Chapter 3
AUGMENTATIVE AND
ALTERNATIVE
COMMUNICATION SYSTEMS
Sharon L. Glennen
The history of using augmentative and alternative
communication (AAC) systems for communication
is rather brief. Prior to 1975, there were descriptions
of nonspeaking individuals using simple letter
boards, picture boards, and typewriters to
communicate messages (Goldberg & Fenton, 1960;
Goldstein & Cameron, 1952; McDonald & Schultz,
1973; Vicker, 1974). The early use of AAC systems
was limited to a few individuals with physical
handicaps or aphasia who had the ability to
independently point to symbols. Several factors
came together in the late 1970s that had a major
impact on the development of AAC devices. In
1975, PL 94-142 was implemented, mandating that
all handicapped children between 5 and 21 years of
age be provided with a free public education. With
the implementation of this law, nonspeaking
individuals who previously had been excluded from
the educational mainstream began receiving the
attention of speech-language pathologists and
educators.
The development of microcomputer
technology was the second factor that im-
pacted the AAC field. Prior to the development of
microcomputers, AAC devices were handmade
electrical systems, or nonportable computer
systems. Vanderheiden and Grilley (1977) offered
an overview of electronic AAC devices that were
available in the early 1970s. Many of these early
AAC systems consisted of adaptations to electric
typewriters, or were simplistic electronic scanning
devices without printed or spoken output.
The Canon Communicator was one of the first
commercially available augmentative
communication devices specifically designed for
nonspeaking individuals. It was a small device that
strapped to the user's wrist. A small touchpad with
alphabet letters could be used to spell messages
which were printed on a small strip printer. The
Canon Communicator could only be used by
individuals with sufficient spelling and fine motor
abilities. A modified version of the device is still
available commercially (see Appendix). The
AutoCom was of one of the first computerbased
electronic AAC systems that could
59
60 THE HANDBOOK OF AUGMENTATIVE AND
ALTERNATIVE COMMUNICATION
be adapted for a wide variety of users
(Vanderheiden & Grilley, 1976). In its time, the
AutoCom was considered to be a sophisticated
portable AAC device with 128 symbol areas that
could be programmed and customized for the user.
It was a whopping 20 by 24 inches in size, and
weighed a hefty 17 pounds. The AutoCom provided
the user with printed output on a small strip paper
printer, and a 32 character LED display. Although
the AutoCom provided options for using picture
symbols and multiple levels of programming, its use
was still limited to individuals who could access the
device by directly touching the symbols with a
special pointer. Synthesized speech was not an
option in most of these early systems.
In 1978, the Phonic Ear HandiVoice 110 and 120
were developed. These two devices were the first
portable, commercially available AAC systems with
synthesized speech output. Michael Williams, an
AAC user with cerebral palsy, was one of the first
individuals to use the HandiVoice 120. He describes
his use of the system as follows:
It claimed to be a communication device, but what it
really was, was a speech synthesizer hooked up to a
numeric keypad with some firmware in between. The
firmware held the device's very limited vocabulary plus
fortyeight phonemes from which the user could
construct any word of his choosing, thus allowing the
manufacturer to claim that the device had an
unlimited vocabulary. Saying something with this
device was like chiseling words into a stone tablet.
Each vocabulary item or phoneme was accessed by a
unique three digit code. One could build up a series of
these codes in the device buffer and then push a button
to say the assembled linguistic utterance. Does this
sound like work? You bet it was! Communicating with
my letterboard was much faster, and my friends kept
asking me why I was torturing myself with this crude
ugly sounding voice synthesizer. I had no answer for
them that I could put into words. I only knew that this
piece of voice output technology struck a chord so
deep inside me it hurt. It
gave me a hint of what it would be like if I had a
voice, and it was also a hint of things to come.
(Williams, 1995, pp. 3-4)
The HandiVoice devices made professionals and
users aware of the communicative potential for
portable AAC systems with voice output. With
continued advances in microcomputer technology,
AAC devices have become more sophisticated and
more adaptable for a wide variety of users.
Augmentative and alternative communication
strategies can range from using vocalizations and
gestures, to the use of picture-based AAC systems,
to the use of microcomputers for communication.
Although the use of AAC devices tends to be the
focus of the assessment and intervention process,
research shows AAC users rely on other methods of
communication for a large portion of their
communicated messages (Glennen, 1989).
Therefore, although this chapter will focus on AAC
devices and equipment, the use of unaided
communication (e.g., vocalizations, gestures, and
sign language) which is reviewed in Chapter 4,
should not be overlooked.
OVERVIEW OF AAC
SYSTEM TERMINOLOGY
Augmentative and alternative communication
strategies are categorized as unaided or aided.
Unaided methods of communication rely completely
on the user's body to convey communicative
messages. Vocalizations, gestures, sign language,
head nods, and eye gaze are all methods of unaided
communication. Aided communication methods
require the use of tools or equipment in addition to
the user's body. Aided communication methods can
range from using paper and pencil to using
sophisticated laptop computers with speech
synthesizers. In reality, most nonspeaking persons
rely on multiple modalities of
62 THE HANDBOOK OF AND ALTERNATNE COMMUNICATCN
ter boards, and eye gaze boards are examples of lite
technology AAC systems. Other lite technology
strategies use electronic components but are not
computer-based. A Clock Communicator, which
has a battery-operated dial controlled by a switch, is
an example of lite AAC technology. Use of Light
Pointers with simple communication boards, and
switch-activated tape recorders are other examples.
High technology AAC systems contain
microcomputer components which allow for the
storage and retrieval of message information. They
almost always have spoken message output, and
sometimes printed output.
High technology AAC systems can be further
divided into the categories of dedicated devices and
nondedicated devices (see Figure 3-1). Dedicated
AAC systems are those that were developed for the
sole purpose of being an AAC device. The software
and hardware of a dedicated AAC device is
designed with features essential for communication.
Although dedicated systems can often be attached to
a computer to serve as an alternative keyboard, their
primary stand-alone purpose is to enhance the
communication process. Nondedicated AAC
systems are devices that were not specifically
designed for communication, but through
adaptations can be used as AAC systems. Desktop
and laptop computers are often used as
nondedicated AAC devices. By adding special
software, adapted hardware access methods, and a
speech synthesizer, the computer can be used as a
communication tool, yet can still be used for other
functions such as word processing, spreadsheets,
educational software, and computer games.
AAC systems can be used with a variety of
access methods. The access method determines how
the user will select symbols on the AAC device.
Users with good physical ability typically access
their systems using direct selection methods (see
Figure 3-1). When using direct selection, the user is
able to point to all possible
symbol choices on the AAC system. Direct
selection can be achieved by pointing with .fingers
and hands, pointing with other body parts, pointing
with head sticks, splints, or light pointers, and
pointing using eye gaze. The author knows of one
AAC user who pointed to letters on a
communication board with his nose! Eventually a
better method of direct selection was found for this
individual.
Users with more limited physical ability often
cannot directly access symbols with good accuracy.
They need to indirectly select symbol choices by
using scanning access methods (see Figure 3-1).
Scanning involves the systematic presentation of
symbol choices to the user. Once .the desired
symbol is reached it is selected by the user.
Unaided methods of scanning involve a
communication partner who asks 20 questions (or
more), and waits for a yes/no response after each
question. Aided methods of scanning usually
require the use of a switch, which is activated when
the desired selection is reached on the AAC device.
High technology AAC systems have many
different features. The size and weight of AAC
systems vary widely, which affects portability. AAC
systems vary in the number of key/symbol locations
available, the size of the keys, and the configuration
of the keys. Feedback given after selecting a key
also varies. Some AAC devices have fixed displays,
in which the picture or letter symbols never change.
Other devices have dynamic displays, in which the
screen is constantly changing. A standard computer
monitor is an example of a dynamic display. When
using dynamic displays for augmentative
communication, symbol choices on the screen
change based on previous symbol selections. For
example, the Dynavox user begins with a page of
category symbols. By pressing the category symbol
for Fast Food, the device then changes to a different
page with many symbols for food choices (see
Figure 3-2).
 AUGMENTATIVE AND ALTERNATIVE COMMUNICATION SYSTEMS
The method of storing and retrieving
messages also differs across various AAC
devices. Message storage is the process of
prestoring messages into the AAC system.
Message retrieval is the process of using or
retrieving the prestored messages. All high
technology AAC systems have message storage
and retrieval capabilities. The various methods
of storing and retreiving messages will be
reviewed in greater detail later in this chapter.
ACCESS METHODS
As described previously, there are two basic
access methods for using AAC devices, direct
selection and scanning. Each of these methods
will be reviewed in detail in this section.
Direct Selection Access
Methods
Direct Selection Keyboards
Direct selection allows the user access to all
possible symbol choices at all times. Many
dedicated and nondedicated AAC systems allow
the user to directly select choices by pressing a
keyboard. Fingers and hands are traditionally
used to access these keyboards, but head sticks,
adaptive pointers, or other body parts can also be
used. Some keyboards use a mechanical system
of direct selection in which the keys are
physically pushed down by the user. Mechanical
key depression is used to operate standard
computer keyboards. When the key is depressed
a sufficient amount, a signal that the key has
been selected is activated. The Delta Talker,
Alpha Talker, Canon Communicator, Walker
Talker, RealVoice, Light Writer SL30, and
Liberator are dedicated devices that rely on
mechanical key depression for activation.
63
Other direct selection keyboards rely on
touch membrane or touch screen surfaces. A
touch membrane keyboard consists of two
electrically conductive flat surfaces separated
by nonconductive spacers. Touching the
keyboard lightly presses the two surfaces
together which sends an electronic signal to the
AAC system. Many computer touch screens
operate similarly. When using a touch
membrane keyboard or touch screen, the user
does not feel any physical depression of the
surface. The Macaw, Parrot, Digivox, Speak
Easy, Say It All, Say it Simply Plus, VOIS
Series, Message Mate Series, Voice Pal, Mega
Wolf, Voice Mate, Hawk, and Finger Fonicks,
among others, are dedicated AAC devices
which have touch membranes. Nondedicated
adapted computer keyboards that use touch
membranes include Intellikeys, TASH Mini
Keyboard, and Discover: Board. The DynaVox
is a dedicated AAC device with a touch screen
surface. It operates similarly to the Touch
Window which attaches to microcomputers to
provide a touch screen surface. Touch screens
can also be added to standard computer
monitors through a process available from Troll
Technologies, among other companies.
The primary benefit of using a device with
mechanically depressed keys is the tactile
feedback that the user receives when pressing
the keys. Some children and adults demonstrate
better access when using devices that provide a
physical sensation of movement for each key
press. The drawback of using mechanical key
depression is that it requires a set minimal force
and pressure for the user to physically activate
the key. Many individuals with low muscle tone
are unable to apply enough pressure. In contrast,
touch membrane surfaces require very little
pressure for activation. In many cases, touch
membrane activation is achieved by using a
light touch for a set duration of time. Because
touch membrane surfaces
66 THE HANDBOOK OF AUGMENTATIVE AND ALTERNATIVE COMMUNICATION
limited physical capabilities, who only require a
limited number of messages at any one time.
Light and Optical Direct
Selection Pointers
There are many methods of accessing direct
selection devices through light or optical pointer
systems. The most cost-effective method uses a
Class 11 laser light pointer which shines a small
focused red beam of light onto the surface of a
communication system. The beam is powerful
enough to be used across a room to point to persons
or objects. Laser light pointers designed for pointing
to charts during speeches and presentations can
often be purchased for a reasonable price from office
supply stores. Laser light pointers can also be
obtained with rechargeable battery packs which
allow them to be used over longer periods of time.
Class 11 laser light pointers can cause eye injuries if
used incorrectly (Salamo & Jakobs, 1996). These
light pointers should never be directly pointed at an
open eye for more than I second. Most individuals
will reflexively blink when a laser light pointer is
shined into the eye, which provides protection from
injury. Nonspeaking light pointer users often do not
have the physical ability to independently remove
their own light pointers and shine them into their
own eyes. However, other individuals in the user's
environment might remove the laser light and use it
inappropriately. Class Illa laser light pointers are
also commercially available, and can cause eye
injury before reflexive blinking occurs. To date, no
eye injuries have been medically reported for either
type of laser light pointer (Salamo & Jakobs, 1996).
Other light pointers aren't really "lights" at all.
The Delta Talker uses a reflective mirror on the
pointer, which catches a beam from a red
light-emitting-diode
(LED) beside each symbol and reflects the beam
back to the device to signal a message. When the
pointer is aimed between LEDs, there is no visible
light signal observable to the user. Other methods of
making selections with a pointer involve sonar and
infrared technology. The pointer of a sonar device
produces a sound signal that cannot be heard by
humans. A sensor located on the AAC device reads
the location of the sonar pointer. The HeadMaster
system works with Macintosh computers and is a
sonar pointer system. Infrared signals are similar to
those used in TV remote controls. Infrared
technology uses imperceptible high frequency light
beams emitted by the pointer, which are received by
a sensor located near the AAC device. Freewheel,
which is an IBM access method, uses infrared
pointer technology. The Liberator can also be
accessed using an infrared pointer.
Typically light and optical pointers are
mounted on a user's head, preferably at midline, but
sometimes toward the side. Headbands, hats, and
glasses can be used to mount the pointers. Light
pointers can also be held in a user's hands. This is a
beneficial method of direct selection for individuals
with good fine motor control but limited range of
movement with their hands. Use of light or optical
pointers requires good motor abilities. The user
must be able to control small head movements to
direct the beam onto a symbol choice, and then
must hold the beam steady for a period of time to
activate the selection. This need for fine movement
and lack of tactile feedback make light and optical
pointers more difficult to control than head stick
pointers. A head stick gives the user direct physical
feedback for each selection, has a pointer that is
visible to the user at all times, and allows for more
involuntary movement when making selections.
However, head sticks are not cosmetically appealing
to some users.
68 THE HANDBOOK OF AUGMENTATIVE AND
stationary positions looking through the board.
Another method of using E-Tran boards is to use
a dynamic moving eye gaze display. This
method requires the listener to hold the board
for the user. The user then locks his or her eye
gaze on a target and continues to visually track
the target while the listener moves the board.
The listener looks at the user's eyes while
moving the board. When the user's and listener's
eye gaze lock together through the E-Tran, the
symbol that both are looking at is selected. This
method allows for more symbols to be placed
onto the E-Tran board. Eye gaze systems can be
designed to communicate hundreds of symbols
through the use of encoding methods (Goosens
& Crain, 1986).
Methods of Adjusting Direct
Selection Systems
Many nonspeaking persons require extensive
adaptations to direct selection systems to make
the AAC device accessible. Most dedicated and
nondedicated AAC systems have many points of
adjustment that can be made. Key sensitivity
can be adjusted by increasing the length of time
the key must be held before activation occurs.
Individuals with tremor often accidentally
produce multiple activations of keys by hitting
the same key repeatedly during the activation
process. Many AAC systems have a method of
setting a time period between key activations.
Any activations produced before the time period
has ended are ignored.
For users who need to rest their hands or
pointers on the surface of the AAC device,
systems can sometimes be altered to activate
symbols when the pointer is lifted from the
surface of the device rather than when the
pointer first touches the device. This strategy is
called release activation, and it allows users to
move their hands across the surface of the
system without accidentally activating symbols.
Once the
ALTERNATIVE COMMUNICATION
desired symbol is reached, lifting the hand
produces the activation.
Some users of optical pointer systems have
difficulty keeping the beam focused on a target
for a sufficient length of time. The time
necessary for activating a key can be reduced,
but if it is reduced too much, many accidental
key activations will occur. Some AAC devices
use an averaging function for direct selection to
circumvent this problem. When averaging is
used, multiple selections of the same key are
added together until a predetermined threshold
is hit. At that time, the key activation is
triggered. This allows the user to swipe across
the target several times before activing the key.
Averaging can also be used with other methods
of direct selection, but is not as common.
Feedback information provided to the user
can also be varied on most AAC devices.
Tactile feedback is available on devices with
mechanical key activation. Auditory feedback is
frequently provided by adding click or beep
sounds when keys are selected. Some devices
provide auditory feedback by immediately
speaking the message associated with the key.
Finally, some devices provide visual feedback.
For example, Prentke Romich AAC devices
have small LED lights next to each symbol. The
devices can be set up to blink when keys are
activated.
The size of keys can be altered, usually in
multiples that divide the surface of the device
into smaller areas (e.g., 2, 4, 8, 16, 32, 64, 128
keys). Keys can be spaced by not programming
every location, leaving blank keys or dead areas
between active keys. Keyguards, which are
plastic or plexiglass overlays with holes cut out
for each key, can be placed on top of the
keyboard of most AAC devices. Keyguards let
users stabilize their hands or other pointing
mechanisms on top of the keyboard during the
pointing process. The users entire hand can rest
on the device, yet not activate a symbol until a
selection is made by pointing to a key through
the keyguard hole. When keyguards are used
with small
 AUGMENTATIVE AND ALTERNATIVE COMMUNICATION SYSTEMS
key sizes, they can visually block the user from
easily viewing the keys. Clear plastic droolguards
are also available for users who require them.
In summary, there are many different methods
of using and adapting direct selection AAC devices.
The AAC assessment process requires reviewing all
potential access methods and adjusting those
methods to obtain optimum speed and accuracy for
the user. Chapters 5 and 7 in this text reviews these
assessment methods in more detail.
Strengths and Limitations of Direct
Selection Systems
Direct selection AAC systems are typically faster
and more efficient methods of communication than
scanning AAC systems. Users of direct selection
systems can average speeds of 13 to 43 words per
minute when communicating (Foulds, 1980; Szeto,
Allen, & Littrell, 1993). Adding encoding or
prediction methods designed to reduce keystrokes
often speeds up the communication process even
more, sometimes reducing the number of
keystrokes by 50% (Higginbotham, 1992;
Venkatagiri, 1993). However, it should be noted
that these communication speeds are still slow
when compared to speaking rates for nondisabled
individuals (126 to 200 words per minute).
Portability of direct selection AAC systems is
an issue for ambulatory individuals. Many children
and adults with good ambulation skills cannot
reasonably carry an 8 to 10 pound device from
ocation to location. Children and adults who are not
steady ambulators, or who require walkers and
canes for support, have even more difficulty
carrying an AAC device. Several lightweight AAC
devices have been designed to address this problem,
ncluding the Parrot, Canon Communicator, Walker
Talker, Message Mate, Language Master SE, Voice
Mate, and Finger Foniks. Manufacturers of AAC
devices are aware of porta
69
bility issues and have made a concerted effort to
design newer systems that are lighter in weight and
smaller in size.
Indirect Selection Methods
Many physically disabled individuals do not have
the motor abilities necessary for operating direct
selection AAC devices. These individuals require
devices which are accessed using scanning or other
indirect selection methods. As reviewed previously,
scanning methods systematically present selections
to users, who activate switches or other mechanisms
to choose the desired selection. Many dedicated and
nondedicated AAC devices can be adapted for
scanning. These include the A]phaTalker, Delta
Talker, DigiVox, Macaw, DynaVox, Liberator, Real
Voice, Voice Pal Plus, Light Writer SL8, and Scan
It All. Microcomputers can also be adapted for
augmentative communication access through
scanning methods. Talking Screen, Speaking
Dynamically, Scanning WSKE, Ke:nx, Handi Chat,
and Talk About are all software programs that can
be configured for scanning users. These devices and
software programs can be adapted to use many
different methods of scanning which will be
reviewed in this section.
Single Switch Scanning Methods
Single switch scanning methods allow individuals to
use a simple repetitive motor movement to activate
a single switch to control an AAC system. Scanning
systems operated with a single switch usually offer
several different methods of presenting symbol
choices to the user for selection. The simplest
methods of scanning are linear and circular
scanning. Linear scanning involves presenting
symbol choices to the user one at a time in a
line-by-line pattern (see Figure 3-5). The user hits a
switch when the desired selection is reached. All
possible choices are scanned using this