Research Article

Individuals Who Use Augmentative and Alternative

Communication and Participate in Active Recreation:
Perspectives From Adults With Developmental
Disabilities and Acquired Conditions
David J. Hajjara and John W. McCarthyb
a
Department of Speech-Language Pathology and Audiology, Ithaca College, NY b Division of Communication Sciences and Disorders, Ohio
University, Athens

ARTICLE INFO ABSTRACT

Article History: Purpose: The aim of the study was to gather the perspectives and lived experi-
Received June 17, 2021 ences of 10 adults who use augmentative and alternative communication (AAC)
Revision received September 9, 2021 and participate in active recreation. Active recreational participation includes
Accepted October 7, 2021 individual sports such as adaptive skiing, surfing, and cycling, as well as unified
team sports such as soccer, bocce, and basketball.
Editor-in-Chief: Erinn H. Finke Method: This research involved a qualitative study with two separate asynchro-
Editor: Billy T. Ogletree nous online focus groups each conducted over a 6-week span. The focus
groups included literate individuals who use AAC and engage in active recrea-
https://doi.org/10.1044/2021_AJSLP-21-00179 tional pursuits across the United States. One focus group included five indivi-
duals with acquired conditions, and the other group included five individuals
with developmental disabilities.
Results: Thematic analysis of the data from both focus groups revealed five primary
themes with corresponding subthemes: barriers (intrinsic and extrinsic), supports
(intrinsic and extrinsic), benefits (intrinsic and extrinsic), communication (methods),
and recommendations for communication partners and people who use AAC.
Conclusions: This study provides important information to individuals who use
AAC and their communication partners about the benefits of active recreation
and the supports needed to make these experiences successful. As a result of
this study, speech-language pathologists, related professionals, and caregivers
will gain a better understanding of how they can support recreational participa-
tion for people who use AAC with a specific focus on enhancing communication
and expanding social networks.
Supplemental Material: https://doi.org/10.23641/asha.17701043

Community-based recreation and leisure activities
provide opportunities for meaningful participation and
improved quality of life and social engagement for people
with significant communication disabilities who use aug-
mentative and alternative communication (AAC; Dattilo
et al., 2008; McNaughton et al., 2019; Mirenda, 2014). The
Leisure and Well-Being Model promotes active recreational
participation by considering a strengths approach with
a focus on enhancing experiences while recognizing the
impact of individual internal and external factors
Correspondence to David J. Hajjar: dhajjar@ithaca.edu. Disclosure:
The authors have declared that no competing financial or nonfinancial
interests existed at the time of publication.
(Carruthers & Hood, 2007). Recreation and leisure play
a central role in general well-being and provide oppor-
tunities for self-determination and the expression of
one’s full potential, including their strengths, capacities,
and assets (Anderson & Heyne, 2012). Furthermore, recrea-
tional activities promote social networks for people who
use AAC and provide opportunities for developing friend-
ships and feelings of self-respect and self-competence
(Dattilo et al., 2008, 2010; Hajjar et al., 2019).
A wide range of opportunities for leisure and active
recreation are available for the general population; however,
individuals who use AAC may not have access to programs
that provide the necessary support and adaptations to facil-
itate safe and enjoyable participation. Limited access to

American Journal of Speech-Language Pathology • Vol. 31 • 375–389 • January 2022 • Copyright © 2022 The Authors 375
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 recreation can lead to reduced opportunities for social
engagement and restrictions in participation (Balandin,
2011; Light & McNaughton, 2015; Mirenda, 2014). For
people who use AAC, activity and participation limitations
may result from a lack of recreational programs with
skilled and knowledgeable partners and instructors (Dattilo
et al., 2010). Since the infrastructure for inclusive recrea-
tional participation has been inconsistently developed,
people with disabilities have fewer opportunities for com-
munity engagement (Dattilo, 2002). For individuals who
use AAC and have a desire to participate in active recrea-
tion, it is important to consider how intrinsic and extrinsic
factors may impact their experience.
The International Classification of Functioning, Dis-
ability and Health (ICF) model from the World Health
Organization (WHO, 2001) provides a framework for peo-
ple who use AAC to understand the interaction between
environmental and personal factors during recreational par-
ticipation. The ICF framework promotes the importance of
the interaction of these factors as either barriers or sup-
ports, and their influence on activity and participation
levels for people who use AAC (Raghavendra et al., 2007).
Intrinsic factors related to the person and extrinsic factors
related to the environmental context need to be considered
for everyone who engages in active recreational pursuits.
Overall participation patterns are also impacted for
people with acquired conditions like amyotrophic lateral
sclerosis (ALS). These individuals may be unable to work
and, as a result, spend more time at home with limited
community engagement (Beukelman & Light, 2020). As a
result, fewer social interactions will occur and opportu-
nities to build and maintain relationships will be limited.
Since individuals who use AAC typically have smaller
social networks, they often experience increased loneliness,
which can have a negative impact on their happiness and
quality of life (Ballin & Balandin, 2007; Light &
McNaughton, 2015; Mirenda, 2014).
Previous research has focused on community-based
recreation opportunities (Mirenda, 2014; Potvin et al.,
2008); however, speech-language pathologists (SLPs) have
traditionally had less involvement in facilitating recrea-
tional pursuits and enhancing communication and social
interaction in these settings. Some SLPs have successfully
developed programs in tennis and horseback riding for
children with autism and other developmental disabilities.
By focusing on training communication partners and
teaching effective AAC strategies, SLPs have the skills to
support the development and maintenance of adaptive
recreational programs.
Defining Recreation
While considering the development of more inclusive
communities, it is important to consider the impact of
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leisure and recreational activities to provide a better qual-
ity of life for individuals with disabilities (Zabriskie et al.,
2005). The ICF definition of recreation and leisure
includes a wide range of activities, such as engagement in
organized play and sports; programs of physical fitness;
relaxation; going to art galleries, museums, and theaters;
engaging in crafts or hobbies; reading for enjoyment;
playing musical instruments; sightseeing; and traveling
(WHO, 2001). Given the importance that the WHO
places on recreation and leisure, professionals can use the
ICF to justify the value of recreational participation as a
multidimensional activity that emphasizes functionality as
well as an individual’s capacity to participate (Anderson &
Heyne, 2012).
Dattilo et al. (2008) reported that adults with cere-
bral palsy who use AAC primarily engaged in passive
recreational activities (e.g., board or video games, going
to the movies, watching TV, or listening to music). The
adults in the study shared that recreational participation
helped them to develop a positive attitude and build confi-
dence while also educating people in their local commu-
nities. The current study went beyond passive recreational
interests and focused on a more diverse group of participants
who use AAC and consistently engage in active recreation
(e.g., skiing, paddling, biking, hiking). Settings that promote
active recreation provide an inclusive community-based
experience that relies on support from families and care-
givers as well as dedicated instructors and volunteers.
Since most physical barriers have been reduced or
eliminated across active recreational settings, the possibili-
ties for different types of pursuits have greatly expanded for
people who use AAC. With more opportunities for recrea-
tion, it allows individuals with developmental and acquired
conditions to try a sport or activity for the first time or per-
haps re-engage participation in an individual or team sport.
As a result, with the development of new adaptive sport
programs, people who use AAC will have more choices
and control over their leisure and recreational pursuits and
better align personal interests with their individual prefer-
ences, strengths, and goals.
Value and Benefits of Recreation
Since opportunities for community-based inclusion
are inconsistent and since employment opportunities are
limited for people who use AAC, consideration of recrea-
tion and leisure is critical to provide a better quality of life
standard (Light & McNaughton, 2015; Mirenda, 2014).
For some individuals who are unable to work full- or part-
time due to a disability, recreational pursuits may rival
employment and be defined as “serious leisure” activities or
central life interests (Patterson & Pegg, 2009). Since most
active recreation happens in community-based outdoor set-
tings accessed by the general public, this increased visibility
 can help to educate society and increase awareness about
how and why people with disabilities participate.
Recreational participation provides benefits for adults
who use AAC (Dattilo et al., 2008; Lundberg et al., 2011).
The infrastructure of community-based recreational pro-
grams supports the process of developing relationships,
increasing engagement, and fostering independence through
teaching new skills (Dattilo et al., 2008). Patterson and
Pegg (2009) determined that serious engagement in leisure
activities provides people with intellectual disabilities the
necessary confidence to communicate, acquire new
skills that build self-esteem, and facilitate social inclu-
sion across community settings. Furthermore, for people
with acquired medical conditions who may experience
diminished social networks or difficulty returning to the
workforce (Beukelman et al., 2007), recreational partici-
pation may provide meaningful opportunities to reengage
with society, maintain social networks, and promote com-
munity reentry.
Even though people who use AAC represent a hetero-
geneous group with a range of ages and disabilities, active
recreation can be an important shared activity that builds
human connections and sustains social networks. The collec-
tive experiences of the participants in this study offer a better
understanding about the broad benefits of active recreation
relative to quality of life, participation, and engagement with
community stakeholders. In particular, understanding
the perspectives of individuals with both developmental
disabilities and acquired conditions will provide SLPs
and related professionals with key information about
how these individuals participate, access, and engage in
leisure pursuits that exist in their local and regional
communities.
This research will provide SLPs with information
about the benefits of active recreation for individuals who
use AAC. It is important for SLPs to understand the
impact of active recreational pursuits as well as what types
of barriers still exist relative to communication and access
in these settings. The participants in the study provided a
rich overview of their recreational participation while also
offering recommendations to enhance the overall experi-
ence. The findings from the current study will provide
SLPs with a roadmap to train communication partners in
the skills and strategies to support effective use of AAC.
Three research questions provided direction for this
study: (a) What are the lived experiences and perspectives
of individuals with developmental disabilities and acquired
conditions who use AAC and engage in active recreation?
(b) What are the key barriers and supports for individuals
who use AAC and their communication partners across
active recreational settings? and (c) What are the key
recommendations for communication partners who sup-
port individuals who use AAC to access and successfully
engage in active recreation?
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Method
Participants
Purposeful sampling (Suri, 2011) was used to recruit
adults who use AAC and engage in four or more active
recreational pursuits in a 12-month period. Participants
were recruited through e-mail, social media, and posts to
listservs accessed by SLPs and recreational therapists.
Individuals who fit the criteria and were interested in par-
ticipating contacted the first author via e-mail and were
then provided additional details about the study. Potential
participants were also provided with a link to a Qualtrics
survey to gather demographic information, including types
of AAC systems used, and the frequency of active recrea-
tional engagement. Examples of active recreation and
adapted sport were described in recruitment materials to
include, but were not limited to, skiing, snowboarding, pad-
dling, hiking, water-skiing, cycling, rock climbing, and/or
skydiving. After the research team confirmed inclusionary
criteria for the participants, they were provided with instruc-
tions about how to access the password-protected discussion
forum. Participants consented to engage in the study by elec-
tronically signing consent forms and logging on to the dis-
cussion forum with their unique username and passwords.
Pseudonyms were used to protect the identities of all
participants who engaged in the online focus groups. The
study was approved by the institutional review boards at
the institutions of the first and second authors.
Inclusion Criteria
To be eligible for participation in the study, indivi-
duals were required to (a) be over the age of 18 years,
(b) have a diagnosis of a developmental disability or an
acquired neurological condition, (c) have complex communi-
cation needs (speech inadequate to meet communication
needs and current use of AAC), (d) have functional fluency
in reading and writing English, (e) have the ability to pro-
duce text-based responses independently or with minimal
assistance from a partner, (f) have consistent access to the
Internet, and (g) participate in four or more active recrea-
tional pursuits in the past year.
One focus group consisted of five individuals with
developmental disabilities who ranged in age from 19 to
56 years old. Two individuals had a primary diagnosis of
autism spectrum disorder (ASD), two individuals had a pri-
mary diagnosis of cerebral palsy, and one individual had a
primary diagnosis of Rhett syndrome. The second focus
group had five individuals with acquired conditions who
ranged in age from 40 to 58 years old. The participants in
the acquired (AQ) conditions group were all over 40 years
old, compared to the developmental (DEV) group which
had only two participants over age 40 years. In the AQ
group, three individuals had a primary communication
377
 disability resulting from a stroke, one individual had a
traumatic brain injury, and one individual had ALS. All
10 individuals lived in the United States and used aided
AAC to communicate in addition to various unaided
methods such as speech, vocalizations, gestures, and sign
language. Eight participants lived in urban settings within
a 50-mile radius of a city with more than 1 million people,
and two participants were from rural settings in states
with a total population of less than 1.5 million. More
detailed information about the participants can be found
in Table 1.
Research Design
This research involved a qualitative study with two
separate asynchronous online focus groups each conducted
over a 6-week span. The focus groups occurred 18 months
apart, with the AQ group first, followed by the DEV
group. A member check was conducted separately for
each focus group, which involved participants reviewing a
summary of the primary themes and providing any addi-
tional information or observations.
Online focus groups have been used previously in
AAC research to explore new phenomenon and under-
stand perceptions of people with complex communication
needs and their communication partners (Caron & Light,
2016; McNaughton et al., 2002; Therrien, 2019). The
focus groups for this study were conducted in an online
asynchronous manner as a method to encourage more
consistent responses and engagement. Due to the variation
of geographic locations of the participants (e.g., West
Coast and Mid-West), it was important to allow partici-
pant contributions to occur at any time during the week.
Also, the asynchronous approach allowed participants to
have more time to generate responses and not feel rushed
due to slower rates of communication using AAC.
In addition to the asynchronous design, the focus
groups used a hybrid approach (Ryan et al., 2013) com-
bining aspects from an individualist social psychology per-
spective and a social constructionist perspective (Belzile &
Oberg, 2012) to gather the lived experiences of individuals
with developmental disabilities and acquired conditions
who use AAC and engage in active recreational pursuits.
The hybrid design of the focus groups encouraged sharing
of personal opinions and perspectives, in response to
structured and semistructured questions along with partici-
pant interaction.
Materials
The authors worked with graduate students in com-
munication sciences and disorders to develop the following
materials: (a) a demographic questionnaire and (b) topics
and questions for the online focus groups. The demo-
graphic questionnaire (see Supplemental Material S1) was
developed to ensure that participants met the inclusionary
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criteria and to gather important information about their
interest and ability to engage in the study. The focus
group topics and discussion questions were developed by
the authors (see Supplemental Material S2). The primary
topics were the same for each of the focus groups; how-
ever, some of the follow-up questions were unique to each
group, based on the nature and type of participant
responses. For example, individuals in the AQ conditions
focus group were asked questions about their recreational
participation before and after the onset of their medical
condition.
Procedure
Participants first completed the demographic ques-
tionnaire, and all participants noted they would be able to
respond to questions independently or with minimal assis-
tance for setup or typing. After reviewing the question-
naire responses, it was determined by the authors that all
the individuals met the inclusionary criteria for either one
of the focus groups. During the focus groups, typed
responses were collected from the participants using the
following software programs: PHP Phorum and Google
Groups. These programs established a secure password-
protected site for the moderator and participants to contri-
bute their responses to weekly questions and topics. The
participants were able to view all responses and return to
previous topic boards during the 6-week asynchronous
focus groups.
Focus Group Structure
The structure of the online focus groups was based
on previous AAC research (Caron & Light, 2016;
McNaughton et al., 2002; Therrien, 2019) that used this
modality. The primary topics and discussion questions
were broken into six topics, one for each week: Week 1:
Practice post: Getting to know each other and sharing
active recreational pursuits; Week 2: Barriers to active
recreation; Week 3: Supports for participation; Week 4:
Communication across the experience; Week 5: Benefits of
active recreation; and Week 6: Recommendations for stake-
holders across the experience.
The participants in each focus group responded to
e-mails from the research team to ensure a reliable method
of communication could be established. Next, the partici-
pants were instructed how to access the online discussion
forum. A practice post provided an opportunity for the
participants to engage with the forum software and under-
stand how to contribute and review responses. Each week,
the participants provided typed responses to the modera-
tors’ question prompts by sharing their personal experi-
ences and unique perspectives about active recreational
participation. In addition to posting, participants were
encouraged to review each other’s responses, make comments,
 Table 1. Characteristics of participants.

Primary Communication
Name Age Education Employment disability status Modes of communication Types of active recreation

Derek 19 Some college Unemployed ASD Non speaking SGD, tablet/mobile device, gestures, Skiing, hiking, biking,
student letter board, vocalizations, whiteboard gymnastics
Gary 56 4-year degree Employed CP Severe speech Tablet/mobile device, vocalizations, Power soccer, snow skiing
(part time) impairment: gestures
nonspeaking
Ginny 27 Some college Unemployed Rhett syndrome Apraxia SGD, tablet/mobile device, natural Pilates, hiking, personal
speech, gestures, whiteboard trainer
Jeff 27 High school Student ASD Minimal functional Tablet/mobile device, letter board Basketball, baseball
speech
Hajjar & McCarthy: Active Recreation for Individuals Who Use AAC

Nick 42 Some college Employed CP Severe speech SGD Hiking, parasailing, kayaking,
(part time) impairment: shooting, swimming
nonspeaking
Adam 42 Bachelor’s Volunteer Stroke: 9 years Aphasia Tablets, phrase boards, signs Cycling, skiing, skydiving,
degree post scuba
Beth 42 Some college Unemployed TBI: 19 years Dysarthria, cognitive Tablet, mobile device Hiking, paddle boards,
post communication kayaks
Brian 46 Bachelor’s Unemployed Stroke: 7 years Aphasia Tablet, computer, texting Skiing, cycling
degree post
Eliza 40 Bachelor’s Unemployed ALS: 14 years post Dysarthria Tobii C15 Skiing, water skiing, cycling
degree
Kevin 58 Juris doctor (JD) Unemployed Stroke: 11 years Aphasia, apraxia Pen/paper, tablet, gesture Water skiing, rock climbing,
post hang-gliding

Note. ASD = autism spectrum disorders; SGD = speech-generating device; CP = cerebral palsy; TBI = traumatic brain injury; ALS = amyotrophic lateral sclerosis; Post time = post
onset of acquired disability.
379

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 or ask follow-up questions, directed to other group members.
Participant’s posts varied in length and complexity; however,
they were primarily in the format of short single sentences.
Overall, participant responses ranged from single words to
short paragraphs. In each focus group, the participants also
responded directly to each other in addition to answering the
moderators’ questions. For example, participants provided
supportive comments and shared adaptive sport contacts and
resources.
The first author and SLP graduate students acted as
the moderators. In this role, they posted new topics and
questions, provided technical support, and sent out e-mail
reminders to alert participants about new topics and to
contribute a response if needed. New topics were posted
by the moderators on Monday mornings for six consecu-
tive weeks for each focus group. After posting, the mod-
erator sent out an e-mail alert to notify participants to
contribute to the forum. In addition, a second weekly
e-mail was sent out on Thursdays to remind participants
to post and review existing responses. It was important for
the participants to review each other’s contributions to the
weekly forum as this encouraged greater interaction and
built a sense of community during the study. After the
conclusion of each 6-week focus group, the typed
responses were summarized in a document that was orga-
nized by the weekly topic areas. This document was sent
to the participants via e-mail, approximately 3 weeks after
the conclusion of the focus group. The purpose of the
member check was to ask the participants about the accu-
racy of the summary and provide a final opportunity for
them to contribute.
Data Analysis
Data collection occurred during two focus groups
and two different member checks. For each focus group,
typed responses were extracted from the discussion forum
and then organized by question topics. The final transcripts
from each group included the original question/s, follow-up
questions, and all participant responses and contributions.
The transcripts were read and reviewed independently by
the first author and a graduate research assistant.
Using the transcripts, data were analyzed separately
using a thematic analysis (Creswell, 2007) and then com-
pared using a content analysis approach (Mayan, 2001).
First, data were broken down into the smallest units of
information that could informatively stand alone (Kvale
& Brinkman, 2009). The units of information were called
“thought units” in the form of a short phrase, sentence, or
multiple sentences that did not make sense if separated.
The first and second authors reviewed the thought units
and identified six primary themes as a result of the analy-
sis and iterative discussion. However, due to the iterative
nature of the data analysis process, five final themes were
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determined based on concept-driven coding (Kvale &
Brinkman, 2009) and similarities observed across the final
303 thought units. See Supplemental Material S3 for the
specific number of thought units associated with each pri-
mary theme. The coding procedure was influenced by the
topics and questions that were presented during the focus
groups. After reviewing and categorizing the thought
units, operational definitions for primary and secondary
themes were finalized. See Supplemental Material S4 for
operational definitions associated with each theme.
After the thematic analysis was conducted for each
group, a content analysis (Mayan, 2001) was used to com-
pare the data from the two different groups. A written
summary with selected quotes from each group was gener-
ated to categorize persistent phrases and ideas across the
topic areas. The first author and a graduate research assis-
tant reviewed the data for similarities and differences
between the focus groups in the context of the five pri-
mary themes. Several interesting similarities and differ-
ences emerged from the data analysis that were pertinent
to both groups. From the individual experiences of each
participant, a collective pattern emerged, which allowed
the research team to report several similarities relative to
communication and AAC across the two groups. Some
differences were also reported, which reflects the unique
nature of each participant and their external supports.
Transparency and Rigor of Data Analysis
Triangulation of the data occurred through peer
review, member check, and reliability check.
Peer Review
Throughout the study, the second author served as
the primary individual responsible for peer review. This
individual, who was familiar with the project and the
objectives of the research, provided consistent constructive
feedback during all procedures and aspects of data collec-
tion and analysis, through active listening and discussion,
asking questions, and making suggestions based on pre-
vious research and clinical experience.
Member Check
During the member check process, the interpretation
of the data went back to the 10 participants to provide
them with an opportunity for validation and feedback
(Creswell, 2007). The first author sent one e-mail to the
five participants with acquired conditions and a different
e-mail to the five participants with developmental disabil-
ities. Each e-mail had an attached summary specific to the
ideas and quotes from their focus group along with a
description of the five primary themes and corresponding
subthemes. A total of seven participants responded across
the two focus groups. Four out of the five participants
 from the AQ conditions focus group responded, and three
out of the five participants from the developmental dis-
abilities focus group responded. All the participants who
responded verified that the summary accurately repre-
sented their perspectives and did not provide any addi-
tional feedback.
determined by calculating the number of thought units in
agreement divided by the total number of thought units
coded then multiplied by 100.
Results

Reliability Check
The first author met with two graduate students to
explain the process of conducting interrater reliability.
These students had not been part of any prior analysis in
this study. After the students reviewed the operational
definitions for each primary theme, they were trained to
complete the reliability check. Once the students reached
90% agreement in categorizing a practice set of thought
units, they started the interrater reliability task.
The students were presented with 20% of the total
thought units from each focus group. The thought units
were presented in random order, and the graduate stu-
dents worked independently to separately review and code
the units into one of the five primary themes. The students
used the operational definitions as a guide. For the AQ
conditions focus group, 92% agreement was achieved in
coding the thought units based on the primary themes and
94% agreement in coding units based on subthemes. For
the developmental disabilities focus group, 90% agreement
was achieved in coding the thought units based on the
primary themes and 90% agreement in coding units based
on the subthemes. Reliability for both focus groups was
Results are presented from the two focus groups with
the following primary themes identified from the data: bar-
riers, supports, benefits, communication, and recommenda-
tions. Data identified as uncodable were excluded from the
thematic analysis. Subthemes were identified to further
characterize the data across four out of the five primary
themes. See Table 2 for information about primary themes,
subthemes, and examples from both focus groups.
Intrinsic and extrinsic factors were identified as sub-
themes for the following three primary themes: barriers,
supports, and benefits. Using these consistent subthemes
provided structure to identify and recognize both the envir-
onmental influences and personal impacts that are asso-
ciated with some aspects of active recreation. Next, the pri-
mary theme of recommendations was further organized
into two subthemes focusing on people who use AAC and
their communication partners. The final theme, communi-
cation, focused exclusively on using multimodal communi-
cation methods across active recreational experiences.
Primary themes, subthemes, definitions, and selected
quotes will be presented in the next section from partici-
pants in both the DEV and AQ focus groups. For some

Table 2. Primary themes from both focus groups.

Examples discussed by adults who use AAC

Theme Subthemes Developmental Acquired

Barriers Intrinsic • Communication during the activity • Expressive communication

• Physical abilities and motivation • Giving up control during the activity
Extrinsic • Availability of programs and cost • Transportation
• Facilitator knowledge and skill • Planning and preparation for activities
Supports Intrinsic • Multimodal communication • Positive outlook and personal attitude
• Willing to try new activities • High tolerance for risk-taking
Extrinsic • Caregivers, volunteers, and instructors • Volunteers and instructors
• Adaptive equipment • Support from other participants
Benefits Intrinsic • Enjoyment and fun • Thrill of trying new activities
• Rush of adrenaline and excitement • Enjoyment and fun
• Health and wellness • Building confidence
Extrinsic • Educating the general public • Sharing personal interests with others
• Being part of a shared community • Social opportunities and meeting new
people
Communication Methods • Natural speech, gestures, whiteboards, • Facial expressions, gestures, paper-based
speech-generating device, letterboards methods, speech-generating device, writing,
• Yes/no questions, provide choices eye-gaze, photos
Recommendations People who • Try new activities and adaptive sports • Stretch boundaries and expand horizons,
use AAC • Learn about the sport first and how it can be do not be afraid to try something new
adapted for your needs • Take pictures and share your experiences
Partners • Be willing to learn multimodal methods • Communication training for instructors
• Establish gestures for communication • Ask yes/no questions during the activity

Note. AAC = augmentative and alternative communication.

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 of the primary themes, similarities and/or differences were
noted based on the collective perspectives from the adults
in both focus groups. See Table 3 for a summary of simi-
larities and differences between the two focus groups
across the five themes.
Primary Themes: Quotes and Examples
Barriers
When participants discussed the topic of barriers
across active recreation, they identified both extrinsic and
intrinsic factors that can impact their use of aided AAC
(e.g., speech-generating devices [SGDs], tablets) in pro-
gram settings. Other challenges included the availability of
adaptive recreation programs in some regions, issues
related to facilitator skills and knowledge, and maintain-
ing personal motivation to participate.
Most of the participants indicated that it was diffi-
cult to use aided AAC systems across active recreational
environments. Kevin (AQ) stated that: “I don’t use any
communication devices when participating in active
recreation, they are too difficult to use.” Furthermore,
Gary (DEV) shared that: “I don’t have my iPad mounted
on my soccer chair due to the active nature of the game.”
Ginny (DEV) reported that: “It takes me a very long time
to communicate and I am unable to type during recrea-
tional activities.” Some individuals were unable to partici-
pate due to a range of intrinsic and/or extrinsic factors.
For example, both Gary and Nick from the DEV focus
group expressed frustration related to their attempts to try
skydiving. Gary said, “I had a chance to go sky-diving,
Table 3. Similarities and differences between focus groups.
Primary theme Similarities (both groups)
Barriers • difficulty using aided AAC
• restricted participation in some
specific activities
Supports • encouragement from recreation
staff and other participants
• assistance from instructors and
volunteers
Benefits • enjoyment and fun
• social interaction and shared
community
Communication • use of multimodal communication
• use of low-tech/paper-based AAC
• collection of digital media
Recommendations • expand training for instructors and
volunteers
• encourage individuals who use
AAC to engage in active recreation
Note. AAC = augmentative and alternative communication.
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however, when I got there and suited up, they determined
they could not take me since I could not stand up straight,
I was very disappointed.” Nick shared a similar experi-
ence: “When I tried to go sky diving, the instructor was
too small of a person to jump with me.”
One difference that was noted between the two focus
groups related to maintaining control and independence
when participating in recreation. Adults with acquired
conditions shared that they needed to make adjustments
about their ability to participate in some activities and
learn to accept their current skills and abilities. Eliza, a
participant with ALS, stated that: “Giving up control is
difficult to do, the top ways my recreational experiences
have changed include; physically needing assistance to
participate, giving up control, finding ways to communi-
cate, and not being motivated all the time.” Also, Brian
(AQ) mentioned a challenge adjusting to participation in
adaptive skiing: “Before my stroke, I skied black dia-
monds, now, that is too difficult, I ski on the blue and
green trails instead.”
Supports
In discussing the concept of supports in active
recreation, participants noted both extrinsic and intrinsic
factors that were key to having a successful experience. In
the area of external factors, participants discussed the
importance of trained volunteers, encouragement from
other athletes in adaptive programs, and having access to
adaptive equipment. Jeff (DEV) shared that: “One of the
main things I need is a smile and encouraging words from
volunteers and professionals to be able to succeed.”
Differences
Acquired Developmental
• adjusting to changes in the type • some activities seem
and scope of active recreation repetitive
• giving up control and
independence
• more discussion about intrinsic • more discussion about
supports extrinsic supports
• more discussion about trying new • more involvement in team
activities sports like soccer or baseball
• greater focus on aligning activity
with current skills
• No significant differences noted
• No significant differences noted
 Furthermore, Jeff also stressed the importance of having
experienced volunteers and individual support:
I need to have one to one support to be successful.
It helps me to have someone verbally prompt me
through each step so I can move faster. I need help
with learning by having someone physically support
me through it. Good coaches understand me and
keep looking at me during the activity and watching
my reaction to see when I have gotten my body
organized enough to catch, hit, or dribble.
Participants from both focus groups discussed the
level of trust needed by recreational staff to engage in
high-risk sports like skiing or snowboarding. Eliza (AQ)
reflected on her early experience with volunteers from an
adaptive snow sports program:
The first day I went up the chair lift in a bi-ski, I
decided that if I didn’t want to sit home looking out
the window, I would have to trust these people with
my safety. It was the only option for me to
participate.
Finally, in the area of extrinsic factors, participants
noted the support from other athletes and caregivers who
engaged in active recreation. Participants appreciated their
own personal situations more while observing other ath-
letes in adaptive programs. Beth (AQ) shared that: “Per-
spective is important, I don’t have to look far before find-
ing someone whose struggles seem worse than my own.
Seeing other people try new things, encourages me to get
out there.”
When considering intrinsic factors to support suc-
cessful recreational participation, the participants dis-
cussed the importance of motivation, multimodal commu-
nication, and maintaining a positive attitude. Specifically,
participants from the AQ conditions focus group were
more likely to talk about risk-taking behaviors, being will-
ing to try new activities, and maintaining an overall posi-
tive outlook.
Beth (AQ) shared that: “I try to stay positive
through my life, if I have a bad day, I just try to look at
it as a bad day, but that’s not my entire life.” Also, Eliza
(AQ) stated the significance of expressive communication
to indicate basic wants and needs across the recreational
experience: “Be patient, give us (participants who use
AAC) a chance to get the message across, if the partici-
pant can’t talk ask them if they have a signal for yes and
then no (maybe an eye blink).” Finally, both Eliza and
Adam (AQ) shared a similar sentiment when discussing
the option to try new sports and having a lack of fear.
Adam, who is a motivational speaker and guest lecturer
for preprofessional health students in higher education as
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well as first responders, said that: “I refuse to let aphasia
get in my way, I understand what people are saying and I
can read well; I knew I had to overcome my fears or I
could not ask others to do the same.”
Some differences were noted between the two groups
in the area of supports. Overall, the adults with develop-
mental disabilities talked primarily about external sup-
ports and less about intrinsic factors. Also, adults from
the AQ conditions group shared more about psychosocial
factors such as motivation and maintaining a positive atti-
tude during the recreational experience.
Benefits
The next primary theme was related to benefits
resulting from active recreational participation. Partici-
pants from both focus groups discussed intrinsic and
extrinsic benefits. Examples of intrinsic benefits included
enjoyment, health and wellness, as well as impacting psy-
chosocial skills like building confidence. Derek (DEV)
indicated that: “The primary benefits I experience are
being fit, learning new skills, and having fun.” Brian (AQ)
shared that: “Skiing is exercise, skiing is great and it gives
me confidence.”
Examples of extrinsic benefits discussed by the parti-
cipants included being part of a shared community, shar-
ing personal interests with others, and social opportunities
involving new and familiar people. Jeff (DEV) stated that:
“Adaptive sports provide a social outlet for me and an
opportunity to make friends and interact with people with
and without disabilities.” Furthermore, Eliza (AQ) com-
mented that: “I have finally landed in a place where I fit
in again, the most important things for me about partici-
pating in adaptive recreation is meeting new people who
are living well despite their challenges.” Kevin (AQ) sum-
marized that: “Meeting new people has been a good thing
and I have met many people through these activities that
have expanded my social opportunities.”
Generally, the intrinsic and extrinsic type of benefits
shared by individuals in both focus groups was similar.
Participants expressed the value of their recreational com-
munities and the underlying enjoyment and positive feel-
ings they experienced through consistent engagement in
adaptive sports and outdoor leisure pursuits. Three partici-
pants in the AQ conditions focus group mentioned the
adventure and excitement of trying new activities. Due to
the nature of their acquired conditions, these individuals
reinvented recreational participation for themselves and
aligned their leisure opportunities with their current skills
and abilities.
Communication
This primary theme focused on communication
modalities and specific strategies that participants found
beneficial across recreational settings. For example, Ginny
383
 (DEV) shared that: “When I ride horses, people use a
whiteboard to check in with me. By using this system, I
can use the whiteboard throughout a riding session to
make meaningful choices and advocate when I don’t like
an activity.” Derek (DEV) agreed with Ginny about the
importance of multimodal communication, and also
mentioned educating partners: “I typically use white-
boards to make choices, and I think it is important for
instructors to understand that using AAC is just one way
that I communicate.”
Eliza (AQ) explained that having access to her SGD is
critical to respond to complex questions; however, she noted
several limitations using it in active recreational spaces:
My computer is not very helpful to communicate
during most recreation; due to weather, sunlight,
and the nature of the activity. I made a paper chart
with essential phrases on the front and letters on the
back that I can point to and keep it on my lap.
Participants from both groups discussed the impor-
tance of paper-based communication systems and how this
type of AAC seems most effective in recreational settings
due to the number of unfamiliar partners, time demands,
public environments with lots of background noise, and
the use of specific activity-based equipment (e.g., bi-ski,
tandem kayaks and bicycles) that may not support mount-
ing of SGDs. Jeff (DEV) explained that, “I typically use a
letterboard because it is faster than my iPad and time is
short during the activity, but I like talking to the volun-
teers and coaches before or after a game using my iPad.”
The concept of different phases of recreational activities
(e.g., before, during, or after) seemed to influence the type
of communication modality used.
Gary (DEV) shared more about this based on his
experience: “During practice, I communicate by using nat-
ural speech and gestures. For snow skiing, I do this as
well and partners ask me yes/no type questions. After ski-
ing, I use my iPad for communication.” The strategy of
using yes/no communication was also echoed by several
other participants in both focus groups. In addition to
Gary, both Eliza and Beth, from the AQ focus group,
agreed that partners should establish a quick yes/no com-
munication and be sure to check in at different phases
and transitions across the experience.
Finally, participants discussed the importance of
taking photos and videos with the intention to use digital
media for the purpose of sharing, communicating with
others, and maintaining social networks. Several partici-
pants commented about their personal use of social media,
which was described as an important tool to make con-
nections with other participants and program instructors.
Ginny, Nick, and Gary all from the DEV focus group
mentioned Facebook groups as a preferred method to
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share photos, engage with other participants, and provide
input and recommendations based on their adaptive sport
experiences. Gary shared about his experience using a
Facebook group specific to his power soccer team:
For my team, I set up a group on Facebook which
includes all the athletes so we can share ideas, strate-
gies, and I can provide input. Before practice, I usually
communicate with my teammates and after practice
I share what I think we need to work on. I also take
photos and post these for the group to share.
Overall, the participants discussed social media in a
positive manner as it allowed them more time to compose
messages, review, and share photos and videos.
It was evident from the rich contributions that parti-
cipants from both focus groups had a lot to share relative
to specific strategies and modes of communication. Based
on analysis of the focus group data, there were more simi-
larities that were discussed specifically in the use of multi-
modal communication methods. Some of the more com-
mon methods for communication used in active recreation
included paper-based or low-technology AAC, gestures,
facial expressions, vocalizations, and limited use of aided
AAC. Another similarity between the focus groups was in
the area of capturing and sharing photos and videos.
Seven out of the 10 participants indicated that they consis-
tently capture photos and videos from recreation, whereas
six of the participants also shared their photos on social
media.
Recommendations
Participants discussed recommendations for both
people who use AAC and their communication partners
(e.g., instructors, volunteers, caregivers). Most of the
recommendations directed toward people who use AAC
focused on being open to trying new activities, having
courage, and expanding your horizons. In addition, some
participants shared specific names of adaptive programs
or online resources to help individuals and families link
up with local and regional programs. See Supplemental
Material S5 for a list of programs recommended by the
participants as well as additional adaptive sport resources
compiled by the research team.
Adam (AQ) urged his focus group to: “Stretch your
boundaries and expand your horizons after becoming dis-
abled, I tell people that ‘anything is possible’ in my work
to educate others about aphasia and the impact of stroke.
Check out the ‘No Barriers Summit’.” Furthermore, Gary
(DEV) shared a similar piece of advice for novices in this
area: “Learn about the sport and how it can be adapted,
don’t be scared or hesitant to try something new, or a
sport that may appear unsafe, I encourage anyone with a
disability to participate in sports and recreation.”
 Participants recommended that communication part-
ners get additional training and focus on improving and
enhancing communication. Several comments were related
to training volunteers and instructors, with a focus on
improving communication skills. Derek (DEV) was look-
ing for more support in using his AAC system across the
activity: “Volunteers should learn my AAC method and
have it available to me, they should also ask questions, be
willing to communicate and try to converse normally.”
Kevin (AQ) stated that: “Trained volunteers are key, all of
the programs I participated in have been coordinated
through disability groups, community aphasia centers, or
rehabilitation hospitals.” Finally, Eliza (AQ) provided expli-
cit recommendations for instructors and program directors:
Programs could enhance the experience for people
with complex communications by educating their
volunteers about helpful strategies. For some exam-
ples: always assume the participant can understand
even though they can’t speak well, be patient- give
us a chance to get the message across, if the partici-
pant can’t talk ask them if they have a signal for
yes and then no (maybe an eye blink or something
else), if the participant is getting frustrated stop
what you are doing - be still and check if they are
trying to communicate with you.
typically requires greater physical demands, specialized
equipment, introduces greater risk, and may involve
greater opportunity for community integration. Table 4
includes the range of active recreation and leisure activ-
ities for the adult participants from this study.
Many of the activities in Table 4 are offered by
adaptive sport programs that have experienced volunteers
and have established an inventory of specialized equip-
ment and gear. Chun et al. (2008) determined that strong
connections between improved quality of life and partici-
pation in adaptive sport programs were found for indivi-
duals with physical and cognitive disabilities who engaged
in adaptive skiing. Active recreational participation may
have limited appeal for some people; however, the per-
spectives and experiences from the participants in this
study may serve to inspire, motivate, and encourage peo-
ple with disabilities to expand their horizons and seek out
other types of leisure opportunities. Upon reviewing the
list of activities of the participants, it is evident that
recreational professionals have made it possible for parti-
cipation across a wide range of active experiences.
Facilitating Active Recreational Participation
For people who use AAC, active recreational participa-
tion promotes opportunities for wellness, social interaction,

Table 4. Recreational activities of the participants.

Discussion
Activity No. of participants
Leisure and recreation are key areas that support
Cycling 5
the well-being, growth, and happiness of the general popu- Paddling (kayak or canoe) 4
lation in the United States and around the world. This is Water-skiing 4
also true for many people who use AAC who find recrea- Swimming 4
Hiking 3
tional activities to be a meaningful part of their lives Jogging 3
(Carruthers & Hood, 2007). The aim of this study was to Shooting 3
gather the lived experiences and perspectives of adults Yoga 2
Horseback riding 2
who use AAC and also engage in active recreation. The Rock climbing 2
participants in the focus groups served as strong advocates Surfing 2
for recreational participation in the lives of individuals Snowboarding 2
Sailing 2
who use AAC. Rowing 2
Skydiving 2
Active Recreational Opportunities Basketball 2
Power soccer 2
Fencing 1
The participants in this study shared their past Bocci 1
experiences engaging in active recreational pursuits, such Archery 1
Snowshoeing 1
as skiing, cycling, paddling, and even skydiving. Dattilo Softball 1
et al. (2008) conducted a focus group with people with Baseball 1
cerebral palsy who use AAC and found that although Gymnastics 1
Golf 1
recreational and leisure pursuits were beneficial, most of Parasailing 1
the recreational activities were considered passive in nat- Hang gliding 1
ure (e.g., table games, watching movies, reading). This Bungee jumping 1
Ziplining 1
study extended beyond passive recreational pursuits to Pickleball 1
better understand the nature of active recreation, which

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 and communication with both familiar and unfamiliar
partners across a range of settings (e.g., ski areas, boat
launches, gyms). In some instances, there are barriers that
may limit participation (e.g., availability of programs,
transportation, cost); however, most of the physical bar-
riers have been reduced with the advent of accessible
equipment provided by trained volunteers and instructors.
Active recreation programs offer an important outlet for
those individuals with significant disabilities who would
like to consistently engage and participate in individual or
team sports.
The ICF/WHO framework focuses on the influence
of environmental and personal factors and how these may
lead to limitations in participation and communication for
some people who use AAC (Raghavendra et al., 2007).
Participants in both focus groups noted that intrinsic and
extrinsic factors may impact successful engagement in
active recreation.
In the focus groups, the participants discussed sev-
eral of these factors by providing examples. First, several
participants reported that SGDs were not typically used
during recreation due to the active nature of many sports,
combined with the need for other types of equipment and
gear. Next, participants stated that their tablets and SGDs
were not durable enough to tolerate some of the common
natural elements (e.g., cold temperatures, terrain, natural
elements like snow and rain) that exist in active recreational
environments, so instead, multimodal communication meth-
ods (e.g., use of gestures, vocalizations, writing, communi-
cation boards) were used.
Impact of Recreational Participation
Qualitative research plays an important role in the
introduction of new ideas based on the collective views of
a specific targeted population of individuals. The perspec-
tives shared during this study are important for SLPs and
other communication partners to understand as they sup-
port recreational participation for people who use AAC.
People Who Use AAC and Communication
Partners
Based on the perspectives and experiences shared in
the focus groups, it is evident that recreational participa-
tion has significant value for people who use AAC in
building social relationships and enhancing quality of life.
Since adaptive sport programs have an inclusive infra-
structure, these settings provide motivating opportunities
for individuals to meet others with similar interests, try
new sports and activities, and participate with family and
friends. Several intrinsic and extrinsic benefits were noted
by the participants as their active recreational pursuits
seemed to define these individuals in a manner that is
similar to one’s career and lifelong vocational pursuits.
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In addition to the benefits reported for people who
use AAC, participants from both focus groups consistently
mentioned the critical role of communication partners.
Since aided methods (e.g., tablet, SGD) were not com-
monly used in active recreational settings, participants
recommended additional training for instructors and
volunteers to learn about different types of multimodal
communication methods. Hajjar et al. (2016) reported on
the experiences of volunteer instructors from active recrea-
tional programs and the need for more focused partner
training. As a result of additional training, recreational
stakeholders will have the tools and strategies to be more
effective communication partners.
SLPs
SLPs can support recreational participation for peo-
ple who use AAC by (a) educating and empowering indi-
viduals and families to engage in active recreational pur-
suits, (b) enhancing participation and communication by
training recreational stakeholders, and (c) developing an
infrastructure for people who use AAC to communicate
about their recreational experiences with a focus on using
digital media to facilitate sharing.
Educate and empower families and caregivers. Families
and caregivers play a fundamental role in supporting indivi-
duals with disabilities and influencing their involvement in
recreation. Since the number of certified recreational pro-
fessionals is limited, SLPs should support recreational par-
ticipation for their clients, by educating families about
established adaptive programs and the potential social and
wellness benefits. Participation in recreational programs will
lead to greater opportunities for the development and main-
tenance of friendships and increased community engagement.
See Supplemental Material S5 for a resource that includes
a range of adaptive programs across the United States.
Training stakeholders in recreation. SLPs could also
support people who use AAC by implementing communi-
cation partner training. Partner training could be con-
ducted in collaboration with adaptive sport programs and
focus on providing an overview of general strategies to
support a range of participants who use AAC. Some
training would be more directed and focus on providing
individual support and strategies to instructors who con-
sistently teach participants on a seasonal basis. Hajjar
et al. (2020) had success with the implementation of an
online asynchronous training that targeted volunteers in a
kayaking program that supported people who use AAC to
take photos and videos. Partner training could also have a
broader focus on communication, teaching strategies such
as wait time, modeling, and use of open-ended versus yes/
no questions. As a result of additional training, partners
in recreation will have increased knowledge and skills to
support all participants in the areas of social interaction
and expressive and receptive language.
 Using digital media to share recreational experiences.
Finally, SLPs can support people who use AAC to share
their recreational experiences using digital media and
other types of software and technology. SLPs could assist
individuals to gather and organize photos and/or videos
captured from recreational experiences to support online
or face-to-face sharing. Photos and videos could also be
used in visual scene displays (VSDs), which are a type of
AAC intervention that supports language development in
children and general expressive language skills with
adults. For example, adults with chronic aphasia who use
AAC may use VSDs to provide contextual structure when
telling a story or recalling past events. Also, beginning
communicators who use AAC may use VSDs to increase
their frequency of communicative turns (Beukelman &
Light, 2020).
Recreational Stakeholders
Recreational stakeholders such as instructors, volun-
teers, and program directors have a significant impact on
the overall quality of the leisure experience for people
who use AAC. These individuals have worked to make
active recreation more accessible by reducing physical bar-
riers across a range of activities and sports. As discussed
by the participants in the focus groups, there is still more
work to be done to improve access and the availability of
programs. Not all individuals who use AAC have consis-
tent opportunities to participate due to a lack of adaptive
programs as well as a limited number of recreational pro-
fessionals in some regions of the United States. Further-
more, it is evident that additional training could be bene-
ficial for program instructors and staff to recognize mul-
timodal communication and ensure full participation
across the experience.
Limitations and Future Directions
The findings of this study contribute to the knowl-
edge base about the important role of active recreation in
the lives of individuals who use AAC. Despite the rich
contributions from the participants providing information
about the benefits of active recreation, there are some lim-
itations in the study to consider. Although a smaller num-
ber of participants (n = 10) is common for focus group
research (Ryan et al., 2013), the thoughts and opinions of
this small group may not reflect the perspectives and
experiences of other individuals who use AAC. In addi-
tion, some of the inclusionary criteria for participation in
the focus groups may limit the generalizability of the find-
ings to a specific subset of individuals who use AAC. For
example, the participants in the focus groups were
required to have basic literacy skills to generate responses,
read other responses, and contribute to the reciprocal par-
ticipatory interaction that existed for each discussion
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topic. It is possible that those individuals who use AAC
and are not literate or able to independently compose
messages may contribute different perspectives. Although
this study included perspectives from individuals with both
developmental and acquired disabilities, not all disability
categories were represented. Also, a small number of par-
ticipants represented various disability categories (e.g., one
person with ALS, two individuals with ASD), and these
specific viewpoints may not accurately represent the ideas
and opinions of people with these types of conditions or
disabilities. Finally, participants in the focus groups repre-
sented only specific subsets of geographic locations around
the United States. Even though participants were from a
range of locations (e.g., West Coast, Midwest, New York
City, and New England), it is likely that participants from
other regions of the United States and/or international
regions would provide different types of experiences based
on the culture and availability of recreation programs.
The findings from this study provide a direction for
future research to support individuals who use AAC as
well as their families and caregivers. To capture the per-
spectives of nonliterate individuals who use AAC, it would
be beneficial to engage with families and caregivers to
gather their perspectives about both active and passive
recreational pursuits. In addition, although some research
has focused on training volunteers in recreation (Hajjar
et al., 2020), additional research would be beneficial about
broad communication partner training directed toward
recreational stakeholders. Specific training interventions
could be developed with a focus on creating communica-
tion opportunities, using multimodal methods, and intro-
ducing other evidence-based strategies for AAC partners.
Finally, it would be beneficial for individuals in the AAC
and recreation communities to collaborate in participatory
action research using collective case study methodology.
With a specific focus on the intrinsic and extrinsic factors
that impact individual participation, more targeted solu-
tions could be considered for a broader impact.
Conclusions
Recreation and leisure activities promote general
well-being and provide opportunities for self-determination
and the development and maintenance of social networks
for people who use AAC. In this study, adults with devel-
opmental disabilities and acquired medical conditions
shared their lived experiences and perspectives about enga-
ging in active recreational pursuits. Even though partici-
pants stated benefits of active recreational participation,
they also noted some current challenges in the areas of
communication, technology, and access to local and/or
regional adaptive sport programs. Despite the small num-
ber of participants in the study, their collective perspectives
387
 will add to and expand the current knowledge base in the
areas of recreation and AAC. Recommendations support
more training for partners in recreation with specific focus
on facilitating multimodal communication across the
experience. As a result of this study, SLPs, related profes-
sionals, and recreational stakeholders will have a better
understanding of the importance of promoting recreation
and leisure as a critical need in the lives of people who
use AAC.
Acknowledgments
The authors report no external funding sources to
support this research. The authors would like to thank the
10 participants in this study and the families, caregivers,
and therapists who supported these individuals in sharing
their ideas and perspectives. Also, the authors would like
to thank the graduate students at Ohio University, Alyson
Spitzley, Shelby Roberts, and Jessica Jarvis (Apsley), as
well as undergraduate and graduate students at Ithaca Col-
lege, Julia Cohen, Isabelle Michaud, and Hanna Fuchs.
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