Augmentative and Alternative Communication: Supporting

Children and Adults with Complex Communication Needs

Visit the link below to download the full version of this book:
https://cheaptodownload.com/product/augmentative-and-alternative-communication-s
upporting-children-and-adults-with-complex-communication-needs-4th-edition-full-
pdf-download/
This page intentionally left blank.
 Augmentative &
Alternative Communication
Supporting Children and Adults
with Complex Communication Needs
Fourth Edition

by

David R. Beukelman, Ph.D.

University of Nebraska
Lincoln

and

Pat Mirenda, Ph.D.

University of British Columbia
Vancouver

Baltimore • London • Sydney

Paul H. Brookes Publishing Co.
Post Office Box 10624
Baltimore, Maryland 21285-0624

www.brookespublishing.com

Copyright © 2013 by Paul H. Brookes Publishing Co., Inc.

All rights reserved.
Previous edition copyright © 2005

“Paul H. Brookes Publishing Co.” is a registered trademark

of Paul H. Brookes Publishing Co., Inc.

Typeset by Network Publishing Partners, Inc., Glenview, Illinois.

Manufactured in the United States of America by
Sheridan Books, Inc., Chelsea, Michigan.

Photos are used by permission of the individuals pictured and/or their parents/guardians.

The individuals described in this book are composites or real people whose situations are masked and
are based on the authors’ experiences or real people whose names and identifying details are used by
permission. Except where used by permission, names and identifying details have been changed to
protect confidentiality.

Purchasers of Augmentative and Alternative Communication: Supporting Children and Adults with Complex
Communication Needs, Fourth Edition, are granted permission to photocopy forms for educational
­purposes. The forms may not be reproduced to generate revenue for any program or individual.
Photocopies may only be made from an original book. Unauthorized use beyond this privilege is prosecutable
under federal law. You will see the copyright protection notice at the bottom of each photocopiable page.

Library of Congress Cataloging-in-Publication Data

Beukelman, David R., 1943–
Augmentative and alternative communication: supporting children and adults with complex
­communication needs / by David R. Beukelman and Pat Mirenda.—4th ed.
  p.  cm.
Rev. ed. of: Augmentative & alternative communication / by David R. Beukelman, Pat Mirenda.
3rd ed. c2005.
Includes bibliographical references and index.
ISBN 978-1-59857-196-7 (hardcover)—ISBN 1-59857-196-6 (hardcover)
I. Mirenda, Pat. II. Beukelman, David R., 1943- Augmentative & alternative communication. III. Title.
[DNLM: 1. Communication Disorders—rehabilitation. 2. Communication Aids for Disabled.
3. Needs Assessment. 4. Nonverbal Communication. WL 340.2]

616.85’503—dc23 2012015676

British Library Cataloguing in Publication data are available from the British Library.

2016 2015 2014 2013 2012

10   9   8   7   6   5   4   3   2   1

Contents

About the Authors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

About the Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Part I Introduction to Augmentative and Alternative Communication

1 Augmentative and Alternative Communication Processes . . . . . . . . . . . . . 3
2 Message Management: Vocabulary, Small Talk, and Narratives . . . . . . . . 17
3 Symbols and Rate Enhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
4 Alternative Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
5 Principles of Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
6 Assessment of Specific Capabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
7 Principles of Decision Making, Intervention, and Evaluation . . . . . . . . . 187

Part II Augmentative and Alternative Communication

Interventions for Individuals with Developmental Disabilities
8 Augmentative and Alternative Communication
Issues for People with Developmental Disabilities . . . . . . . . . . . . . . . . . . 203
9 Supporting Participation and
Communication for Beginning Communicators . . . . . . . . . . . . . . . . . . . . 225
10 Language Development and Intervention:
Challenges, Supports, and Instructional Approaches . . . . . . . . . . . . . . . 255
11 Instruction to Support Linguistic and Social Competence . . . . . . . . . . . 279
12 Literacy Intervention for Individuals
with Complex Communication Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Janice C. Light and David B. McNaughton
13 Educational Inclusion of Students
with Complex Communication Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353

v
Part III Augmentative and Alternative Communication
Interventions for Individuals with Acquired Disabilities
14 Adults with Acquired Physical Conditions . . . . . . . . . . . . . . . . . . . . . . . . 379
with Laura Ball
15 Adults with Severe Aphasia and Apraxia of Speech . . . . . . . . . . . . . . . . 405
Kathryn L. Garrett and Joanne P. Lasker
16 Adults with Degenerative Cognitive and Linguistic Disorders . . . . . . . 447
with Elizabeth Hanson
17 Individuals with Traumatic Brain Injury . . . . . . . . . . . . . . . . . . . . . . . . . . 461
with Susan Fager
18 Augmentative and Alternative Communication in
Intensive, Acute, and Long-Term Acute Medical Settings . . . . . . . . . . . . 475

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
Resources and Web Links. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557

vi
About the Authors

David R. Beukelman, Ph.D., Professor, Department of Special Education and

Communication Disorders, University of Nebraska–Lincoln, 118 Barkley Memorial
Center, Lincoln, NE 68583

Dr. Beukelman is the Barkley Professor of Communication Disorders at the University

of Nebraska–Lincoln and a senior researcher in the Institute for Rehabilitation Science
and Engineering at Madonna Rehabilitation Hospital. He is a research partner in
the AAC-RERC (Rehabilitation Engineering Research Center on Communication
Enhancement). He is coeditor of the Augmentative and Alternative Communication
Series published by Paul H. Brookes Publishing Co. Previously, Dr. Beukelman was
Director of Research and Education at the Munroe-Meyer Institute for Genetics and
Rehabilitation at the University of Nebraska Medical Center. He was Director of
the Communication Disorders and Augmentative Communication programs at the
University of Washington Medical Center and Associate Professor in the Department
of Rehabilitation Medicine at the University of Washington–Seattle. Dr. Beukelman
specializes in the areas of augmentative communication and motor speech disorders
of children and adults.

Pat Mirenda, Ph.D., Professor, Faculty of Education, University of British Columbia,

2125 Main Mall, Vancouver, British Columbia V6T 1Z4, Canada

Dr. Mirenda is a doctoral-level Board Certified Behavior Analyst (BCBA-D) who

specializes in augmentative communication and positive behavior supports for in-
dividuals with developmental disabilities. She is a professor in the Department of
Educational and Counseling Psychology and Special Education and director of the
Centre for Interdisciplinary Research and Collaboration in Autism at the University
of British Columbia. Previously, she was a faculty member in the Department of
Special Education and Communication Disorders at the University of Nebraska–
Lincoln. From 1998 to 2002, she was editor of the journal Augmentative and Alternative
Communication. In 2004, she was named a Fellow of the American Speech-Language-
Hearing Association and was awarded the Killam Teaching Prize at the University
of British Columbia. In 2008, she was named a Fellow of the International Society for
Augmentative and Alternative Communication. Dr. Mirenda is the author of numer-
ous book chapters and research publications; she lectures widely and teaches courses
on augmentative and alternative communication, inclusive education, developmen-
tal disabilities, autism, and positive behavior support. Her coedited book, Autism
Spectrum Disorders and AAC, was published in December 2009.

vii
This page intentionally left blank.
About the Contributors

Laura J. Ball, Ph.D., Associate Professor, Department of Communication Sciences

and Disorders, East Carolina University, 3310AE Allied Health Sciences, Mail Stop
668, Greenville, NC 27834

Dr. Ball completed her Ph.D. at the University of Nebraska–Lincoln and has focused
research interests in augmentative and alternative communication (AAC) and motor
speech disorders. Dr. Ball has more than 25 years’ experience as a speech-language
pathologist, working with people with complex communication needs who rely on
AAC. She has strong research interest in amyotrophic lateral sclerosis and has au-
thored publications in the areas of AAC, dysarthria, and apraxia.

Susan Fager, Ph.D., CCC-SLP, Assistant Director, Communication Center, Institute

for Rehabilitation Science and Engineering, Madonna Rehabilitation Hospital, 5401
South Street, Lincoln, NE 68506

Dr. Fager is a researcher and augmentative and alternative communication specialist

at the Institute for Rehabilitation Science and Engineering at Madonna Rehabilitation
Hospital. She specializes in speech disorders of people with neurologic conditions
such as traumatic brain injury, brainstem stroke, amyotrophic lateral sclerosis, and
Parkinson’s disease.

Kathryn L. Garrett, Ph.D., CCC-SLP, Alternative Communication Therapies, LLC,

1401 Forbes Avenue, Suite 201, Pittsburgh, PA 15219

Dr. Garrett currently treats individuals with complex communication disorders

associated with aphasia and brain injury at her private practice in Pittsburgh,
Pennsylvania. She collaborates on research projects in the area of severe aphasia,
interaction, and supportive communication strategies with colleagues from Buffalo
University and Florida State University.

ix
x   About the Contributors

Elizabeth K. Hanson, Ph.D., CCC-SLP, Associate Professor, Department of Commu-

nication Sciences and Disorders, University of South Dakota, 414 East Clark Street,
Vermillion, SD 57069

Dr. Hanson earned her M.S. at the University of Wisconsin–Madison and her Ph.D. at
the University of Nebraska–Lincoln. Her research interests are in augmentative and
alternative communication (AAC) and motor speech disorders. Her clinical practice
and supervision focuses on providing AAC services for people with complex com-
munication needs across the life span.

Joanne P. Lasker, Ph.D., CCC-SLP, Associate Professor, School of Communication

Science and Disorders, Florida State University, 127 Honors Way, Mail Code 32306-
1200, Tallahassee, FL 32306

Dr. Lasker has published numerous papers and chapters related to assessment and
treatment of adults living with acquired neurogenic communication disorders who
may benefit from augmentative and alternative communication (AAC) techniques,
in particular people living with aphasia. Her research has explored issues pertaining
to AAC assessment protocols, context-based intervention practices, partner training,
and the acceptance of AAC approaches by adults with severe communication disor-
ders and their communication partners. She has presented nationally and interna-
tionally on these topics.

Janice C. Light, Ph.D., Department of Communication Sciences and Disorders, The

Pennsylvania State University, 308G Ford Building, University Park, PA 16802

Dr. Light holds the Hintz Family Endowed Chair in Children’s Communicative
Competence in the Department of Communication Sciences and Disorders at the
Pennsylvania State University. She is actively involved in research, personnel
preparation, and service delivery in the area of augmentative and alternative com-
munication (AAC). She is currently one of the project directors of the AAC-RERC
(Rehabilitation Engineering Research Center on Communication Enhancement),
a virtual research consortium funded by the National Institute on Disability and
Rehabilitation Research. Dr. Light is the author of many peer-reviewed papers, book
chapters, and books. She has received numerous awards in recognition of her re-
search and teaching contributions to the field.

David B. McNaughton, Ph.D., Professor of Education, Department of Educational

and School Psychology and Special Education, The Pennsylvania State University,
227 CEDAR Building, University Park, PA 16802

Dr. McNaughton teaches coursework in augmentative communication and assistive

technology and collaboration skills for working with parents and educational team
members. Dr. McNaughton’s research interests include literacy instruction for indi-
viduals who rely on augmentative and alternative communication, and employment
supports for individuals with severe disabilities.
Preface

As was the case for previous editions, the fourth edition of Augmentative and Alternative
Communication: Supporting Children and Adults with Complex Communication Needs is
an introductory text written for practicing professionals, preprofessional students,
and others who are interested in learning more about communication options for
people who are unable to meet their daily communication needs through natural
modes such as speech, gestures, or handwriting. Because severe communication dis-
orders can result from a variety of conditions, diseases, and syndromes that affect
people of all ages, many individuals may be interested in these approaches. Several
characteristics of the augmentative and alternative communication (AAC) field have
shaped the format, content, and organization of this book. First, AAC is a multidis-
ciplinary field in which individuals with complex communication needs (CCN) and
their families, along with computer programmers, educators, engineers, linguists,
occupational therapists, physical therapists, psychologists, speech-language patholo-
gists, and many other professionals have contributed to the knowledge and practice
base. We have attempted to be sensitive to these people’s multiple perspectives and
contributions by directly citing pertinent information from a wide variety of sources
and by guiding the reader to appropriate additional resources when necessary.
Second, the AAC field has developed in many countries over the past six de-
cades. For example, in 2011, individuals from more than 62 countries were mem-
bers of the International Society for Augmentative and Alternative Communication.
Although we are both from North America, we have made an effort to offer an in-
ternational perspective in this book by including information about the contribu-
tions of researchers, clinicians, and people who rely on AAC from around the world.
Unfortunately, within the constraints of an introductory textbook, only a limited
number of these contributions can be cited specifically. Thus, we acknowledge that
our primary sources of material have come from North America and hope that our
AAC colleagues in other countries will tolerate our inability to represent multina-
tional efforts more comprehensively.
Third, AAC interventions involve both electronic (i.e., digital) and nonelectronic
systems. AAC technology changes very rapidly—products are being upgraded con-
tinually, and new products are always being introduced. Such product information
presented in book form would be outdated very quickly. Therefore, we refer our
readers to the AAC web site hosted by the Barkley AAC Center at the University
of Nebraska–Lincoln (http://aac.unl.edu), which provides links to the web sites
of manufacturers and publishers in the AAC field. Information on this web site is

xi
xii  Preface

updated regularly. In addition, readers may refer to the Resources and Web Links
section in this book for more information about the companies and organizations
providing the AAC products and services that are mentioned in this book.
A fourth characteristic of the AAC field is that it incorporates three general areas
of information. The first area relates to the processes of AAC: messages, symbols,
alternative access, assessment, and intervention planning. The second area describes
procedures that have been developed to serve individuals with developmental dis-
abilities who require AAC services. The third area focuses on people with disabilities
that are acquired later in life. In an effort to cover these areas, we have divided the
book into three sections.
Specifically, the seven chapters in Part I are organized to introduce readers to
AAC processes. Chapter 1 introduces the reader to AAC in general and to people
with CCN in particular. Often using these individuals’ own words, we attempt to
convey what it means to communicate using AAC systems. Chapter 2 reviews the
message types that are frequently communicated by people who rely on AAC and
are thus stored in their systems. Chapter 3 is a detailed presentation of the most
common aided and unaided symbol systems used to represent messages, as well
as an introduction to the most common message encoding and rate-enhancement
strategies. Chapter 4 discusses a range of alternative access options that are designed
to accommodate a variety of motor, language, and cognitive impairments. Chapter
5 focuses on the various personnel involved in AAC interventions and their respec-
tive roles, as well as AAC assessment models and phases. This chapter also intro-
duces the Participation Model for assessment and intervention planning that is used
throughout the remainder of the book. Chapter 6 provides information about specific
strategies for assessing the communication, language, motor, literacy, and sensory
capabilities of people with CCN. Finally, Chapter 7 considers the principles of AAC
intervention decision making to address both opportunity and access barriers, with
emphasis on the importance of evidence-based practice and measurement of func-
tional outcomes.
Part II contains six chapters that review AAC interventions for individuals with
developmental disabilities. Specifically, Chapter 8 introduces AAC concerns unique
to people with cerebral palsy, intellectual disabilities, autism spectrum disorders,
deaf-blindness, and suspected childhood apraxia of speech. Chapter 9 introduces a
number of strategies that can be used to resolve opportunity barriers and enhance the
communicative participation of nonsymbolic communicators and those who are just
beginning to use symbols to communicate. Chapter 10 summarizes what we know
about the language development of people with CCN and how to support language
learning and development in general. Chapter 11 builds on this discussion in order to
discuss specific strategies that can be used to teach skills required for communicative
competence, especially in the linguistic and social domains. Chapter 12, written by
Janice C. Light and David B. McNaughton, focuses on the factors that affect literacy
learning in people with CCN, strategies for fostering emergent literacy, and the key
components of interventions for teaching conventional and advanced literacy skills.
Finally, Chapter 13 provides guidelines for thinking about and planning for inclusive
education for students with CCN, along with general strategies for how this might be
accomplished.
Part III, composed of the last five chapters of the book, focuses on individuals
with acquired communication disorders. Chapter 14, written with Laura J. Ball, re-
views AAC interventions for adults with acquired physical disabilities, including
amyotrophic lateral sclerosis, multiple sclerosis, Parkinson’s disease, and brainstem
 Preface  xiii

stroke. Chapter 15, written by Kathryn L. Garrett and Joanne P. Lasker, describes
a functional classification scheme for people with severe aphasia and contains re-
lated ­intervention strategies and techniques. Chapter 16, written with Elizabeth K.
Hanson, introduces AAC strategies for people with degenerative language and cog-
nitive disorders, ­including primary progressive aphasia and dementia. Chapter 17,
written with Susan Fager, addresses AAC assessment and intervention techniques
that are organized according to the cognitive levels of people with traumatic brain
injury. Finally, Chapter 18 reviews a wide range of AAC interventions for people in
intensive and acute care medical settings. Particular attention is focused on individu-
als who are unable to communicate because of respiratory impairments.
As we revised this book, we remained keenly aware of our dependence on those
who have documented their experiences in the AAC field. In order to tell the “AAC
story,” we expected to cite traditional documents—professional research papers,
scholarly books, and manuals. What we found is that we also made extensive use of
the perspectives of people who rely on AAC, as documented in a variety of maga-
zines, video recordings, web sites, and other popular sources. We also wish to thank
those publishers, editors, associations, manufacturers, and institutions who sup-
ported the newsletters, bulletins, books, videos, magazines, web sites, and journals
that now contain the historical record of the AAC field. Without these resources, we
simply would have been unable to compile this book. We also want to acknowledge
the role of the Barkley Trust in supporting AAC efforts at the University of Nebraska–
Lincoln through the years. While we were revising this book, David R. Beukelman
also served as Senior Researcher in the Research Institute for Rehabilitation Science
and Engineering at Madonna Rehabilitation Hospital. In addition, we have appreci-
ated the support, encouragement, and assistance we received from Astrid Zuckerman
and Susan Hills at Paul H. Brookes Publishing Co., and Linda Wolf.
We note that this edition of this book and the previous three editions were collab-
orative efforts, with both of us completing those tasks that fit our areas of expertise
and skills. Because we shared these tasks so completely, it was difficult to order the
authorship for the first edition, and we had hoped to reverse the order for subsequent
editions. We have not done so, however, in order not to confuse the status of this book
as a fourth edition.
This page intentionally left blank.
Acknowledgments

Special appreciation is due to a number of individuals with whom we have been

fortunate to work before and during the production of this book. These include the
students, families, staff, and administrators of the public school system in Lincoln,
Nebraska; the Research Institute for Rehabilitation Science and Engineering at
Madonna Rehabilitation Hospital; Quality Living, Inc.; Services for Students with
Disabilities at the University of Nebraska–Lincoln; Special Education Technology–
British Columbia; Communication Assistance for Youth and Adults; and the Sunny
Hill Health Centre for Children. These individuals have collaborated with us exten-
sively over the years and have thus greatly contributed to our augmentative and
alternative communication (AAC) experiences and knowledge. Cay Holbrook, Janet
Jamieson, and Brenda Fossett in the Department of Educational and Counselling
Psychology and Special Education at the University of British Columbia also pro-
vided substantive input to one or more chapters in Part II of this book. Heidi Menard
managed the reference list and proofed, checked, and rechecked the manuscript.
Finally, we thank the many people who rely on AAC with whom we have worked,
and their families—they have taught us about the AAC field and have a­ llowed us to
use their stories. May their voices grow ever stronger.

xv
This page intentionally left blank.
To the Barkley Board of Trustees, who determined nearly 30 years ago to allocate
funds from the Barkley Trust to support a research, educational, and intervention
emphasis on augmentative and alternative communication at the University of
Nebraska–Lincoln. Through the years, this support has funded faculty and staff
salaries as well as doctoral student scholarships.

I wish to thank my wife, Helen, who has been generous with her patience,
understanding, and support over the years.
—David Beukelman

I am grateful beyond words to Jackie for her support and cheerleading through
all four editions of this book. It never would have happened without you!
—Pat Mirenda
This page intentionally left blank.
PA R T I

Introduction to Augmentative
and Alternative Communication
This page intentionally left blank.
CHAPTER 1

Augmentative and Alternative

Communication Processes

The silence of speechlessness is never golden. We all need to communicate and

connect with each other—not just in one way, but also in as many ways possible.
It is a basic human need, a basic human right. And much more than this, it is a
basic human power. (Bob Williams, 2000, p. 248)

Michael Williams has relied on augmentative and alternative communication (AAC)

strategies throughout his life. To learn more about him and his communication strate-
gies, access his webcast, How Far We’ve Come, How Far We’ve Got to Go: Tales from the
Trenches (Williams, 2006).
For most of you who read this book, daily communication is so effortless and
efficient that you hardly think about it when you interact with others face to face,
over the phone, through e-mail, by texting, or through social media. You probably
do not remember the effort that you initially expended as an infant and toddler to
learn to speak because now these processes are largely automatic. Usually, you just
“talk,” formulating your messages and executing speech movements as you ex-
press yourself. However, effortless communication is not an option for all people
(Beukelman & Ray, 2010) because some are unable to meet their daily communication
needs through natural speech. Yet, effective communication is essential for learning
and development, personal care, social engagement, education, and employment. It
is also essential for medical care as noted in a statement from the Joint Commission
titled Advancing Effective Communication, Cultural Competence, and Patient- and Family-
Centered Care: A Roadmap for Hospitals:

No longer considered to be simply a patient’s right, effective communication is now

accepted as an essential component of quality care and patient safety [5,6].…Effective
communication [is] the successful joint establishment of meaning wherein patients and
health care providers exchange information, enabling patients to participate actively in
their care from admission through discharge, and ensuring that the responsibilities of
both patients and providers are understood. (2010, p. 1)

3
4  Introduction to AAC

The purpose of this book is to introduce you to people who rely on AAC, to the
AAC supports that they use to meet their communication needs, and to those who
assist them. Approximately 1.3% of all people, or about 4 million Americans, can-
not rely on their natural speech to meet their daily communication needs. Without
access to speech, these people face severe restrictions in their communication and
participation in all aspects of life—education, medical care, employment, family, and
community involvement—unless they are provided with other communication sup-
ports. The development of AAC strategies offers great potential to enhance the com-
municative effectiveness of people with complex communication needs. However,
for many, this potential has not been fully realized. There is an urgent need for people
to assist those who rely on AAC strategies. In addition to helping those who rely on
AAC and their families and caregivers, there is a continuing need to develop a range
of competent AAC stakeholders, such as those who design new technologies; edu-
cators; speech-language pathologists; physical therapists; occupational therapists;
rehabilitation engineers, and technicians who provide AAC intervention services;
people who shape public policy and funding; and researchers who document AAC
use and acceptance patterns as well as investigate communication processes when
AAC strategies are used.

WHAT IS AUGMENTATIVE AND

ALTERNATIVE COMMUNICATION?
The American Speech-Language-Hearing Association (ASHA) Special Interest Division
12: Augmentative and Alternative Communication (AAC) defined AAC as follows:

Augmentative and alternative communication (AAC) refers to an area of research, clini-

cal, and educational practice. AAC involves attempts to study and when necessary com-
pensate for temporary or permanent impairments, activity limitations, and participation
restrictions of individuals with severe disorders of speech-language production and/
or comprehension, including spoken and written modes of communication. (2005, p. 1)

AAC intervention services and AAC technology are part of the habilitation and
rehabilitation services and technology designation within the U.S. health care reform
of 2010. Rehabilitation refers to intervention strategies and technologies that help
someone who has an acquired disability regain a capability, whereas habilitation re-
fers to intervention strategies and technologies that assist a person, such as someone
with a developmental disability, to develop a capability for the first time.

WHO RELIES ON AUGMENTATIVE

AND ALTERNATIVE COMMUNICATION?
There is no typical person who relies on AAC. They come from all age groups, so-
cioeconomic groups, and ethnic and racial backgrounds. Their only unifying charac-
teristic is the fact that they require adaptive assistance for speaking and/or writing
because their gestural, spoken, and/or written communication is temporarily or per-
manently inadequate to meet all of their communication needs. Some of these indi-
viduals may be able to produce a limited amount of speech that is inadequate to meet
their varied communication needs.
A variety of congenital or acquired conditions can cause the inability to speak
or write without adaptive assistance. The most common congenital causes of such
 AAC Processes  5

severe communication disorders include severe intellectual disability, cerebral palsy,

autism, and developmental apraxia of speech. The acquired medical conditions that
most often result in the need for AAC assistance include amyotrophic lateral sclero-
sis, multiple sclerosis, traumatic brain injury, and stroke. (See Parts II and III of this
book for prevalence figures and demographic information related to each of these
groups of people.)
Published prevalence reports of the number of people with severe speech and/
or writing limitations vary to some extent depending on the country, age group,
and type(s) of disability surveyed. In Canada, data from the 2001 Participation and
Activity Limitation Survey suggested that approximately 318,000 Canadians older
than age 4 years have difficulty speaking and being understood (Cossette & Duclos,
2003); this represents approximately 1.5% of the total population older than age 4
years. Paralleling the Canadian data, a study by Enderby and Philipp (1986) sug-
gested that 800,000 individuals (1.4% of the total population) in the United Kingdom
have a severe communication disorder that makes it difficult for them to be under-
stood by anyone outside their immediate family. An Australian survey of the prov-
ince of Victoria, which has more than 4 million residents, identified approximately
5,000 individuals who were unable to speak adequately for communication; this rep-
resents 1.2% of the population (Bloomberg & Johnson, 1990).
The prevalence of severe communication disorders appears to vary considerably
with age. Based on the results of several studies, Blackstone (1990) suggested that
0.2%–0.6% of the total school-age population worldwide has a severe speech impair-
ment. A Canadian study suggested that the prevalence increases to 0.8% of individu-
als from age 45 to 54 years and reaches a high of 4.2% for people age 85 years and
older (Hirdes, Ellis-Hale, & Pearson Hirdes, 1993).

WHAT IS IT LIKE TO RELY ON AUGMENTATIVE

AND ALTERNATIVE COMMUNICATION STRATEGIES?
Perhaps more relevant (certainly, more interesting) than demographic figures are the
stories and experiences of people who rely on AAC. In Table 1.1, we provide re-
sources that contain first-person accounts in the writings and presentations of people
who rely on AAC. From these and other accounts, we can sense what it is like to be
unable to communicate through traditional speech or writing and to rely on AAC.
Rick Creech, a young man with cerebral palsy, provided a stark description of being
unable to speak:

Table 1.1. Selected first-person accounts by individuals who rely on augmentative and alternative
communication
Brown, C. (1954). My left foot. London: Secker & Warburg.
Fried-Oken, M., & Bersani, H.A., Jr. (Eds.). (2000). Speaking up and spelling it out: Personal essays on
augmentative and alternative communication. Baltimore: Paul H. Brookes Publishing Co.
Fried-Oken, M., Howard, J., & Stewart, S. (1991). Feedback on AAC intervention from adults who are
temporarily unable to speak. Augmentative and Alternative Communication, 7, 43–50.
Mirenda, P., & Bopp, K. (2003). “Playing the game”: Strategic competence in AAC. In J.C. Light, D.R.
Beukelman, & J. Reichle (Eds.), Communicative competence for individuals who use AAC: From
research to effective practice (pp. 401–437). Baltimore: Paul H. Brookes Publishing Co.
Nolan, C. (1987). Under the eye of the clock. New York: St. Martin’s Press.
Williams, M., & Krezman, C. (Eds.). (2000). Beneath the surface: Creative expression of augmented
communicators. Toronto: International Society for Augmentative and Alternative Communication.