int. j. lang. comm. dis., 2001, vol. 36, no.

1, 107–115

Notes and Discussion

Views of young people using augmentative
and alternative communication systems

Mike Clarke†*, Helen McConachie‡, Katie Price§ and

Pam Wood†
†Institute of Child Health, The Wolfson Centre, Mecklenburgh Square,
London, UK
‡Child and Adolescent Mental Health, The Fleming NuYeld Unit, Newcastle
upon Tyne, UK
§ Neurodisability Service, Great Ormond Street Hospital for Children
NHS Trust, London, UK
(Received November 1999; accepted May 2000)

Abstract
Children with physical impairments who cannot use intelligible speech are often
recommended augmentative and alternative communication (AAC) systems. In
England and Wales, it is usually the job of speech and language therapists to
support development in AAC skills. This paper reports Ž ndings from discussion
with children and young people who use AAC systems concerning their attitudes
and opinions towards the organization of speech and language therapy, the role
of the speech and language therapist in school and issues concerned with AAC
systems themselves. Six young adults and 17 children from London education
authorities were interviewed on a one-to-one basis and in focus groups. Children
were interviewed who had a communication aid incorporating at least 20
symbols and/or pictures and/or written words, language understanding at the
two-word level and above, i.e. they demonstrated understanding of adult requests
with at least two information carrying words. For children using communication
aids, it is conceivable that their communication systems do not contain appro-
priate symbol vocabulary to express complex ideas, opinions and feelings.
Consequently, a symbol-based interview tool was designed to allow children to
express complex issues through visual means. Most children interviewed
reported that their AAC system was useful to them. Further analysis of opinions
revealed that negative attitudes towards AAC systems were primarily associated
with operational issues (technical skills required to operate an AAC system)
and issues of self-image/identity, and to some degree, with a lack of perceived
beneŽ t in interaction. In apparent contrast to therapists’ preferred models of
working, children and young people identiŽ ed a preference for therapy organized

*Address correspondence to: Mike Clarke, Institute of Child Health, The Wolfson Centre,
Mecklenburgh Square, London WC1N 2AP, UK.

International Journal of Language & Communication Disorders

ISSN 1368-282 2 print/ISSN 1460-698 4 online © 2001 Royal College of Speech & Language Therapists
http://www.tandf.co.uk/journals
108 M. Clarke et al.

on a one-to-one basis targeting linguistic and operational skills. It is suggested

that more acceptable and individualized design of AAC systems could have
implications for their use in school and other contexts. The value of service
users’ views in service planning and evaluation are discussed.

Keywords: attitudes, augmentative and alternative communication (AAC),

children, speech and language therapy.

Introduction
Children who experience persistent diYculties producing intelligible speech are
often recommended augmentative and alternative communication (AAC) systems
such as speech synthesizers, symbol/picture charts and books of symbols/pictures.
AAC systems are expected to eVectively support children’s ‘natural’ communication
modes such as gesture and facial expression. Children aim to maximize their
communicative potential by combining modes of communication, and partners in
interaction learn to recognize and respond to these strategies. In school, the
development of skills in AAC system use requires considerable training and support
for children, staV and AAC users’ peers. In England and Wales, speech and language
therapists have traditionally taken a central role in this support and training.

AAC systems
The potential of AAC systems is often not recognized: communication aids are
under-utilized, and many barriers exist to children’s self-expression (e.g. JolleV et al.
1992). When interviewed, parents have identiŽ ed such factors as teacher strategies
and lack of speech and language therapy as barriers to communication aid use (Ko
et al. 1998). In turn, teachers and speech and language therapists have identiŽ ed
some child characteristics, including motivation, as in uential in success and failure
in aid use (e.g. McConachie et al. 1999). The concept of motivation is a construct
of extrinsic variables (e.g. an environment that motivates communication) and
intrinsic sources, that is factors associated directly with the individual (e.g. child’s
concern about appearing diVerent from the peer group). It seems that intrinsic
factors aVecting young people’s motivation are less well documented than extrinsic
variables (e.g. Goossens’ et al. 1981). Insights from adult AAC system users are
available (e.g. Huer and Lloyd 1990); however, opinions and personal experiences
of children and young people are rarely documented beyond personal accounts (e.g.
Ellis 1997). What do young AAC system users think about AAC systems?

Speech and language therapy provision

The validity of children’s views as service users has been recognized (e.g. UN 1989).
In Health Service provision, it is suggested that the choice of service delivery model
should incorporate the opinions of the clients they serve (DoH 1998). This approach
is relevant for children as they are viewed as (Ward 1997: 3) ‘individuals separate
from, as well as part of, their families’. For speech and language therapists working
in schools in England and Wales, a requirement to obtain children’s views is
embedded within the principles of the Code of Practice (DfEE 1994).
In the main, models of service provision to children using AAC systems have
Young people and augmentative and alternative communication systems 109

been in uenced by preferences for intervention based on participation in natural

interactive environments rather than didactic teaching (e.g. Roulstone 1983, Reid
et al. 1996). Light (1989) has categorized core skills required for the development
of communicative competence in AAC system use; linguistic skills—syntactic and
referential aspects of communication including learning the meanings of pictures
and symbols; operational skills—technical skills required to operate the communica-
tion system, for example learning the layout of symbols and aid accessing techniques;
social skills— skills in social rules of communication; strategic skills—compensatory
skills to maintain eVective communication beyond system limitations. School-based
therapy conducted in functional settings (i.e. the classroom) is commonly delivered
by therapists replicating natural contexts in group working, favouring social skills
development over improvement in linguistic skills (McConachie et al. 1999).
The perspectives of adults using AAC systems and parents/carers have been
documented to measure satisfaction with the process of service delivery (Bryen
et al. 1995). There is, however, little evidence that decisions regarding service
provision for children using AAC systems are made in response to children’s
preferences. What are the opinions of children and young people using communica-
tion aids concerning the speech and language therapy they receive?
This paper reports the Ž ndings from discussion with children and young people
using communication aids concerning their attitudes and opinions towards the
organization of speech and language therapy, the role of the speech and language
therapist in school and issues directly concerned with the AAC systems they use.

Methodology
Subjects
Children were identiŽ ed through a whole population survey of children using
communication aids in six London education authorities. Children were identiŽ ed
who had (1) a communication aid incorporating at least 20 symbols and/or pictures
and/or written words, (2) language understanding at or above the two word level,
i.e. they demonstrated understanding of adult requests with at least two information
carrying words. Children’s understanding of spoken grammar was assessed using
the Test for Reception of Grammar (Bishop 1983) or the Derbyshire Language
Scheme (Knowles and Masidlover 1982). Children were excluded if they had a
degenerative condition, or a communication disorder that was primarily social in
character, such as autism (Clarke et al. 2000). Young adult AAC users were identiŽ ed
through attendance at the Communication Matters National Symposium 1998—
UK Chapter of the International Society for Augmentative and Alternative
Communication.

Measures
Focus group interviews
Focus groups are unstructured interviews carried out with small groups of particip-
ants. Members of the group explore issues through shared discussion with each
other and the group facilitator (Morgan 1993). Focus groups were used at two
points in the research. First, the young adults were interviewed to inform and
structure further group and one-to-one interviews. This meeting was convened at
110 M. Clarke et al.

Table 1. Subject characteristics

Children Young adults

Education/employment
Mainstream school 2 —
Special school 15 —
College — 5
Self employed — 1
Principal AAC System
VOCA 12 6
chart/book 5 —
Additional learning needs*
None 6 —
MLD 7 —
SLD 4 —
Median age 12 years —

*Based on local therapists’ detailed clinical knowledge of individual children’s learning strengths and
needs, documented through the annual review of statement of special educational need in collaboration
with school staV and relevant professionals.

Communication Matters ( UK Branch of the International Society for Augmentative

and Alternative Communication) National Symposium, Lancaster. Second, some of
the children who took part in the one-to-one interviews were later involved in
focus groups.

One-to-one interviews
A procedure for interviewing non-verbal adults (Murphy 1998) was adopted as a
basis from which an interview tool for young communication aid users was
developed. Children were asked to place symbols, representing elements pertinent
to their life experience, (including communication aids and the speech and language
therapist), on three dimensions presented visually: cool/uncool, fun/boring, useful/
useless. The locations of symbols on the three construct dimensions were coded as
positive, neutral or negative and explored further. For example, a symbol repres-
enting the child’s communication aid was placed at the centre of a board. Symbols
representing positive or negative issues associated with communication aids were
then introduced. These were accepted as opinions shared by the interviewee or
rejected. Strongly felt issues were placed close to the symbol representing commun-
ication aid. Relevant issues, but perhaps less so, were placed further away. In this
way a visual representation of the child’s experiences and opinions was created.
The procedure was repeated for issues concerning speech and language therapy.
Where possible, the interviews were expanded into unstructured discussion.

Procedures
Assent was gained from the children through shared discussion with their speech
and language therapist, class teacher and/or learning support assistant (LSA) using
symbol-based information sheets and consent forms to describe each aspect of the
child’s involvement.
Young people and augmentative and alternative communication systems 111

One-to-one and focus group interviews with children were based on the follow-
ing principles: (1) conŽ dentiality is established between the interviewer and the
child, (2) the child is informed that the interviewer will keep some notes, (3) it is
emphasized that there are no right or wrong answers and (4) the interviewer
demonstrates to the child how they can stop the interview at any time (Beresford
1997).

Analysis
The interviews were transcribed and their content analysed by three members of
the research team. Data were related to the categories of communicative competence
documented by Light (1989): linguistic competence; operational competence, social
competence and strategic competence, and to an apparent preference for therapy
conducted in classroom settings. Additional categories were developed during the
process of data collection and analysis. Key themes and concepts were conŽ rmed
through shared discussion between researchers, and frequency counts of the number
of issues by type (Bowling 1997).

Results
AAC systems
Most children in one-to-one interviews emphasized that they considered AAC
systems to be uncool and boring. However, eleven of 17 children indicated that their
AAC system was useful to them. Further analysis of these opinions revealed that
negative attitudes towards AAC systems were primarily associated with operational
issues and issues of self image/identity and to some degree with a lack of perceived
beneŽ t in interaction; for example:
E Operational diYculties—‘too diYcult’, ‘too heavy’, ‘don’t know where the
words are’, ‘[it] breaks’.
E Issues of self-image/identity—‘I’m the only one [using AAC]’, ‘[it] looks
stupid’, ‘[it is] embarrassing’, ‘[using a symbol book means someone else
speaks the words, it is] not my voice’.
E Lack of perceived beneŽ t in interaction; ‘[AAC] doesn’t get me what I want ’,
‘[AAC is] slow’.

Positive attitudes towards AAC systems also focused on their value within inter-
action, and factors of self-image/identity:
E Perceived beneŽ t in interaction—‘lets me say anything’, ‘helps me make
friends’ ‘makes people listen’, ‘[it] tells jokes’.
E Issues of self-image/identity—‘[it is] my voice’.

Additionally, children highlighted the issue of personal ‘ownership’ of the system

as potentially improving the perceived value of AAC equipment; for example, ‘I
want my own design’ ‘[I want to] design the format so I understand it, I’m not
overloaded’.
112 M. Clarke et al.

Speech and language therapy provision—the role of the therapist

Children expressed positive opinions concerning the role of speech and language
therapists and participation in therapy. Positive opinions centred on the
characteristics of interaction between children and therapists:
‘[She] listens to me.’
‘[She] knows how I communicate.’
‘[She] helps me feel special.’
‘[She has] time to talk.’
‘[I can] talk more.’
‘[It is] personal.’
‘[I can] say what I feel.’
Negative attitudes toward therapists tended to focus on the content of activities
and organizational factors:
‘[I have] no new ideas.’
‘[The therapist is] too busy.’
‘[There is] no time to speak.’
‘Therapists not having time to give.’

Speech and language therapy provision—organization of therapy

Communication aid users delivered a strong message about the preferred location
of therapy in school. Almost without exception, children and young adults favoured
direct one-to-one therapy in a context outside the classroom.
‘This idea about not taking children out of the room is a get out.’
‘[In a one-to-one I can] talk more’, ‘[I can] say what I feel.’
‘I think groups are boring because everyone works diVerent[ly].’
Additionally, the preferred focus of therapy re ected operational and linguistic
targets rather than social and strategic.
‘Learning where the words are stored.’
‘Making sentences.’
‘Teaching strategies for using the machine.’
‘[Learning] how to build up sentences for chat.’

Discussion
This paper aimed to explore the perceptions of young people and children who use
communication aids about speech and language therapy provision and their AAC
systems. Young people and children using AAC systems have delivered a forthright
message concerning the systems and services they use.
Some evidence suggests that when interviewing people with learning diYculty
professionals may distort or misinterpret behaviours and opinions (e.g. Antaki and
Rapley 1996). Issues discussed in one-to-one interviews validate children’s own
experiences by drawing on the issues raised by young adults using AAC systems.
The one-to-one interview procedure attempted, therefore, to structure but not
constrain interviewees. Some of the focus group interviews beneŽ ted from working
with children in same school groups. Pre-existing groups were more likely to
Young people and augmentative and alternative communication systems 113

comment on actual shared experiences and may challenge each other’s perceptions
( Kitzinger 1994). Additionally, pre-existing groups are more likely to be sensitive
to children’s individual styles of communication, ensuring the views of all members
are heard.
Many interviewees experienced diYculties with operational aspects of aid use
and perceived communication aids to be of limited value in interaction. Perhaps
unsurprisingly, for many children AAC systems were associated with negative impact
on self-image. It would seem that for the general population assistive technology
(such as mobile phones, electronic organizers) is viewed positively, but for the
children and young people interviewed, generally this is not the case. Some distrib-
utors and producers of augmentative and alternative communication equipment
have begun to value the importance of contemporary design as well as functional
quality (B. Perks, personal communication, 1999). In developing symbol
charts/books for use in school and at home adults are likely to beneŽ t from sharing
design and layout decisions with the system user. Communication aids developed
collaboratively are likely to look ‘good’ in the eyes of the user and be intuitive in
use. It may be hypothesized that more acceptable and individualized design could
have implications for aid use in school and other contexts.
AAC users have highlighted improvement in linguistic and operational compet-
ence as priorities for therapy. They suggest that this is best achieved through direct
one-to-one therapy. Such views are in apparent opposition to current understanding
of ‘good practice’, with therapy based in functional settings. It would seem that
speech and language therapists might beneŽ t from consulting service users in
developing principles of ‘good practice’. In addition, AAC users have described
one-to-one sessions with speech and language therapists as opportunities to take a
more equal role in conversation, often talking about personal issues and feelings.
In valuing one-to-one therapy, AAC users appear to re ect positively on therapists’
skills in shaping and supporting the characteristics of interaction. Although this
time in therapy seems to be a valued source of support for AAC users it may prove
diYcult to demonstrate its eVectiveness and cost-eVectiveness for commissioners
of services. Whilst in certain circumstances the role of counsellor is a recognized
part of clinicians’ work (RCSLT 1996), it is likely that documenting positive
outcome of this aspect of therapy will require skills in measuring children’s changing
opinions and feelings about communication using AAC systems.
Identifying the views of young people with communication diYculties forms
an essential element of the process of outcome measurement in a more general
sense. In recent years, clinicians in the Ž eld of AAC have begun to pay close
attention to the eYcacy of intervention (e.g. Grandlund and Blackstone 1999).
However, detailing evidence for positive outcomes of AAC intervention represents
a signiŽ cant challenge to professionals in the Ž eld. In addition to measures of
progress such as increased aid use and expanding the range of communicative
functions typically used by children (McConachie et al. 1999), intervention for
children using AAC systems in school will include supporting peer relationships
and shared participation in learning and play. However, therapists lack appropriate
models of language acquisition (von Tetchner et al. 1996) and social inclusion for
children using AAC systems. Identifying relevant and meaningful goals and their
evaluation is likely to place strong emphasis on users’ opinions as children are
recognized as ‘stakeholders’ in goal setting and outcome measurement.
Clearly, children and young people using AAC systems have important and
114 M. Clarke et al.

potentially in uential opinions concerning themselves and the services they use. It
is clear that appraisal through seeking the opinions of children and young people
using AAC systems can potentially beneŽ t service planners, manufacturers of AAC
equipment and support understanding of the diverse roles of speech and language
therapists.

Acknowledgements
The authors acknowledge the contribution of Dr Nicola Grove and Maxwell Wide
in the development of the interview procedure, and Gill Craig for advice in analysis.
The authors thank the steering group, schools, therapists and in particular the
children and young people who participated in the study. This work was undertaken
by Great Ormond Street Hospital for the Children NHS Trust, which received a
proportion of its funding from the NHS Executive; the views expressed here are
those of the authors and not necessarily those of the NHS Executive. Data are
derived from a research project funded by the NHS Executive National R&D
Programme for People with Physical and Complex Disabilities entitled ‘Evaluation
of Speech and Language Therapy for Children using Communication Aids’, by
McConachie, Clarke, Wood, Price and Grove.

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