) children were about equally likely to be identified with ASD, but more likely to be identified with ASD than Black and Hispanic children. Somali children with ASD were significantly more likely to have an intellectual disability than children with ASD in all other racial and ethnic groups.

Comparing Single Case Design Overlap-Based Effect Size Metrics From Studies Examining Speech Generating Device Interventions.

Meaningfully synthesizing single case experimental data from intervention studies comprised of individuals with low incidence conditions and generating effect size estimates remains challenging. Seven effect size metrics were compared for single case design (SCD) data focused on teaching speech generating device use to individuals with intellectual and developmental disabilities (IDD) with moderate to profound levels of impairment. The effect size metrics included percent of data points exceeding the median (PEM), percent of nonoverlapping data (PND), improvement rate difference (IRD), percent of all nonoverlapping data (PAND), Phi, nonoverlap of all pairs (NAP), and Tau(novlap). Results showed that among the seven effect size metrics, PAND, Phi, IRD, and PND were more effective in quantifying intervention effects for the data sample (N = 285 phase or condition contrasts). Results are discussed with respect to issues concerning extracting and calculating effect sizes, visual analysis, and SCD intervention research in IDD.

A Comparison of High and Low Dosages of a Component of Milieu Teaching Strategies for Two Preschool-Age Learners With Autism Spectrum Disorder.

PURPOSE: The intersection of treatment intensity and communication intervention is an emerging area of investigation. Milieu teaching (MT) approaches for teaching communication skills to children with autism spectrum disorder (ASD) have a substantial evidence base (see Goldstein, 2002). However, a relatively small percentage (37.8%) of MT studies have fully detailed the parameters that are required to determine treatment intensity (Parker-McGowan et al., 2014). This study compared the effect of two dosages of the modeling component of milieu teaching on acquisition and maintenance of new vocabulary for two preschoolers with ASD. METHOD: Low- and high-dosage conditions were compared within an adapted alternating treatments design. Participants were two preschool-age children with ASD. RESULTS: Results suggested a functional relationship between dose of MT models and acquisition of vocabulary items. For 1 participant, a high-dose application yielded more efficient acquisition. For the second participant, a low-dose application yielded more efficient acquisition. CONCLUSION: The results of this study highlight the influence of individual differences in ostensibly similar persons and response to intervention. The need for better quantifying dosage parameters and examining the relationship between dosage and intervention approaches for preschool-age learners with ASD is discussed.

Communication Intervention to Teach Requesting Through Aided AAC for Two Learners With Rett Syndrome.

Evidence on effective communication interventions for persons with Rett syndrome is needed to drive the standard of care with this population. This study examined the effectiveness of an intervention package to teach multiple, aided communication requests for two persons with Rett syndrome (ages 27 and 7) through within participant, adapted multiple baseline designs across items/activities. Participants were taught graphic mode requests on speech generating devices, with access methods based on motor ability; one participant responded by pressing a touch screen, and one participant responded by fixed eye-gaze. Results are discussed in relation to the effectiveness of the intervention packages on increasing the accuracy of independent request selection responses emitted and the number of sessions required to reach an a priori performance criterion for both participants. Difficulties during initial prompting and during prompt fading with the eye-gaze response are considered. The findings suggest implications related to emerging evidence on the intervention methods to teach requesting skills to this population, and future research directions for communication intervention options for persons with severe communication impairment and limited motor repertoires.

Teaching a Child With Autism to Request Breaks While Concurrently Increasing Task Engagement.

PURPOSE: An intervention package, including teaching break requests and tolerance for delay in reinforcement delivery to increase task engagement, was implemented with a 4-year-old child with an autism spectrum disorder who did not engage for a duration commensurate with individual education program team expectations. METHOD: A multiple-probe design across tasks was implemented. Dependent measures taken included engagement duration and the production of spoken break requests after work completion. Intervention was implemented with tasks involving short periods of engagement prior to the learner's disengagement. The possibility of the learner's overgeneralized production of break requests with tasks originally associated with longer engagement was also examined. RESULTS: The participant learned to request breaks in short engagement tasks. In addition, engagement increased dramatically without off-task behavior. Overgeneralized use of break requests with long engagement tasks did not occur. Generalization of break requests to untrained short engagement tasks that were not the focus of intervention (but were associated with escape and short engagement) did not occur until the intervention package was implemented. CONCLUSIONS: The combination of teaching break requests and tolerance for delay in reinforcement delivery was effective in addressing problem behavior. Implications for enhancing properly generalized and moderated use of break requests across different tasks or contexts are discussed.

Describing treatment intensity in milieu teaching interventions for children with developmental disabilities: a review.

PURPOSE: This investigation aimed to apply the dosage framework proposed by Warren, Fey, and Yoder (2007) to variations of milieu language teaching intervention strategies to explore how each of the dosage parameters (i.e., dose, dose form, dose frequency, total duration, and cumulative intervention intensity) was reported in the located empirically based applications with learners between birth and 23 years of age. METHOD: A systematic search located existing studies that implemented a milieu teaching intervention for children with developmental disabilities. Dosage data were then extracted from 42 studies along with study characteristics and participant characteristics. RESULTS: Only 37.8% of empirical investigations provided a clear definition of treatment intensity and reported the full range of dosage parameters, thus making it difficult to compare the results across investigations. Of the investigations that reported on all dosage parameters, the majority were single-case design as opposed to group design studies. CONCLUSIONS: Given the limited reporting of dosage parameters in existing studies, there is a need for closer attention to reporting this information in early communication intervention protocols. Replication and customization of interventions for learners experiencing developmental disabilities will only be possible with additional empirical examination of dosage parameters.

Communication modality sampling for a toddler with Angelman syndrome.

PURPOSE: Vocal, gestural, and graphic communication modes were implemented concurrently with a toddler with Angelman syndrome to identify the most efficiently learned communication mode to emphasize in an initial augmentative communication system. METHOD: Symbols representing preferred objects were introduced in vocal, gestural, and graphic communication modes using an alternating treatment single-subject experimental design. Conventionally accepted prompting strategies were used to teach symbols in each communication mode. Because the learner did not vocally imitate, vocal mode intervention focused on increasing vocal frequency as an initial step. RESULTS: When graphic and gestural mode performances were compared, the learner most accurately produced requests in graphic mode (percentage of nonoverlapping data = 96). Given the lack of success in prompting vocal productions, a comparison between vocal and the other two communication modes was not made. CONCLUSION: A growing body of evidence suggests that concurrent modality sampling is a promising low-inference, data-driven procedure that can be used to inform selection of a communication mode(s) for initial emphasis with young children. Concurrent modality sampling can guide clinical decisions regarding the allocation of treatment resources to promote success in building an initial communicative repertoire.

Single-subject experimental design for evidence-based practice.

PURPOSE: Single-subject experimental designs (SSEDs) represent an important tool in the development and implementation of evidence-based practice in communication sciences and disorders. The purpose of this article is to review the strategies and tactics of SSEDs and their application in speech-language pathology research. METHOD: The authors discuss the requirements of each design, followed by advantages and disadvantages. The logic and methods for evaluating effects in SSED are reviewed as well as contemporary issues regarding data analysis with SSED data sets. Examples of challenges in executing SSEDs are included. Specific exemplars of how SSEDs have been used in speech-language pathology research are provided throughout. CONCLUSION: SSED studies provide a flexible alternative to traditional group designs in the development and identification of evidence-based practice in the field of communication sciences and disorders.

Synthesized speech intelligibility and early preschool-age children: comparing accuracy for single-word repetition with repeated exposure.

PURPOSE: This investigation examined the effect of repeated exposure to novel and repeated spoken words in typical environments on the intelligibility of 2 synthesized voices and human recorded speech in preschools. METHOD: Eighteen preschoolers listened to and repeated single words presented in human-recorded speech, DECtalk Paul, and AT&T Voice Michael during 5 experimental sessions. Stimuli consisted of repeated and novel words presented in each speech output condition during each session. Sessions took place in the presence of typically occurring noise in classroom or home settings. RESULTS: There was a significant main effect for voice as participants accurately identified significantly more words in the human-recorded speech and AT&T Voice than in the DECtalk speech output condition. When averaged across speech output conditions, children increased their accuracy as they participated in additional sessions. There was a statistically significant interaction between session and voice. DECtalk had a slightly larger effect of session than did AT&T Voice and human-recorded speech.

Group-item and directed scanning: examining preschoolers' accuracy and efficiency in two augmentative communication symbol selection methods.

PURPOSE: The current investigation compared directed scanning and group-item scanning among typically developing 4-year-old children. Of specific interest were their accuracy, selection speed, and efficiency of cursor movement in selecting colored line drawn symbols representing object vocabulary. METHOD: Twelve 4-year-olds made selections in both directed and group-item scanning conditions using a 36-symbol array that required matching line drawn symbols to pictures. RESULTS: The majority of participants took more time in the directed scanning condition. Though not statistically significant, participants tended to be more accurate in their use of directed scanning. The cursor movements required (as a proportion of optimal cursor movements) were similar for both scanning selection techniques. CONCLUSIONS: Among typically developing 4-year-olds, there appears to be a trade-off between speed and accuracy in symbol selection when using directed or group-item scanning. Better accuracy with directed scanning appears to come at the cost of a slower response time. Whereas group-item scanning may be faster, it results in a decreased number of accurate responses. Applications for clinical practice and implications for future research are discussed.