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.

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.

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.

Cognitive-perceptual load modulates hand selection in left-handers to a greater extent than in right-handers.

Previous studies have proposed that selecting which hand to use for a reaching task appears to be modulated by a factor described as "task difficulty," defined by either the requirement for spatial precision or movement sequences. However, we previously reported that analysis of the movement costs associated with even simple movements plays a major role in hand selection. We further demonstrated, in right-handers, that cognitive-perceptual loading modulates hand selection by interfering with the analysis of such costs. It has been reported that left-handers tend to show less dominant hand bias in selecting which hand to use during reaching. We, therefore, hypothesized that hand selection would be less affected by cognitive-perceptual loading in left-handers than in right-handers. We employed a visual search task that presented different levels of difficulty (cognitive-perceptual load), as established in previous studies. Our findings indicate that left-handed participants tend to show greater modulation of hand selection by cognitive-perceptual loading than right-handers. Left-handers showed lower dominant hand reaction times than right-handers, and greater high-cost movements that reached to extremes of the contralateral workspace under the most difficult task conditions. We previously showed in this task that midline crossing has high-energy and time costs and that they occur more frequently under cognitively demanding conditions. The current study revealed that midline crossing was associated with the lowest reaction times, in both handedness groups. The fact that left-handers showed lower dominant hand reaction times, and a greater number of high-cost cross-midline reaches under the most cognitively demanding conditions suggests that these actions were erroneous.

Designing Developmentally Sensitive AAC Technologies for Young Children with Complex Communication Needs: Considerations of Communication, Working Memory, Attention, Motor Skills, and Sensory-Perception.

Young children who require augmentative and alternative communication (AAC) must be provided with AAC technologies that are designed to meet their needs and accommodate their skills. One critical aspect of matching the system design features of aided AAC technologies to the needs and abilities of the child with complex communication needs is a consideration of the child's developmental skills. This article provides an overview of specific, early developmental milestones in communication, cognition (i.e., attention and working memory), motor skills, and sensory-perception (including visual attention) that influence decisions regarding AAC system design for young children. Developmental considerations are also reviewed for young children with Down's syndrome, a group that often benefits from early provision of AAC. Based on developmental theory and milestones, specific recommendations are provided for the design of developmentally sensitive AAC technologies for young children who are beginning communicators.

Preliminary investigation of visual attention to complex AAC visual scene displays in individuals with and without developmental disabilities.

Visual scene displays (VSDs) are one type of augmentative and alternative communication (AAC) display in which an integrated scene (typically a photograph) presents people engaged in shared activities, with "hotspots" for the concepts embedded within. Most AAC displays are more complex than a single VSD, and also contain a navigation bar. This preliminary study examined visual attention to these more complex AAC displays by participants with autism spectrum disorder (ASD) (n = 13), Down syndrome (n = 13), intellectual and developmental disabilities other than Down syndrome or ASD (n = 9), and preschoolers with typical development (n = 20). Participants viewed images that simulated complex AAC displays containing a main VSD and a navigation bar with thumbnail VSDs arranged in one of four locations (top, bottom, left, or right). Both the main VSD and the navigation bar attracted attention, with participants across groups looking at both elements more than expected based on the space those elements occupied within the display. Within the main VSD, participants spent more time fixating on the meaningful elements (i.e., children and shared activity) compared to the background. Results suggested that gaze patterns to the meaningful elements of the main VSD were influenced by the location of the navigation bar. The finding that bar location may influence visual attention patterns makes it an important AAC system design factor that warrants additional research.

Designing effective AAC displays for individuals with developmental or acquired disabilities: State of the science and future research directions.

This paper reviews research on the impact of AAC display variables on visual attention and performance of children with developmental disabilities and adults with acquired conditions, and considers implications for designing effective visual scene displays (VSDs) or grids. When using VSDs with children with developmental disabilities or adults with acquired conditions, research supports the use of personalized photo VSDs that include familiar people engaged in meaningful activities, with navigation bars with thumbnail VSDs, located adjacent to the main VSD. Adults with acquired conditions seem to benefit from the inclusion of text boxes adjacent to the scene. Emerging evidence supports the use of motion to capture visual attention to VSDs (video VSDs) or to specific elements in VSDs. When using grid displays with children with developmental disabilities, research supports the use of spatial cues and clustering based on internal symbol colour to facilitate visual searching and selection. Background colour does not seem to facilitate searching for symbols on smaller displays, and may actually distract children from processing the meaningful components of symbols. Preliminary research suggests that the organization of onscreen keyboards and the number, types, and pairings of symbols in grids may impact performance of adults with acquired conditions. Directions for future research are discussed.

Effects of background color and symbol arrangement cues on construction of multi-symbol messages by young children without disabilities: implications for aided AAC design.

Children whose speech does not meet their communication needs often benefit from augmentative and alternative communication (AAC). The design of an AAC display may influence the child's ability to communicate effectively. The current study examined how symbol background color cues and symbol arrangement affected construction of multi-symbol messages using line-drawing symbols, by young children with typical development. Participants (N = 52) heard a spoken phrase matching a photograph and selected line drawings within a 4 × 4 array. Friedman two-way ANOVAs evaluated speed and accuracy of multi-symbol message construction under four conditions in which the background color and arrangement of symbols was manipulated. Participants demonstrated significantly faster response times when symbols were arranged by word-class category compared to no symbol arrangement. The majority of children responded faster when symbols had white backgrounds, but this effect failed to reach statistical significance. This study provides preliminary evidence suggesting the importance of symbol arrangement for young children. The findings highlight the need for caution when incorporating background color on displays for young children. Future research is needed to examine the effect of visual cues on children who use AAC and consider additional factors that could influence efficacy of symbol arrangement and background color use.

Multi-Province Listeriosis Outbreak Linked to Contaminated Deli Meat Consumed Primarily in Institutional Settings, Canada, 2008.

A multi-province outbreak of listeriosis occurred in Canada from June to November 2008. Fifty-seven persons were infected with 1 of 3 similar outbreak strains defined by pulsed-field gel electrophoresis, and 24 (42%) individuals died. Forty-one (72%) of 57 individuals were residents of long-term care facilities or hospital inpatients during their exposure period. Descriptive epidemiology, product traceback, and detection of the outbreak strains of Listeria monocytogenes in food samples and the plant environment confirmed delicatessen meat manufactured by one establishment and purchased primarily by institutions was the source of the outbreak. The food safety investigation identified a plant environment conducive to the introduction and proliferation of L. monocytogenes and persistently contaminated with Listeria spp. This outbreak demonstrated the need for improved listeriosis surveillance, strict control of L. monocytogenes in establishments producing ready-to-eat foods, and advice to vulnerable populations and institutions serving these populations regarding which high-risk foods to avoid.

Building Evidence-based Practice in AAC Display Design for Young Children: Current Practices and Future Directions.

Each time a practitioner creates or modifies an augmentative and alternative communication (AAC) display for a client, that practitioner must make a series of decisions about which vocabulary concepts to include, as well as physical and organizational features of the display. Yet, little is known about what factors influence the actual decisions and their outcomes. This research examined the design factors identified as priorities by speech-language pathologists (SLPs) when creating AAC displays for young children (age 10 years and under), and their rationale for the selection of these priorities. An online survey gathered ratings and comments from 112 SLPs with experience in AAC concerning the importance of a variety of factors related to designing an aided AAC display. Results indicated that some decisions were supported by existing research evidence, such as choosing vocabulary, collaborating with key stakeholders, and supporting partner modeling. Other decisions highlight areas for future research, including use of visual scene display layouts, symbol background color, and supports for motor planning.

N400 brain responses to spoken phrases paired with photographs of scenes: implications for visual scene displays in AAC systems.

Augmentative and alternative communication (AAC) systems are often implemented for individuals whose speech cannot meet their full communication needs. One type of aided display is called a Visual Scene Display (VSD). VSDs consist of integrated scenes (such as photographs) in which language concepts are embedded. Often, the representations of concepts on VSDs are perceptually similar to their referents. Given this physical resemblance, one may ask how well VSDs support development of symbolic functioning. We used brain imaging techniques to examine whether matches and mismatches between the content of spoken messages and photographic images of scenes evoke neural activity similar to activity that occurs to spoken or written words. Electroencephalography (EEG) was recorded from 15 college students who were shown photographs paired with spoken phrases that were either matched or mismatched to the concepts embedded within each photograph. Of interest was the N400 component, a negative deflecting wave 400 ms post-stimulus that is considered to be an index of semantic functioning. An N400 response in the mismatched condition (but not the matched) would replicate brain responses to traditional linguistic symbols. An N400 was found, exclusively in the mismatched condition, suggesting that mismatches between spoken messages and VSD-type representations set the stage for the N400 in ways similar to traditional linguistic symbols.

Neural Activity Associated with Visual Search for Line Drawings on AAC Displays: An Exploration of the Use of fMRI.

Visual aided augmentative and alternative communication (AAC) consists of books or technologies that contain visual symbols to supplement spoken language. A common observation concerning some forms of aided AAC is that message preparation can be frustratingly slow. We explored the uses of fMRI to examine the neural correlates of visual search for line drawings on AAC displays in 18 college students under two experimental conditions. Under one condition, the location of the icons remained stable and participants were able to learn the spatial layout of the display. Under the other condition, constant shuffling of the locations of the icons prevented participants from learning the layout, impeding rapid search. Brain activation was contrasted under these conditions. Rapid search in the stable display was associated with greater activation of cortical and subcortical regions associated with memory, motor learning, and dorsal visual pathways compared to the search in the unpredictable display. Rapid search for line drawings on stable AAC displays involves not just the conceptual knowledge of the symbol meaning but also the integration of motor, memory, and visual-spatial knowledge about the display layout. Further research must study individuals who use AAC, as well as the functional effect of interventions that promote knowledge about array layout.

Eye tracking research to answer questions about augmentative and alternative communication assessment and intervention.

Recently, eye tracking technologies (i.e., technologies that automatically track the point of an individual's gaze while that person views or interacts with a visual image) have become available for research purposes. Based on the sampling of the orientation of the individual's eyes, researchers can quantify which locations within the visual image were fixated (viewed), for how long, and how many times. These automated eye tracking research technologies open up a wealth of avenues for investigating how individuals with developmental or acquired communication disabilities may respond to aided augmentative and alternative communication (AAC) systems. In this paper, we introduce basic terminology and explore some of the special challenges of conducting eye tracking research with populations with disabilities who might use AAC, including challenges of inferring attention from the presence of fixation and challenges related to calibration that may result from participant characteristics, behavioral idiosyncracies, and/or the number of calibration points. We also examine how the technology can be applied to ask well-structured experimental questions that have direct clinical relevance, with a focus on the unique contributions that eye tracking research can provide by (a) allowing evaluation of skills in individuals who are difficult to assess via traditional methods, and (b) facilitating access to information on underlying visual cognitive processes that is not accessible via traditional behavioral measures.

The potential influence of stimulus overselectivity in AAC: information from eye tracking and behavioral studies of attention with individuals with intellectual disabilities.

This paper examines the phenomenon of stimulus overselectivity, or overselective attention, as it may impact AAC training and use in individuals with intellectual disabilities. Stimulus overselectivity is defined as an atypical limitation in the number of stimuli or stimulus features within an image that are attended to and subsequently learned. Within AAC, the term stimulus could refer to symbols or line drawings on speech-generating devices, drawings or pictures on low-technology systems, and/or the elements within visual scene displays. In this context, overselective attention may result in unusual or uneven error patterns such as confusion between two symbols that share a single feature, or difficulties with transitioning between different types of hardware. We review some of the ways that overselective attention has been studied behaviorally. We then examine how eye tracking technology allows a glimpse into some of the behavioral characteristics of overselective attention. We describe an intervention approach, differential observing responses, that may reduce or eliminate overselectivity, and we consider this type of intervention as it relates to issues of relevance for AAC.

Preliminary study of gaze toward humans in photographs by individuals with autism, Down syndrome, or other intellectual disabilities: implications for design of visual scene displays.

Visual scene displays (VSDs) are a form of augmentative and alternative communication display in which language concepts are embedded into an image of a naturalistic event. VSDs are based on the theory that language learning occurs through interactions with other people, and recommendations for VSD design have emphasized using images of these events that include humans. However, many VSDs also include other items that could potentially be distracting. We examined gaze fixation in 18 school-aged participants with and without severe intellectual/developmental disabilities (i.e., individuals with typical development, autism, Down syndrome and other intellectual disabilities) while they viewed photographs with human figures of various sizes and locations in the image, appearing alongside other interesting, and potentially distracting items. In all groups, the human figures attracted attention rapidly (within 1.5 seconds). The proportions of each participant's own fixation time spent on the human figures were similar across all groups, as were the proportions of total fixations made to the human figures. Although the findings are preliminary, this initial evidence supports the inclusion of humans in VSD images.

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.

Working memory demands of aided augmentative and alternative communication for individuals with developmental disabilities.

When speech is not functional to meet some or all of an individual's communication needs, aided augmentative and alternative communication (AAC) systems are often implemented. Although aided AAC systems offer some advantages over speech, they also impose some unique demands, especially on working memory, which is commonly defined as the cognitive system by which individuals maintain and manipulate information while completing tasks. For instance, the presence of an external aided AAC device containing arrays of symbols, not all of which are visible simultaneously, presents multiple working memory demands: individuals must maintain the target concepts in mind, all the while (a) navigating through multiple pages, (b) remembering the appropriate or most efficient navigation path, (c) locating the target symbols within the array once the host page has been located, and (d) inhibiting responses to potentially interesting distracters throughout the process. Each of these task demands involves one or more working memory operations that have been identified and studied extensively in research in the cognitive sciences. Failure to acknowledge or understand how working memory might interact with AAC use may place unintentional barriers to effective AAC interventions. This paper explores current information about working memory operations and highlights some of the most relevant issues that warrant further direct study.

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.

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.

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.