Visual fixation patterns to AAC displays are significantly correlated with motor selection for individuals with Down syndrome or individuals on the autism spectrum.

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

A qualitative pilot study of adult AAC users' experiences related to accessing and receiving mental health services.

There is currently limited research related to mental health supports for individuals who use AAC, particularly about the actual lived experiences of AAC users who receive mental health services. There may be alterations to mental health services for individuals who use AAC. The aim of this study was to gain the perspectives of AAC users on accessing and receiving mental health services. Three participants who used AAC and received mental health services shared their experiences related to receiving mental health services. Data were analyzed using an inductive approach in which themes were based on participants' experiences. Five major themes were generated: (a) Time, (b) Communication Partner Skills, (c) Advocacy, (d) Means of Expression, and (e) Diagnosis. Participants described factors that positively or negatively impacted their experiences. Participant experiences were examined in light of Bronfenbrenner's Ecological Systems model. The findings of this study provide insights into the perspectives of individuals who use AAC in accessing mental health services, uncovering various barriers and facilitators within the patient-psychotherapist microsystem. Factors such as time constraints, communication partner skills, advocacy, means of expression, and diagnosis-related challenges significantly influenced the quality of interaction between patients using AAC and their mental health provider. The study also reveals the broader impacts of AAC on interactions within the meso-, exo-, and macro-systems, suggesting the need for improved involvement of speech-language pathologists and policy changes to support effective communication and accessibility for individuals using AAC in mental health settings. Ultimately, future research should involve participants of varying ages, diagnoses, and backgrounds and should include a variety of stakeholders.

Speech-Language Pathologists' Approach to Alternative Access for Augmentative and Alternative Communication for Children With Motor Impairments.

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

Community-based COVID-19 outbreak of the B.1.1.7 (Alpha) variant of concern in Newfoundland, February to March 2021.

Background: From March 2020 to January 2021, Newfoundland and Labrador experienced 408 coronavirus disease 2019 (COVID-19) cases (incidence 78 per 100,000). In February and March 2021, a community outbreak of the B.1.1.7 (Alpha) variant occurred in the Eastern Regional Health Authority. This article describes the epidemiology of this variant of concern outbreak, identifies settings that likely contributed to spread and informs recommendations for public health measures (PHMs). Methods: Provincial surveillance data were linked with case interview data and a school class roster. Descriptive epidemiological methods were used to characterize the outbreak. Secondary attack rates (SAR) were calculated for households and classrooms. Results: This outbreak involved 577 laboratory-confirmed and 38 probable cases. Whole genome sequencing determined cases were B.1.1.7. The median age was 31 years and the highest proportion of cases were in the 15 to 19-year age group (29%); 293 (51%) were female and 140 (24%) were asymptomatic upon identification. Early cases were linked to a high school, sports activities, a restaurant and social gatherings. As the outbreak progressed, cases were associated with household transmission, a daycare, healthcare settings and a workplace. The unadjusted SAR estimate among laboratory-confirmed cases was 24.4% for households and 19.3% for classroom exposures. When adjusted for other potential exposures, SAR estimates were 19.9% for households and 11.3% for classrooms. Conclusion: This outbreak demonstrated how B.1.1.7 spread rapidly through a community with previously low COVID-19 transmission and few preventative PHMs in place. Implementation and compliance with school and community-based PHMs is critical for preventing transmission during outbreaks.

Functional Magnetic Resonance Imaging Activation During Unscripted Discourse in People With Poststroke Aphasia.

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

An Evidence-Based Approach to Augmentative and Alternative Communication Design for Individuals With Cortical Visual Impairment.

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

A biophysiological framework exploring factors affecting speech and swallowing in clinical populations: focus on individuals with Down syndrome.

Speech and swallowing are complex sensorimotor behaviors accomplished using shared vocal tract anatomy. Efficient swallowing and accurate speech require a coordinated interplay between multiple streams of sensory feedback and skilled motor behaviors. Due to the shared anatomy, speech and swallowing are often both impacted in individuals with various neurogenic and developmental diseases, disorders, or injuries. In this review paper, we present an integrated biophysiological framework for modeling how sensory and motor changes alter functional oropharyngeal behaviors of speech and swallowing, as well as the potential downstream effects to the related areas of language and literacy. We discuss this framework with specific reference to individuals with Down syndrome (DS). Individuals with DS experience known craniofacial anomalies that impact their oropharyngeal somatosensation and skilled motor output for functional oral-pharyngeal activities such as speech and swallowing. Given the increased risk of dysphagia and "silent" aspiration in individuals with DS, it is likely somatosensory deficits are present as well. The purpose of this paper is to review the functional impact of structural and sensory alterations on skilled orofacial behaviors in DS as well as related skills in language and literacy development. We briefly discuss how the basis of this framework can be used to direct future research studies in swallowing, speech, and language and be applied to other clinical populations.

Demands Associated With an Augmentative and Alternative Communication System in Relation to Alternative Forms of Access for Individuals With Motor Impairments.

PURPOSE: Successful adoption and use of aided augmentative and alternative communication (AAC) must address how to promote fluid, efficient, and organized execution of the motor behavior needed to access the AAC system. A substantial number of people who use AAC have significant motor impairments and require "alternative" access options, such as eye gaze or switch use. Such individuals may be particularly vulnerable to interference from a poorly designed system. However, the inherent demands of alternative access methods have received little direct study. The goal of this tutorial is to offer a clinically and theoretically guided framework for considerations concerning AAC access, with the hope of spurring further discussion and empirical research. METHOD: A framework that draws upon dynamic systems theory was used to illustrate the interactions between the various elements of importance to AAC access. Information and research from the fields of motor learning, developmental dynamic systems theory, AAC, and assistive technology was integrated into this tutorial to examine their applications for alternative AAC access methods. RESULTS: The framework illustrated that AAC access involves a complex coordination between individual skills, the demands of the communication environment, the activity being undertaken, and the supports and demands inherent in the AAC system itself. CONCLUSIONS: Awareness of the many demands that alternative forms of access place on the person who uses them can guide clinicians during assessment and intervention decision making regarding access options for individuals with significant motor impairments. Specific directions for future research are considered.

Supporting Access to Mental Health Services for Patients Who Use Augmentative and Alternative Communication: A Proposed Framework and Suggestions for Future Directions.

PURPOSE: The purpose of this review article is to examine interacting factors that affect the psychotherapeutic process for patients who use augmentative and alternative communication (AAC). This is examined from two perspectives: (a) how the skills and needs brought by the individual with communication disabilities influence the process of therapy and (b) how the individual's ecological systems may affect an individual's mental health and their access to mental health supports. Understanding these factors will guide future efforts aimed at ensuring that individuals with communication disorders have adequate access to services and supports for mental health. METHOD: A narrative synthesis approach was used to explore the interaction of psychotherapy and the use of AAC. Existing research in the fields of psychotherapy and speech-language pathology was examined for its relevance to issues of communication using AAC. Specifically, information was synthesized concerning mental health, prevalence rates of mental health diagnoses, the provision of traditional psychotherapy, and communicating via AAC in order to describe the intersection of psychotherapy and AAC. This narrative synthesis approach sought to initiate discussion of relevant factors that may affect the psychotherapeutic process for patients who use AAC. RESULTS: A variety of factors may affect the psychotherapeutic process for patients who use AAC. Bronfenbrenner's (1977) Ecological Systems Theory was used to explore access to mental health services for individuals who use AAC at the levels of microsystem, mesosystem, exosystem, and macrosystem. Such factors include alterations to communication between patient and psychotherapist, skills brought by the patient, involvement of a communication assistant and/or speech-language pathologist, education and skill level of the psychotherapist, appropriateness of billing codes, and system and policy factors that may affect the provision of mental health services to patients who use AAC. CONCLUSION: It is necessary to explore the factors that affect the provision of psychotherapy for patients who use AAC in order to more fully address the mental health needs of individuals with communication disorders. Further research is needed to determine the impacts of these factors and ways to address those impacts.

Judicious Arrangement of Symbols on a Simulated Augmentative and Alternative Communication Display Optimizes Visual Attention by Individuals With Down Syndrome.

PURPOSE: Aided augmentative and alternative communication (AAC) displays are often designed as symmetrical row-column grids, with each square in the grid containing a symbol. To maximize vocabulary on displays, symbols are often placed close to one another, and background color cuing is used to signal/differentiate symbols across different grammatical categories. However, from a visual and developmental standpoint, these display features (close-set symbols and use of background color cues) may not be optimal. In particular, placing symbols quite close together may result in visual crowding, in which individual symbols cannot be distinguished due to the presence of many neighbors, or flankers. This research sought to examine the role of display arrangement and background color cuing on the efficiency of visual attention during search. METHOD: Ten adolescents and adults with Down syndrome underwent a visual search task while a research-based eye tracking system recorded their patterns of visual attention. Participants searched for symbol targets on displays with varying levels of visual crowding and background color cuing. RESULTS: Spatial arrangements that reduced visual crowding and that used the spatial organization to cue the grammatical category of symbols resulted in significantly fewer fixations to nonrelevant distracters during search and reduced the likelihood of fixations away from the target once it was located. Background color was helpful in reducing the latency to find the target. DISCUSSION: Spatial cues may offer a powerful means to maximize the efficiency of search within AAC displays. Background color cuing may facilitate speed to locate targets in these older individuals. Implications for AAC design, as well as future avenues for maximizing (growing) vocabulary, are discussed.

The impact of pertussis vaccine programme changes on pertussis disease burden in Manitoba, 1992-2017-an age-period-cohort analysis.

BACKGROUND: Changes to pertussis vaccination programmes can have impacts on disease burden that should be estimated independently from factors such as age- and period-related trends. We used age-period-cohort (APC) models to explore pertussis incidence in Manitoba over a 25-year period (1992-2017). METHODS: We identified all laboratory-confirmed cases of pertussis from Manitoba's Communicable Diseases Database and calculated age-standardized incidence rates. We used APC models to investigate trends in pertussis incidence. RESULTS: During the study period, 2479 cases were reported. Age-standardized rates were highest during a large outbreak in 1994 (55 cases/100 000 person-years), with much lower peaks in 1998, 2012 and 2016. We saw strong age and cohort effects in the APC models, with a steady decrease in incidence with increasing age and increased risk in the cohort born between 1980 and 1995. CONCLUSIONS: The highest risk for pertussis was consistently in young children, regardless of birth cohort or time period. The 1981 programme change to an adsorbed whole-cell pertussis vaccine with low effectiveness resulted in reduced protection in the 1981-95 birth cohort and contributed to the largest outbreak of disease during the 25-year study period.

Centering the family in their system: a framework to promote family-centered AAC services.

Families are the most significant communication partners for an individual with complex communication needs. Even though family-centered approaches are recommended to support augmentative and alternative communication (AAC) services for an individual, it is difficult to establish a successful plan that fits each individual's family. A framework for practitioners is proposed to effectively obtain and understand information about a family's unique dynamics as part of service delivery to positively impact AAC device uptake and long-term use. The goal of using this model is to minimize the disruption to the family while maximizing the integration of the AAC system. This paper proposes and illustrates a framework to enrich AAC services through the integration of several theoretical models of family systems theory, family paradigms, and a procedure called the self-created genogram. This paper begins by reviewing ecological family systems theory and family systems to guide and provide a framework to support effective AAC implementation. The process of self-creating genograms is then introduced as a means to obtain a rich perspective on family characteristics and dynamics that is informed by the individual who uses AAC. All of this information allows professionals to provide relevant information and tailor options for the family. As a result, the family is able to make informed decisions about AAC intervention in a manner most consistent with how they typically operate. Finally, we apply this framework to a hypothetical case of a child with autism and complex communication needs across three timepoints (preschool, late elementary/early middle school, and high school/post-secondary transition) to demonstrate how this framework can be used in clinical practice.

Patterns and descriptors of COVID-19 testing and lab-confirmed COVID-19 incidence in Manitoba, Canada, March 2020-May 2021: A population-based study.

BACKGROUND: We studied lab-confirmed COVID-19 infection (LCCI) testing, incidence, and severity. METHODS: We included all Manitoba residents and limited our severity analysis to LCCI patients. We calculated testing, incidence and vaccination rates between March 8, 2020 and June 1, 2021. We estimated the association between patient characteristics and testing (rate ratio [RR]; Poisson regression), including the reason for testing (screening, symptomatic, contact/outbreak asymptomatic), incidence (hazard ratio [HR]; Cox regression), and severity (prevalence ratio [PR], Cox regression). FINDINGS: The overall testing rate during the second/third wave was 570/1,000 person-years, with an LCCI rate of 50/1,000 person-years. The secondary attack rate during the second/third wave was 16%. Across regions, young children (<10) had the lowest positivity for symptomatic testing, the highest positivity for asymptomatic testing, and the highest risk of LCCI as asymptomatic contact. People in the lowest income quintile had the highest risk of LCCI, 1.3-6x the hazard of those in the highest income quintile. Long-term care (LTC) residents were particularly affected in the second wave with HRs>10 for asymptomatic residents. INTERPRETATION: Although the severity of LCCI in children was low, they have a high risk of asymptomatic positivity. The groups most vulnerable to LCCI, who should remain a focus of public health, were residents of Manitoba's North, LTC facilities, and low-income neighbourhoods. FUNDING: Canada Research Chair Program.

Pertussis vaccine effectiveness and duration of protection - A systematic review and meta-analysis.

A comprehensive review of observational pertussis vaccine effectiveness (VE) studies is needed to update gaps from previous reviews. We conducted a systematic review of VE and duration of protection studies for the whole-cell (wP) and acellular (aP) pertussis vaccines and conducted a formal meta-analysis using random effects models. Evidence continues to suggest that receipt of any pertussis vaccine confers protection in the short-term against disease although this protection wanes rapidly for aP vaccine. We detected significant heterogeneity in pooled estimates due, in part, to factors such as bias and confounding which may be mitigated by study design. Our review of possible sources of heterogeneity may help interpretation of other VE studies and aid design decisions in future pertussis VE research.

Visual Attention to Cued Targets in Simulated Aided Augmentative and Alternative Communication Displays for Individuals With Intellectual and Developmental Disabilities.

Purpose Many aided augmentative and alternative communication (AAC) systems require the use of an external display that is represented via a visual modality. It is critical to evaluate and understand visual-perceptual processing in individuals with disabilities who could benefit from AAC. One way to evaluate how individuals process visual materials is through research-based automated eye-tracking technologies that obtain a fine-grained stream of data concerning gaze paths of visual attention. Method The current study examined how individuals with autism spectrum disorder (n = 13), Down syndrome (n = 13), intellectual and developmental disabilities (n = 9), or typical development (n = 20) responded to a spoken prompt to find a thumbnail-sized navigation key within a complex AAC display, including a main visual scene display (VSD) and a navigation bar of four thumbnail-sized VSDs. Stimuli were presented on a monitor containing automated eye-tracking research technology that recorded patterns of visual attention. Results Participants across groups spent more time fixating on a target thumbnail VSD navigation image after the presentation of the spoken cue to look at the target, compared to before the presentation of the spoken cue; they also spent more time looking at the target thumbnail VSD than the other thumbnail-sized VSDs in the navigation bar after the cue. Discussion Participants were able to locate the target thumbnail VSDs, even within the context of a visually complex AAC display. Implications for the design of AAC displays and for assessment of comprehension are discussed.

A multisite study of pertussis vaccine effectiveness by time since last vaccine dose from three Canadian provinces: A Canadian Immunization Research Network study.

BACKGROUND: Pertussis remains poorly controlled relative to other diseases targeted by childhood vaccination programs. We combined estimates from four population-based studies of pertussis vaccine effectiveness (VE) in three Canadian provinces using a meta-analytic approach to improve precision and explore regional variation in VE and durability of protection. METHODS: Studies were conducted in Alberta, Manitoba, and Ontario over periods ranging from 1996 to 2015. Adjusted log odds ratios (OR; VE = 100*[1-OR]) of the effect of vaccination on pertussis risk were estimated by time since last vaccination in each study and pooled using DerSimonian and Laird random-effects models. We used the I2 statistic to estimate between-study heterogeneity and assessed methodological and clinical heterogeneity through subgroup analyses of study design and age. RESULTS: Data on 3,270 pertussis cases and 23,863 controls were available. Pertussis VE declined from 86% (95% CI 79%-90%, I2 = 81.5%) at < 1 year since last vaccination to 51% (11%-74%, I2 = 80.9%) by ≥ 8 years. Effect estimates were the most heterogeneous in the least and most elapsed time periods since last vaccine dose. This was attributable mostly to variation between provinces in the distribution of age groups and number of vaccine doses received within time periods, as well as study design and small numbers in the most elapsed time period. INTERPRETATION: Consistent trends of decreasing pertussis VE with increasing time since last vaccination across three Canadian provinces indicate the need for immunization schedules and vaccine development to optimize protection for all individuals, especially for adolescents and young adults at greatest risk of infection.

The Early Development of Emotional Competence Profile: A Means to Share Information About Emotional Status and Expression by Children With Complex Communication Needs.

Purpose This clinical focus article introduces a summary profile template, called the Early Development of Emotional Competence Profile (EDEC-P). This profile distills information from a longer interview tool that solicits a detailed case history (the EDEC), but in a format that is readily accessible for communication partners of children with complex communication needs, including parents, educators, and other professionals. Method In this clinical focus article, we will (a) introduce the EDEC-P structure, (b) illustrate via case examples the types of information that can be shared, and (c) offer preliminary feedback from parents and other professionals on its usefulness. We will review literature that supports the importance of scaffolding communication about emotions by specialists who work with children with complex communication needs and by parents and other communication partners. Results An EDEC-P was generated for two participants as an illustration of the process. Feedback was solicited from these children's parents and other communication partners. The feedback demonstrated that the EDEC-P was viewed as a positive tool and identified some of the ways that it might be used. Conclusions The EDEC-P may be useful for professionals who are interested in approaching communication about emotions in children with complex communication needs. Guidelines are proposed to present and discuss the results from the interview to support the decision-making process in the clinical practice and next steps in research. Supplemental Material https://doi.org/10.23641/asha.14219777.

Children With Cortical Visual Impairment and Complex Communication Needs: Identifying Gaps Between Needs and Current Practice.

Purpose This scoping study sought to establish a baseline for how well the needs of children with cortical visual impairment (CVI) who use augmentative and alternative communication (AAC) are currently aligned with the services available to them. CVI is the most common cause of visual impairment in children today, and AAC methods rely heavily on vision. Yet, the prevalence of CVI in children who use AAC methods is not yet known, and there is virtually no research concerning use of AAC with children with CVI. Our overarching goals were to identify barriers and suggest priorities for improving outcomes for these children. Method Surveys were distributed anonymously online to professionals from multiple disciplines in different school-based settings and to parents of children with CVI who use AAC. Results School-based professionals identified many barriers, including a lack of knowledge and skills about CVI and about AAC, limited access to training and experts, and concerns about services being delivered in isolated silos with limited time allotted for interprofessional collaboration and planning. Parent reported that their children (M age = 11 years) continued to rely predominantly on body-based forms of communication and lacked access to symbolic language, which, in AAC, is primarily visually based. Conclusions The barriers to services identified by school-based professionals indicate a need to develop and disseminate reliable information about CVI and AAC, both at a preservice and in-service level and, while doing so, to respect the diversity of stakeholders who need this information, including parents. Future research on what types of AAC approaches support the development of language and communication skills for children with CVI is essential.

Speech-Language pathologists' decisions when designing an aided AAC display for a compilation case study of a beginning communicator.

PURPOSE: The current study sought to identify decisions speech-language pathologists (SLPs) make and their rationale for those decisions when designing an AAC display for a hypothetical school-aged child who was a beginning communicator. Augmentative and alternative communication (AAC) displays support communicative interactions for children who are unable to use spoken language to meet their communication needs. Children who are at the early stages of learning language, often termed beginning or emerging communicators, may rely heavily on the AAC display to support comprehension and expression. Thus, it is important for speech-language pathologists (SLPs) to design a display that facilitates beginning communicators' communication development. METHODS: This paper reports on the answers related to a specific case study presented in an online survey completed by 77 SLPs with experience in AAC. RESULTS: Data illustrated design decisions driven by child-specific characteristics and informed by research regarding type of layout, representation, and the importance of various design features. CONCLUSIONS: Suggestions for future research are provided, including identifying goals and communicative functions best supported by different types of displays, clinicians' challenges/successes growing a system with the child, and determining the importance of symbol arrangement and organisation in communicative tasks by AAC users.Implications for RehabilitationIdentification of current practices reported by speech-language pathologists given a case study to develop and implement future research.A gap between research and practice suggests the need for better dissemination and application of research supporting the inclusion of people engaged in the event depicted in a visual scene display.Foundations for future research to provide guidance regarding best design of and communication goals supported by visual scene displays and grid-based displays.