Bilingual Users of AAC

Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations
Volume 22, April 2015, Copyright © 2015 American Speech-Language-Hearing Association
Practical Resources for Provision of Services to Culturally

and Linguistically Diverse Users of AAC
Elena Dukhovny
Department of Communicative Sciences and Disorders, California State University East Bay
Hayward, CA
E. Betsy Kelly
Kelly Communication Therapy, Communicative Disorders
Fairfax, California
Financial Disclosure: Elena Dukhovny is an assistant professor at California State University East
Bay. E. Betsy Kelly is a speech-language pathologist and AAC therapist at Kelly Communication
Therapy.
Nonfinancial Disclosure: Elena Dukhovny has previously published in the subject area. E. Betsy
Kelly has no nonfinancial interests related to the content of this article.
Abstract
According to the 2010 U.S. Census, over 20% of Americans speak a language other than
English in the home, with Spanish, Chinese, and French being the languages most
commonly spoken, aside from English. However, few augmentative and alternative
communication (AAC) systems offer multilingual support for individuals with limited
functional speech. There has been much discussion in the AAC community about best
practices in AAC system design and intervention strategies, but limited resources exist to
help us provide robust, flexible systems for users who speak languages other than English.
We must provide services that take into consideration the unique needs of culturally and
linguistically diverse users of AAC and help them reach their full communication potential.
This article outlines basic guidelines for best practices in AAC design and selection, and
presents practical applications of these best practices to multilingual/multicultural clients.
Augmentative and alternative communication (AAC) tools are used by individuals with
severely limited intelligible speech to supplement or substitute for spoken communication
(Roseberry-McKibbin, 2007, p. 423). A survey of people with speech disorders suggested that, in
North America, about 1% experience communication impairments severe enough to warrant AAC
to supplement existing speech or replace speech that is not functional (Castrogiovanni, 2008).
While “there is no typical person who relies on AAC,” (Beukelman & Mirenda, 2013, p. 4), several
generalizations can be made. A broad range of conditions, developmental or acquired, can cause
inability to speak. Common developmental disorders that may leave an individual with no
functional speech include cerebral palsy, mental retardation, and autism. For children, AAC
systems are not only a means to represent existing language, but also tools to support language
acquisition. Several acquired adult neurogenic disorders such as aphasia, dysarthria, and
apraxia can also impact language and/or motor speech production significantly enough to
warrant AAC. Depending on the nature of the disorder, those in need of AAC may demonstrate a
mix of cognitive and physical impairments. The communication of AAC users is almost always
multi-modal and includes gestures, signs, residual vocalizations, and eye gaze in addition to
aided systems (Light & Drager, 2008).
According to the 2010 U.S. Census (Ryan, 2013), over 20% of Americans speak a
language other than English in the home, with Spanish, Chinese, and French the most common
languages spoken, and other languages appearing with high frequency in particular geographic
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areas. American English can be further subdivided into several common dialects. In order to
serve our diverse client populations, AAC tools should support a variety of languages and dialects
whenever possible. The purpose of this paper is to suggest factors for systematic consideration of
AAC tools with regard to supporting multilingual users, as well as introduce the reader to some
existing resources in multilingual AAC. Two case studies are included to illustrate some of the
considerations in AAC tool selection.
Aided Augmentative & Alternative Communication: An Overview

General Categories of Aided AAC
The term “AAC” encompasses a wide range of tools and systems used to represent language,
including traditional orthography, drawings, photographs, gestures, manual signs, and other types
of visual symbols. AAC methods that rely only on the user’s body to convey messages (e.g., sign
language) are typically labeled “unaided,” while AAC systems that require the use of tools or
equipment in addition to the user’s body are considered “aided.” In this paper, we will primarily
consider aided AAC tools.
The spectrum of aided AAC has been traditionally divided into three broad categories
of complexity: no technology, low-technology, and high-technology. Non-technological aided
communication typically includes albums or boards of printed symbols (pictures or words). Non-
tech communication systems can include any number of symbols, but do not provide any voice
output capability (see Figure 1). A low-technology device typically consists of a customized static
symbol display on a pre-set grid, with capability to record and retrieve auditory labels for each
symbol. These devices usually have capability for anywhere from one to several dozen symbols.
High-technology devices (Figure 2) have traditionally been defined as “computerized systems that
are operated through special software” (Lloyd, Fuller, & Arvidson, 1997, p. 108). Systems that
produce speech when a symbol is accessed are typically known as speech generating devices
(SGDs) or voice output communication aids (VOCAs). The world of high-technology devices has
been revolutionized in the last five years with the rise of relatively low-cost AAC applications for
touch-screen tablets. A variety of aided AAC systems have been found effective in improving
communication for people who cannot speak (Schlosser, 2003) but almost no comparisons exist
of relative effectiveness of different aided AAC systems (Light & Drager, 2008).
Figure 1. No-Tech Communication Board
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Figure 2. A High-Tech Device From the Accent Series
Source. Prentke Romich Company (PRC). 2015. Retrieved November 30, 2014 from www.prentrom.com
Across the spectrum of complexity, aided AAC may be categorized according to several
overlapping parameters, including presence and type of speech generating capacity,
representation and organization of vocabulary, and the method by which the AAC user can
access the system. Knowledge of these parameters is highly relevant to AAC selection for
multilingual users.
Speech Generating Capacity
Voice output on high-tech AAC systems may be produced via synthesized and/or digitized
speech. Digitized voice output replays pre-recorded human speech and therefore sounds most natural,
maintaining intonation and stress patterns. It allows the user and her speech-language pathologist
(SLP) to record messages in any language and dialect, as long as an unimpaired speaker of that
language or dialect is available. With digitized speech, users also have a choice of language for each
individual message they record, which is helpful for clients who may mix multiple languages/
dialects in a single interaction (i.e., code-mix). Digitized speech is a great solution for users who
need an AAC tool with a limited number of words or phrases, as well as for users who speak
languages for which synthesized speech is not available. However, recording a digitized voice
message for every vocabulary item becomes hard to sustain as a user’s vocabulary grows.
Synthesized voice output is generated by software that changes typed text to speech (TTS).
Unlike digitized speech, synthesized speech allows the user to produce spontaneous utterances
that have not been pre-recorded into a device. Modern TTS technology converts text to speech
with high intelligibility and, as technology advances, with close to natural intonation and prosody.
In recent years, TTS technology has been developed for dozens of languages (The Acapela Group,
2014), including those spoken most frequently in the United States, and many AAC system
developers purchase TTS technology for their devices.
Organization of Vocabulary
Two important related characteristics of picture-based AAC are the length of utterance
produced via a single icon hit and the ability to produce novel, spontaneous utterances. A single
icon, when accessed, may speak a single word, a phrase, a sentence, or a whole paragraph. Having
each icon represent a phrase or sentence increases the speed of communication, but limits creation
of spontaneous novel utterances, whereas having each icon or combination of icons represent a
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word initially decreases the speed of communication, but supports creation of spontaneous
language. Systems that rely on word-by-word access need a high level of organization to support
users in searching amongst hundreds or thousands of words on a grid display.
The type of language organization on a device has high relevance for multilingual
capacities of AAC tools. Because phrase-based and limited-vocabulary systems do not require a
great deal of language structure, it is relatively simple to create a phrase-based AAC system in
any language, given the appropriate voice output tools. Systems that support spontaneous
production of novel utterances require language organization and grammatical support, and
therefore must be developed individually in each new language.
Another means of vocabulary organization is a visual scene display, where vocabulary
items are organized by activity and placed not on a grid, but on a high-context picture of the
relevant situation or location (Light & Drager, 2008). Finally, orthography-based AAC tools,
otherwise known as text-based systems, typically utilize a combination of keyboard access and
word prediction.
Access Methods
Aided AAC systems can be accessed directly by touching an icon on screen or printed board.
For people with profound motor impairment who do not have the fine motor capacity for direct
access, indirect access methods include visual and auditory scanning that can be stopped on the
necessary icon with a single movement. During visual scanning, icons are pointed out on a board
or highlighted on the screen. During auditory scanning, icon labels are spoken aloud by the device
or the communication partner (Roseberry-McKibbin, 2007, p. 425).
AAC Support for Multilingual Clients

Case Study: Salvador A.
The following case study outlines assessment and intervention with a young English-
Spanish bilingual boy in need of AAC:
Salvador, a four-year-old student in a non-public preschool, comes from a family that
speaks only Spanish in the home. He was referred to this preschool because his school district
does not have any speech and language classrooms to meet his needs. Salvador has fewer than
5 word approximations, but his family reports that he understands well in Spanish. His previous
teachers and therapist report that he has mild-moderate receptive delays in both English and
Spanish. He is ambulatory. Salvador has a mild impairment of fine motor skills. Occupational and
speech therapists have diagnosed him with oral apraxia, limb apraxia, and apraxia of speech, but
he has not been given any medical diagnosis by his pediatrician. Salvador has no behavioral
issues, participates willingly in classroom activities, and is eager to interact with friends. Although
he has received an hour of speech and language therapy per week, he has not received any
intervention targeting AAC. His modes of communication include pointing, non-speech vocalization,
gestures, fewer than 5 signs, hand leading, and about 5 word approximations. He shows
frustration when he cannot be understood.
Salvador’s receptive language was formally assessed using the Preschool Language Scales,
Fifth Edition Spanish/English version with an interpreter and English speaking SLP present. Ideally,
Salvador would have been assessed by a bilingual therapist, but none was available. He was also
observed in his classroom, where the therapist used a list of forms and functions of communication
to catalogue his expressive language. The therapist and interpreter helped the family to complete the
MacArthur-Bates Communicative Development Inventories-Words and Gestures (Fenson et al., 2007).
This tool is available in Spanish as well as English, so Salvador’s teacher filled out the English
version. Although Salvador was too old to use the regular norms for this instrument, it was found to
be helpful given Salvador’s limited expressive communication. The test was used informally to gather
information, and the norms were not used. The conclusions of the therapist were that Salvador
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presented with mild-moderate receptive delays in Spanish and moderate receptive delays in English.
He demonstrated profound expressive delays across both languages.
A Need for Family-Centered AAC
We know that, in order to be successful, AAC intervention must be family-centered (Angelo,
2000). Therefore, it is essential that AAC therapists consider a client’s cultural environment and
linguistic needs in the home when providing services. Soto and Yu (2014) emphasize the importance
of involving families in AAC system design. They state that, by considering a family’s linguistic
practices and values, a professional can design systems that encourage family involvement. A
communication system might be as simple as a small set of gestures and objects, or might be as
complex as a high-tech dedicated communication device, but every system must be customized to
the needs of the client.
Lack of family involvement in the AAC process has been cited as one of the factors
contributing to device abandonment (Bailey, Parette, Stoner, Angell, & Carroll, 2006), which
we know to be a common problem among AAC users. Without language that allows users to
communicate in the home, individuals are isolated from their family members, and AAC interventions
are bound to be insufficient at best.
Selecting a language for intervention with individuals who are bilingual is a complex process,
informed by a client’s skill level in each language. Deciding upon an intervention language becomes
even more complex when a professional must create language tools for a user. If a therapist is
not proficient in both of the client’s languages, she is obligated to seek resources that will allow
her to provide the necessary AAC tools. Without AAC systems provided in their home languages,
individuals will be unable to communicate through their augmented modes in their homes and
communities. (For a sample of web-based resources for multilingual AAC, see Appendix A.)
Assessment for AAC in Multilingual Populations
General Assessment Guidelines. Assessment of clients with limited functional speech
typically differs from assessment of speaking clients in several key ways. Complete assessment of
an individual for an AAC device typically involves a team of professionals, such as an SLP who
specializes in AAC, or a non-SLP assistive technology (AT) specialist, an occupational therapist
(OT), physical therapist, teacher, social worker, and more (Roseberry-McKibbin, 2007, p. 426). In
addition to assessment of speech and language, an AAC evaluation includes assessment of many
other characteristics relevant to a client’s success with a device, including gross motor and fine
motor skills, visual acuity, and optimal positioning for non-ambulatory clients. Any standardized
language tests must be adapted for non-verbal response, which means that SLPs may not use
standardized scores from spoken response-based assessments. Some individuals with the ability
to point may be able to participate in testing using an instrument that requires only pointing
as a response mode. The Boehm Test of Basic Concepts, 3rd ed. (Boehm, 2001), the Receptive One
Word Picture Vocabulary Test-Revised (Martin & Brownell, 2010), and Peabody Picture Vocabulary
Test-4th ed. (L. M. Dunn & Dunn, 2007) are examples of tests that require only pointing as a
response, and are available in both Spanish and English. The Test of Auditory Comprehension of
Language-Revised (Carrow-Woolfolk, 2014) is a more comprehensive look at receptive language,
and requires only pointing from the respondent. It is available only in English, but could be
adapted to be administered by a bilingual therapist. Tests that only require pointing can easily be
adapted for administration to an individual who uses another response mode such as eye gaze
or partner assisted scanning, but care must be taken, and norms cannot be used.
Typically, much of the information in an AAC assessment is gathered through informal
testing and a thorough case history/ interview process with relevant individuals, using guidelines
such as the Functional Communication Profile-Revised (Kleiman, 2014) or the Communication
Matrix (Rowland, 2004). Following evaluation of the client, an AAC assessment includes two
other components: a thorough description of situations and environments in which the client is
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expected to participate, and a process called “feature matching,” where several AAC tools that are
broadly expected to match the client’s needs are evaluated in detail to see whether the available
device features match the profile of the client’s strengths and weaknesses. The Social Networks
Assessment (Blackstone & Hunt Berg, 2012) is one tool that may be used to guide the description
of an individual’s social situations and communication partners. There are several informal
feature-matching rubrics available that can support the feature-matching process (e.g., Gosnell,
2011). The initial evaluation is followed by a period of several weeks to several months of trial
with a selected AAC tool.
Issues in Assessment Specific to CLD Clients. Several issues in AAC assessment are
particularly relevant for clients from culturally and linguistically diverse (CLD) backgrounds. For
individuals from CLD backgrounds, it is important to collect a thorough description of prior
language exposure and proficiency, as well as current levels of functioning in every language the
client regularly uses. It is also important to match the client’s languages with the environments
in which he typically uses them. When feature-matching an AAC tool with a client’s strengths
and weaknesses, SLPs will need to consider, in addition to other features, the availability and
type of multilingual options on the device.
AAC assessment for CLD families will also need to include consideration of the attitudes,
knowledge, and beliefs of the individual’s communication partners with regard to AAC. In one
study of a Mexican-American community, parents of children with AAC needs were uncomfortable
with using high-tech AAC tools (Huer, Parette, & Saenz, 2001). In the sections below, we outline
categories of AAC systems currently available, highlighting their multilingual functionality.
AAC Tools for Multilingual Clients
Dedicated AAC Systems with Multilingual Capabilities. For many years, in order
to access voice output communication, individuals needed to purchase a dedicated high-tech
communication device. In today’s AAC world, a high-tech communication device is often a
touch-screen computer without an attached keyboard, but can also be a laptop that runs voice
output software, or an application on a tablet. Originally, however, devices were “dedicated” to
communication, and did not have other purposes such as computing or entertainment. When
comparing devices, therapists will find that many devices have an option to function only as a
device (“dedicated”) or also as a laptop computer or tablet (“integrated device”). Some insurance
funding cannot be applied to integrated devices, therefore care should be taken in deciding which
model of a device to order.
According to the Prentke Romich Company (PRC), one of the most well-known suppliers of
AAC devices, their company produced their first communication device in the late 1960’s, and it
was a simple keyboard that spoke the words that a user typed into it. In the mid-80’s, Dynavox
was formed and began providing voice output communication systems, as well. In the beginning,
devices were simply empty boxes to be programmed with specific vocabulary for the individual
client. This was time consuming and inefficient, and often therapists had difficulty providing a
well-organized vocabulary system for clients. As the field of AAC advanced, companies such as
Prentke Romich and Dynavox developed “language maps” (i.e., built-in organizational structures
for easier search and morphological/syntactic support) to be customized as needed by SLPs and
clients. Today, some high-tech devices come pre-programmed with language maps that can help
individuals to communicate anything they wish to say fluently and spontaneously. An example of
one such device is the Eco, from PRC, which contains several language maps, one of which is
called “Unity 144”. Unity 144 comes pre-loaded with thousands of words, and can be customized
to include any word the user desires.
Full-featured dedicated devices may be appropriate for users who have motor impairment
and need to access their device via a method other than direct selection (e.g., via switch scanning
or eye gaze). Other features that might make dedicated or integrated speech generating devices
more appealing include complex language maps with grammatical support, warranties for repairs
(often not available for tablet computers running applications), and access to technical support
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(sometimes not available for applications). Alternately, the relatively high cost of traditional
speech generating devices may steer some users in the direction of applications.
AAC systems have evolved to include language maps in many languages. The AAC
systems discussed below are high-tech, dedicated devices that have multiple languages available
with complex language maps. The list is by no means exhaustive, but is intended to provide
therapists seeking systems for CLD clients a place to start in the search for the right tools.
Dedicated devices were chosen for discussion in this article based on several factors:
1. Tools commonly used/seen in the authors’ clinical practice;
2. Number of languages available; and
3. Amount of information available to consumers about the device.
This is by no means an exhaustive review of the devices available, but rather represents a
selection of devices thought to be important for discussion by the authors.
Dynavox/Tobii T-Series and I-series Devices. One of the two new lines of devices from
the recently merged AAC producers Dynavox and Tobii (TobiiDynavox, 2014), the T-Series,
includes devices that are small and intended to be carried by ambulatory users, as well as larger
devices intended to be mounted to a wheelchair. T-series users can access the vocabulary in the
devices via touchscreen, keyboard, mouse/trackball, switch scanning with audio feedback, or
head tracking. The language system on the devices is called “Compass”. The software includes
language maps in English, German, French, Portuguese, and Spanish, with Norwegian and
Swedish page sets in development.
The I-Series devices by Tobii are designed for individuals who require eye-gaze as a method
of access for their communication device. There are several sizes of devices, and they use the
software program Communicator or Sono Suite by Tobii. These devices are available with voices in
English (United States), Chinese, Danish, Dutch, English (UK) Finnish, French, German, Italian,
Japanese, Norwegian, Portuguese, Spanish (Americas), and Swedish. All of the I-series and
T-Series devices can be ordered as either dedicated or integrated devices.
Grid Pad Go, Pro, and Eye. The Grid Pad Go, Pro, and Eye from the company Sensory
Software (GridPadGo, 2014) are dedicated or integrated devices that run the Grid 2 language
software. This software can be used to communicate through text-to-speech, but can also use
symbol sets. The Sensory Software website indicates that voices and page sets for the devices are
available in more than 20 languages, including Spanish, Arabic, Chinese, and several dialects
of English. The Grid Pad Go and Pro can be accessed via touch screen, while the Grid Pad Eye is
also accessible via eye gaze and switch scanning. Sensory Software has an online forum for sharing
grids that includes grids in many of the languages listed above.
Accent Products. The Accent products are the newest communication aids from the PRC
(Prentke Romich, 2014). The Accent products are notable because the language system contained
within is called Unity, and uses a principle called “semantic compaction.” Semantic compaction
is a method of accessing vocabulary that requires users to access a sequence of several icons
to get the device to speak one word. In this way, the device is able to store thousands of words
without becoming cumbersome or difficult to access. The Unity language maps, which were the
first language maps to be created for AAC, are currently available in English and Spanish. These
devices are well-suited to individuals who need to access complex vocabulary. Another group to
whom this type of system is well-suited are those whose language is still developing (often children)
and who need an AAC tool that can easily grow into a complex vocabulary system. The language
maps in the bilingual version of the Accent devices are designed to facilitate ease of transition
between two languages in order to reduce the motor and cognitive learning load associated with
using a device to speak two languages. There are several sizes of device, some designed for
ambulatory users and some designed to be mounted. The devices have both a touch screen for
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direct selection, and other access methods suited to those who cannot use a finger to select, such
as scanning and eye gaze.
Nova Chat Devices. The Nova Chat Devices from the Saltillo Corporation (2014) come
in three sizes and have a variety of vocabulary files available. Their most well-developed language
map is Nova Chat, which is designed for users who are literate, as only the nouns or “picture
producers” in the system have symbols associated with them. The language software is intended
to allow individuals to create sentences “on the fly” by predicting the user’s next word. Nova Chat
is available in 5 languages: Spanish/English Americas, English, German, Dutch, and French
Canadian.
Boardmaker. Unlike the dedicated hardware described above, Boardmaker is a software
which is widely used by therapists who provide AAC services, particularly to children. According
to the Mayer-Johnson website (Mayer-Johnson, 2014), Boardmaker “lets you create valuable
print materials, like communication boards, with Picture Communication Symbols™ (PCS) and
other pictures and graphics.” Boardmaker has a feature that makes it particularly relevant to
our discussion of CLD learners: the symbols come with labels translated into over 40 languages.
This means that an SLP can type the name of a symbol into the search tool in English, choose a
symbol he likes, and then have the symbol labeled on the board in both English and any other
of the languages supported by Boardmaker. This is a quick, simple way for an SLP who does not
speak a client’s home language to improve the client’s ability to communicate with family and
friends who are literate in languages other than English.
Multilingual AAC Applications for Tablets
In the last few years, the development of mobile technology has changed the world of AAC,
allowing for a wide variety of AAC applications (apps), ranging from free applications with limited
functionality to AAC systems costing hundreds of dollars, with extensive language organization
and additional features such as integrated access to social networks (Farrall, 2014; Beukelman &
Mirenda, 2013). While most apps are currently designed for the iPad™, others can be accessed
via a range of tablets, including Android™ tablets, Kindle™ Fire, and Nook™ devices. These tools
are, on average, significantly more financially accessible to clients than traditional dedicated AAC
devices, and many applications offer free samples, either in the form of limited-time availability or
a “lite” version of the application with limited functionality for users to trial. However, when
selecting AAC apps, the SLP should be aware of multiple payment models, including one-time
purchases vs. monthly subscriptions or, rarely, per-trial payments. Though families may be eager
to buy popular or low-cost AAC apps for their loved ones, SLPs should take the time to conduct a
thorough AAC assessment before recommending the purchase of a particular application.
Considerations for AAC Apps for Multilingual Clients
Case Study: Mykola K.
The following case study outlines informal assessment and app selection for a client with
an acquired language disorder whose dominant language is Ukrainian:
A family comes for consultation to an SLP in the Sacramento, CA area. Mykola K.,
a 76-year-old man who is 2 years post-stroke, has minimal residual speech due to Broca’s
aphasia. Mykola, a native speaker of Ukrainian, spoke limited English before the stroke and
conducted the majority of his day-to-day activities in Ukrainian. He was an avid gardener, was
active in his church, where he helped to put together monthly food support packages for the poor,
and enjoyed spending time with his grandchildren. Since the stroke, he has not been able to
participate in most of his activities because of his severely limited speech and poor intelligibility,
and he has been depressed as a result. Mykola’s adult grandson heard about computer-based
voice output tools, and wants to know whether any of these can help his grandfather rejoin any
of his past activities.
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When considering AAC apps for multilingual clients, SLPs should be aware of two different
app designs. Some applications allow the user to switch languages within the app. Other applications
use the same design to support two different languages within two separately purchased applications
(e.g., the Assistive Express series of AAC apps must be purchased separately in English, Spanish,
German, or Italian; for a full list of apps mentioned in this article, see Appendix B).
The number of mobile AAC applications is large and growing, with many features to
consider. The process of AAC selection always involves matching the technology to the
strengths and weaknesses of the client. While we discuss several AAC applications as salient
examples of certain features relevant to multilingual AAC or our case studies, our mention of
individual applications does not indicate our endorsement of these apps. For a regularly
updated, loosely ranked list of AAC applications for tablets, readers are encouraged to check
out Jane Farrall Consulting (Farrall, 2014). In addition, a recently released app called the “AAC
Ferret” allows users to search for AAC apps by categories, including type of voice output,
though not yet by multilingual capacities.
Highly Literate Clients Who Need to Produce Spontaneous Language. For clients
who have developed or retained reading, writing, and spelling skills, as well as good fine motor
control, text-based applications present effective options for AAC. This type of application typically
includes an on-screen keyboard where a user can type messages, which are then spoken via
text-to-speech technology, described above. Text-based apps usually include word and phrase
prediction features to increase the rate of communication, as well as quick one-hit access to
several commonly used phrases. Because TTS technology is rapidly expanding in many languages,
text-based apps represent promising avenues for clients with multilingual needs. Many text-based
AAC apps take advantage of TTS availability and offer voice output in multiple languages. With
English as the primary language in an app, other languages are either included in the original app
price or may be bought as an in-app purchase. One example of such an app is Typ-O HD. For
clients who can type, this text-based app offers voice output with word and phrase prediction in
several languages, including Spanish. Other text-to-speech apps that offer multilingual support
include ClaroCom, with over a dozen languages available, and Assistive Express, with a series
of apps that includes Spanish.
Clients Who Have Limited Literacy/ Only Need to Produce a Limited Number of
Functional Phrases. For clients who are expected to produce little to no spontaneous complex
syntax, SLPs may consider applications that offer a limited number of pre-programmed functional
phrases. These phrases are typically represented with pictures, either on a grid or within a visual
scene display, and each message is accessed with a minimal number of hits. Because these apps
include a limited number of messages, digitized (recorded) speech presents an easy solution for
multilingual clients. Examples of such apps include the TapSpeak family of single-message and
sequenced-message buttons, useful for emerging communicators, the visual scene display app
Scene&Heard, which includes several messages within a customized context such as a kitchen
or bathroom scene, and the app Voice4u, which presents several dozen fully customizable
messages in list or grid format. Some phrase-based apps also have the synthesized speech option,
including the apps TapToTalk and TalkForMe.
Clients With Limited/Simple Spontaneous Language. For clients who need the
capacity to produce some basic spontaneous utterances, many grid-based AAC apps provide
some pre-programmed vocabulary pages, categorized episodically and/or semantically, with the
expectation that SLPs will create additional pages for each individual user. A growing number
of these have multilingual synthesized speech options available. One example of this is the GoTalk
Now app, which can be programmed to allow users to produce a range of basic sentences. In
addition to voice output in English, the GoTalkNow has additional voices in 20 languages for
purchase, including Spanish and French. Digitized speech is also available. TapSpeak Choice, the
most sophisticated app of the TapSpeak app series, offers TTS support for twenty languages with
a grid-based AAC system.
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Clients Who Need Access to Varied, Complex, Spontaneous Language via Picture
Representations. The biggest challenge for an SLP is supporting multilingual individuals in need
of a full-featured SGD that allows for grammatically correct, spontaneous, complex language.
In addition to some dedicated devices listed above, currently, there are few full-featured AAC
applications available that offer grammatical support for Spanish. Avaz for Autism Spanish, a
stand-alone app from the developers of Avaz for Autism English, offers grammatical support for
language production. Proloquo2Go, one of the first English AAC apps with grammatical support,
is coming out with a Spanish version in early 2015.
Case Study Outcomes

Mykola and his family were interested in helping Mykola produce some common phrases
and tell a few favorite stories. They also wanted to help others communicate with him in the most
supportive way. There was no system available with extensive grammatical support in Ukrainian,
and he would not have benefitted from a complex language system in English. Instead, Mykola
needed a picture-supported, low-cost, phrase-based device with large buttons, where messages
could be recorded in both English and Ukrainian. An assessment was conducted to determine the
messages and languages that would support Mykola’s communication across settings. It was
determined that Mykola would want messages to his church pastor recorded in Ukrainian and
family messages in a combination of Ukrainian for older family members and some limited English
for others.
The family owned an iPad mini that they decided to try to use for communication. They
bought the simple phrase-based app iWant. . ., which allowed the family to take pictures and
record messages for Mykola. Mykola’s first messages were for social events in Ukrainian: “How
are things going?” and “I can talk to you if you ask me yes/no questions.” This helped others hold
brief conversations with him. The family eventually removed the message about yes/no questions
from the iPad and helped Mykola, instead, to keep a simple note with this content in his pocket.
Mykola’s son-in-law and grandson took photos of Mykola’s life events and recorded simple
messages over the photos with Mykola’s consent, using the iWant. . . app, such as “Look at how
well the garden is doing this week.” While we did not have a chance to observe Mykola over the
long-term, several considerations affect the success of AAC in cases like Mykola’s. The willingness
of family to explore technology is an important criterion for success, particularly in cases where the
client was not a fluent technology user prior to developing a communication disorder. Mykola had a
grandson who was familiar with touch-screen technology and was willing to take the lead on
programming and maintaining a simple AAC app. The grandson was fluent in English, though not
in Ukrainian, so other family members participated in creating messages in Ukrainian.
It is also important to integrate any AAC application into a multi-modal communication
system. In Mykola’s case, there was no tool available to support production of grammatically
correct complex expressive language in Ukrainian, nor did it appear that he would have been
ready to learn how to use one. However, the inclusion of key phrases and some guidance for
communication partners in his simple AAC tool made it possible for Mykola to take the lead on
selecting a communication topic and gave communication partners a systematic way to engage in
conversation by asking “yes/no” and choice questions. Many families have the goal of helping
the client tell a few favorite family stories. This goal can be accomplished with “talking photo
album” apps, which can be used to create narratives. Two examples of many such apps are
StoryKit and Pictello.
For Salvador, the team wanted to give access to a complex language map that did not rely
on literacy as he cannot yet read. It was important that Salvador be able to switch easily between
languages, as his world is truly bilingual. His language is in the process of developing, so it
seemed to the team that he should have a language map that as closely mimics typical language
development as possible, and that he be able to access individual words to create novel sentences
34
to represent his ideas. His good fine motor skills meant that he could access a device using a touch
screen, and that small cells would be fine, particularly if a keyguard was available. His device
needed to be small and light enough to be carried by a four-year-old. After much consideration, the
team chose the Accent 1000 Spanish/English version. It is small enough to be carried (using the
integrated handle) but still large enough to allow use of the 84 location language map that is
sufficiently complex. It provides easy access to both languages (language can be switched by
pressing one button) and the language maps for the two languages are similar. Parents will be an
integral part of the process of vocabulary selection, and will receive regular training on using the
device from the AAC specialist through an interpreter. Salvador will be able to independently
communicate both at home and at school.
Follow-up: After one year, Salvador was able to use his device to communicate in single
words and two word phrases within his classroom setting. He used the device both with peers and
adults, and showed a great deal of enthusiasm for and ownership of the device. He was able to
manage some operational functions of his device, such as turning the device on and off, as well as
adjusting the volume and switching between English and Spanish. Unfortunately, Salvador’s use
of the device in Spanish was quite limited. This is possibly because he was not able to receive AAC
intervention bilingually, but rather received services only in English. In the home he continued to
resort to gestures and vocalizations rather than using his device to express more complex
language.
As is clear from the outcomes in this case, it continues to be a challenge for therapists to
provide intervention that results in excellent outcomes for clients in a multilingual population. The
need for bilingual therapists continues to grow, and for now, many clients must receive intervention
only in the dominant language, or not at all. It is clear that Salvador benefitted from receiving his
voice output communication aid, but it seems likely that the benefit would have been greater had a
bilingual therapist been available to the team.
Other Considerations in AAC Selection for Diverse Populations

Though we have focused primarily on issues of multilingualism, there are several other
diversity considerations to keep in mind with regard to AAC. One of these considerations involves
the client’s age. Outward appearance of an AAC system is meaningful to both adult and child
clients. Many AAC systems can be used by children and adults alike, but some device features
are most appropriate for particular age ranges. Selection of age-appropriate devices includes age-
appropriate case designs for tablets and dedicated devices and age-appropriate symbol sets used
in the device interface. For example, in one of the author’s experiences, adult AAC users have
expressed dislike for PCS and other cartoon-like symbols because they feel that the symbols are
childlike and unsophisticated. Care should be taken that visual representations of language are
in line with the needs and values of the individuals who will be using them to communicate.
Similar considerations exist for voice selection, where the voice output on a device should roughly
match the age and gender of the AAC user.
Summary and Conclusions

It is best practice in language intervention to support all the languages used by our
multilingual clients whenever possible. In aided AAC today, many features make this job easier,
including the availability of synthesized voices in many languages, capacity for digitized speech,
multilingual keyboards, and a wide range of picture/symbol supports. AAC systems with
multilingual grammatical support are also in development. When supporting a multilingual client
with AAC needs, in order to be a literate participant in AAC assessment and when working with
AAC specialists, SLPs need to be familiar with assessment considerations and AAC system
features relevant to our multilingual clients.
35
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History:
Received January 2, 2015
Revised March 6, 2015
Accepted March 9, 2015
doi:10.1044/cds22.1.25
37
Appendix A. Resources for Multilingual AAC
This article is intended to allow readers a beginning understanding of multilingual AAC
and some of the many tools available. For those interested in a more in-depth understanding of
the subject, we include some current sources that might be helpful in planning intervention for
multi-lingual users of AAC.
1. ASHA SIG 12, Augmentative and Alternative Communication, with discussion boards
and practical information from therapists working with AAC: http://www.asha.org/
Members/divs/div_12.htm
2. Using MinSpeak systems with bilingual users: Semantic Compaction Systems: http://
www.minspeak.com/users/documents/CultureBilingual.pdf
3. Basic communication boards (“cue cards”) in 69 languages: Eastern Health, a health
services organization: http://www.easternhealth.org.au/services/language-and-
transcultural-services/cue-cards/cue-cards-in-community-languages
4. Sample lesson plan for shared book reading with a bilingual student using AAC:
PrAACtical AAC: http://praacticalaac.org/praactical/praactically-slps-hungry-for-
bilingual-aac/
38
Appendix B. AAC Applications Mentioned in this Article
Inclusion of an application on this list does not constitute endorsement by the authors.
Readers are encouraged to explore AAC applications and consider the app characteristics listed
in the article to help clients make decisions about app selection.
Application Name Developer Website
AAC Ferret www.spectronics.com.au/ferret

Assistive Express http://www.assistiveapps.com/
Avaz for Autism http://www.avazapp.com/
ClaroCom http://www.claro-apps.com/clarocom/
GoTalk Now http://www.attainmentcompany.com/gotalk-now
iWant. . . not available
Pictello http://www.assistiveware.com/
Scene&Heard http://www.therapy-box.co.uk/scene_and_heard.aspx
StoryKit http://en.childrenslibrary.org/
TalkForMe http://www.talkforme.ie/
TapSpeak http://tapspeak.com/drupal/
TapSpeak Sequence http://tapspeak.com/drupal/Sequence
TapSpeak Choice http://tapspeak.com/drupal/Choice
TapToTalk http://www.taptotalk.com/
Typ-O HD http://www.secondguess.dk/Typ-O/Typ-O.html
Voice4U http://voice4uaac.com/
39

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Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations

Volume 22, April 2015, Copyright © 2015 American Speech-Language-Hearing Association

Practical Resources for Provision of Services to Culturally

Aided Augmentative & Alternative Communication: An Overview

Figure 1. No-Tech Communication Board

AAC Support for Multilingual Clients

Case Study Outcomes

Other Considerations in AAC Selection for Diverse Populations

Summary and Conclusions

Application Name Developer Website

AAC Ferret www.spectronics.com.au/ferret

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