Augmentative and Alternative Communication

ISSN: 0743-4618 (Print) 1477-3848 (Online) Journal homepage: http://www.tandfonline.com/loi/iaac20

Early cognitive skills as prerequisites to

augmentative and alternative communication use:
What are we waiting for?

Kathleen Kangas & Lyle Lloyd

To cite this article: Kathleen Kangas & Lyle Lloyd (1988) Early cognitive skills as prerequisites
to augmentative and alternative communication use: What are we waiting for?, Augmentative
and Alternative Communication, 4:4, 211-221

To link to this article: http://dx.doi.org/10.1080/07434618812331274817

Published online: 12 Jul 2009.

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AAC Augmentative and Alternative Communication
Copyright © 1988 by Williams & Wilkins

Early Cognitive Skills As Prerequisites to

Augmentative and Alternative Communication Use:
What Are We Waiting For?
Kathleen A. Kangas and Lyle L. Lloyd
Department of Audiology and Speech Sciences (K.A.K., L.L.L.) and Special Education (L.L.L.), Purdue University, West Lafayette, Indiana 47907, USA

The observation of correlations between cognitive abilities and language and communication
abilities in normally developing children has led to the assumption that there are specific cognitive
prerequisites to the development of symbolic communication. For many individuals with severe
disabilities, this focus has led to a clinical decision to teach these prerequisite skills or to wait for
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them to emerge before providing communication programs either for teaching speech or for
introducing augmentative and alternative communication (AAC) techniques. In this paper, literature
regarding cognitive prerequisites to communication development for nondisabled children and for
individuals with disabilities is reviewed. Issues related to providing communication teaching
programs are discussed, and specific intervention strategies are presented.
KEY WORDS: cognitive prerequisites, intervention, mental retardation

Cognitive prerequisites have been assumed to exist
for the development of symbolic communication Al-
though there are no convincing data to support a strict
cognitive prerequisites hypothesis, reliance on this as-
sumption has shaped the development of language and
communication intervention for individuals with severe
disabilities over the course of the last two decades.
Decisions to provide the services of a speech/language
pathologist and to attempt augmentative and alterna-
tive communication (AAC) approaches have been
based on these assumptions about cognitive prerequi-
sites. The purpose of this paper is to examine some of
the assumptions that have been made regarding cog-
nitive prerequisites to language use and the logic of the
decisions which have followed from those assumptions.
It will be argued that descriptive data regarding child
development have been overextended to a prescriptive
sequence of precommunication and communication in-
tervention for individuals with disabilities. Furthermore,
a model of child development may not be a sufficient
framework for selecting goals of intervention for chil-
dren and adults who experience severely disabling
conditions and who are functioning at early levels with
respect to developmental norms.
Cognitive Hypotheses
The relationship between cognition and language has
been the subject of much research and debate. Rice
(1983) and Rice and Kemper (1984) have reviewed
several explanations of the links between cognition
and language acquisition. They described six different
models which seek to explain this relationship and
reviewed the literature in support of each. One model
211
is the local homologies hypothesis which states that
there is a simultaneous emergence of parallel cognition
and language skills, but that the two do not depend on
each other for development. The interaction hypothesis
is that the influence between the two domains is mutual
and bidirectional with cognition supporting language
and language supporting cognition. The cognition-an-
chored-in-language hypothesis states that cognitive
concepts are unstable until they can be anchored with
linguistic forms and, therefore, language supports cog-
nition. The strong cognitive hypothesis proposes that
cognition causes language to develop. That is, cogni-
tion is necessary before linguistic development, and
that linguistic development will follow from the cognitive
development. The weak cognitive hypothesis states
that cognition is necessary but is not sufficient for
language acquisition. In other words, language cannot
progress without the necessary cognitive base; how-
ever, achieving the appropriate cognitive levels does
not necessarily mean that the expected language skills
will emerge. Rice and Kemper (1984) concluded that
the relationship between cognition and language is very
complex, and no single model is adequate to charac-
terize it. They suggest that language development is
analogous to the growth of a plant, in that it is an
organic process with each element of the process
dependent on the others, but also supporting and nour-
ishing the others.
Weak Cognitive Hypothesis
Of greatest interest here is the weak cognitive hy-
pothesis, because this is the model which appears to
have had the greatest influence on programs and serv-
 212 Kangas and Lloyd
ices for individuals with severe disabilities. Many au-
thors have concluded that the use of symbolic com-
munication is directly dependent upon attainment of
certain cognitive skills. Cromer (1974, 1976) has delin-
eated the weak cognitive hypothesis. While he accepts
the “importance of. . . cognitive processes in determin-
ing various aspects of language acquisition” (Cromer,
1976, p. 291) he also states that this explanation is
not sufficient to explain language acquisition. He con-
tends that “there may be some purely ‘linguistic’ proc-
esses which are also necessary in order to account for
the encoding of thought into language” (Cromer, 1976,
p. 291). A similar position is described by Slobin (1973)
who stated that a child “. . . must have both cognitive
and linguistic discovery procedures available . . .” (p.
186) in order to acquire language. In other words, while
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cognitive development is necessary for language ac-
quisition, cognition alone is not sufficient for language
to develop.
Bates, Benigni, Bretherton, Camaioni, and Volterra
(1977) also discussed cognitive prerequisites to the
development of language. They concluded that Piaget’s
sensorimotor stage 5 level of development was nec-
essary for the use of gestural performatives or “pre-
verbal, intentional communication” (p. 251), and that
sensorimotor stage 6 development was necessary for
the use of words.
An examination of research to support this view that
language development depends on the attainment of
specific cognitive skills reveals little empirical support.
The conclusions are based mostly on data showing a
correlation between cognitive development and the
emergence of speech and not on experimental findings
which could demonstrate a cause and effect relation-
ship. An early longitudinal study by Bates, Camaioni,
and Volterra (1975) was conducted to describe cogni-
tive and communication skill development from birth to
18 months. The data from this study form the basis for
their view of cognition supporting language (Bates,
1976, 1979; Bates et al., 1977). However, this study
was based on only three children, and their ages and
developmental levels at the beginning of the study were
different to the degree that their developmental levels
overlapped during the course of the investigation. The
findings do not reflect three children passing through
the entire span of development studied, and reports of
specific skills at specific points in development are
based on observations of only child who was at that
point of development. It is therefore difficult to gener-
alize the observations of sequences of skill develop-
ment beyond the children studied. A later study by
Bates and her colleagues (Bates, 1979; Bates et al.,
1977) involved 25 children with data recorded cross-
sectionally in four monthly visits. Thus the data were
less sensitive to sequential or concurrent skill devel-
opment. Even if the sequences of cognitive skills and
language development were shown to be invariant,
there would still be no convincing evidence of a causal
relationship, because as the authors acknowledge,
these data are correlational.
Other investigators have presented correlational data
to support the cognitive hypothesis of language devel-
opment. Corrigan (1978) and Smolak (1982) reported
a correlation between sensorimotor stage development
and the emergence of speech in young children. Smolak
(1982) also considered receptive language skills, and
she reported only a weak relationship to cognitive
development. Lowe (1975) and McCune-Nicolich and
Bruskin (1982) found a relationship between the level
of representational play (e.g., feeding self, feeding a
doll) and spoken language development for nondisabled
children. Kahn (1975) reported correlations between
four scales of sensorimotor development (i.e., object
permanence, means-ends, causality, and imitation) and
the presence of single word expressive speech for
children with profound retardation. Lobato, Barrera,
and Feldman (1981) described a similar relationship
between five scales of sensorimotor development (i.e.,
object permanence, means-ends, causality, vocal imi-
tation, and gestural imitation) and gestural communi-
cation for children and adolescents with severe and
profound retardation. Clink, Ryan, Sommers, and
Schrum (1986) found that children’s performance on
sensorimotor scales of mean-ends and relating to ob-
jects was moderately correlated with their progress in
language therapy as measured by a battery of speech
and language tests. While these studies consistently
demonstrate some correlation between cognitive and
language measures, these correlations do not establish
any causal link between the cognitive level and the
language abilities. In fact, a careful review of these data
seems to suggest that there are individuals who show
some use of referential language without showing the
cognitive level expected, as well as some individuals
who show the cognitive level of interest without show-
ing the emergence of referential speech.
Steckol and Leonard (1981) used an experimental
paradigm to investigate the relationship between sen-
sorimotor cognitive development and expressive com-
munication development. They taught means-ends
tasks and schemes for relating to objects (two scales
of sensorimotor behavior thought to be related to lan-
guage) to normally developing children who had not yet
begun to use words nor to use per-formative behaviors
(e.g., the nonverbal behavior of pointing to request an
object). The children who were taught schemes for
relating to objects demonstrated the greatest increase
in pet-formative behaviors when compared to children
who were taught means-ends tasks or to those who
were not taught either set of tasks. Steckol and Leon-
ard (1981) concluded that these data supported a hom-
ologue model of the relationship between sensorimotor
development and communication development. That is,
the data suggested that the two areas were developing
simultaneously, and that while teaching in the cognitive
task did assist communication development, it was not
a prerequisite relationship. This conclusion was based
on the observation that the sequence of acquired be-
haviors was not invariant. That is, some children ad-
vanced in per-formative behaviors and then advanced
 Cognitive Prerequisites
on the schemes for relating to objects tasks, while a
prerequisite relationship would predict that the prog-
ress in relating to objects tasks would always precede
progress in pet-formative behaviors.
Thus, in reviewing available literature, it seems that
there is no clear evidence that language rests on any
well specified cognitive prerequisite skills. Other au-
thors (Guess, 1980; Harris, 1982; Reichle & Karlan,
1985, 1988; Rice, 1983; Rice & Kemper, 1984; Romski
& Sevcik, 1988) have similarly noted an absence of
data to support the cognitive hypothesis of language
development. Although it can be readily agreed that
there must be some relationship between cognition and
language, it should be recognized that the nature of
this relationship is not clearly understood. In concluding
her review of the various models which have been
proposed to explain this relationship, Rice (1983) stated
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that a “striking characteristic of the available literature
is the preliminary, tentative character of the available
evidence and the associated arguments” (p. 354).
Cognitive Hypothesis: Impact on Intervention
In spite of the lack of conclusive evidence to support
cognitive prerequisites to language, this assumption
has had an impact on the services for individuals with
severe disabilities. Language and communication
teaching programs have explicitly or implicitly required
certain prerequisite skills. Several authors (Chapman &
Miller, 1980; Owens & House, 1984; Shane, 1981) have
recommended that the appropriate course of interven-
tion for an individual who has not achieved the cognitive
prerequisites to speech is to teach these cognitive
prerequisite skills first. These recommendations will be
discussed below. Although there will be no attempt
here to provide a comprehensive review of communi-
cation programs, some discussion of the general ap-
proaches to the notion of prerequisites is in order.
Many speech and language programs, although re-
ported to be appropriate for individuals with severe
disabilities, are in fact designed for individuals who have
surpassed the level that is of interest here. These
programs, such as the program by Stremel and Waryas
(1974) and that by Guess, Sailor, and Baer (1976), in
fact require the presence of speech as entry level
criteria, thus obviating the need to consider prerequi-
sites to speech. Another approach has been taken by
some highly structured behavioral programs such as
that by Kent (1974). While not requiring any specific
cognitive prerequisite skills, this program requires cer-
tain task behaviors such as visual attending and motor
imitation. The NonSLIP program (Carrier, 1976; Carrier
& Peak, 1975) requires similar task skills, although this
program is designed to teach the use of nonspeech
symbols. These programs share an underlying assump-
tion that there are certain prerequisite skills needed
before an individual can benefit from the specific com-
munication training program. There is no provision in
these programs for individuals who fail to demonstrate
or to learn the required prerequisite tasks.
213
A different approach to communication programs for
severely disabled individuals is exemplified by curricula
which focus on communicative behavior at a prelinguis-
tic level (Klein et al., 1981; Sternberg, McNerney, &
Pegnatore, 1985; Sternberg, Pegnatore, & Hill, 1983;
Stillman & Battle, 1984; Stremel-Campbell, Johnson-
Darn, Guida, & Udell, 1984). In these programs, there
are no prerequisite skills, either in cognitive nor in
behavioral-task oriented domains. Early communicative
behaviors which do not depend on linguistic symboli-
zation are taught first, thus not excluding any individ-
uals for failing to demonstrate sufficient skill to enter
the programs. None of these programs address the
introduction of a formal AAC symbol system, and only
the Stremel-Campbell et al. (1984) program addresses
a means to move from this prelinguistic level to the
beginning use of speech. However, since these pro-
grams emphasize meaningful communication at an
early level, they remain flexible enough to allow for
exposure to any symbol set which might eventually be
of communicative use to the individual.
As noted above, in addition to the impact on early
speech teaching programs, the development of AAC
for individuals with severe disabilities has also been
influenced by the assumption of cognitive prerequisites
to symbolic communication. Chapman and Miller (1980)
have stated support for what has here been called the
weak cognitive hypothesis (i.e., that cognition is nec-
essary but not sufficient for language to emerge). They
extend this view to the application of AAC approaches
when they state that it is only a child “with production
delay relative to cognitive level, rather than to chrono-
logical age, who is a candidate for a nonvocal system”
(page 163). Similarly, Shane (1981) has stated that a
cognitive development of at least sensorimotor stage 5
or at least 18 months mental age is necessary in order
to consider an AAC approach. He further states that
there must be some evidence for the delay to be
peripheral, or motor based, before implementing an
AAC technique. Owens and House (1984) appear to
propose the most exclusionary criteria. They state that
the individual must show cognitive skills at sensorimo-
tor stage 5 or at a developmental level of age 12 months
in addition to demonstrating certain social/communi-
cative skills and receptive language abilities before AAC
approaches should be considered. Although they refer
to these skills as correlates of expressive language,
they recommend their use as prerequisite criteria. In
proposing these requirements, these authors have not
only accepted the cognitive hypothesis as the expla-
nation for the natural and normal emergence of lan-
guage in nondisabled children; they have also extended
this hypothesis to a definitive restriction on the devel-
opment of communication intervention programs for
individuals with developmental delay. Chapman and
Miller (1980), Owens and House (1984) and Shane
(1981) have implied that if there is a cognitive delay
which has contributed to the delayed language devel-
opment, then there is nothing that a speech and lan-
guage clinician can do to improve the individual’s com-
 214 Kangas and Lloyd
munication. This implication will be challenged in the
arguments which follow. Reichle and Karlan (1985,
1988) in their review of decision rules for the implemen-
tation of AAC, reported that these rules are two-tiered
systems, first requiring the establishment of some level
of severity of speech and language impairment and
then requiring some prerequisite condition. They con-
clude that this leaves many individuals “trapped in a ‘no
man’s land’ of having a sufficiently severe impairment
but failing to have the prerequisites necessary for an
augmentative system” (1985, p. 149).
Application to Individuals with Disabilities
It has often been accepted without question that
what holds true for the development of typical children
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must also be true for children who experience disabili-
ties. This assumption also must be carefully examined.
While information from normally developing children can
lead us into many productive areas for intervention and
research, we need to constantly ask whether or not the
same conditions and relationships will apply to other
populations. Karlan and Lloyd (in press) reviewed avail-
able literature relating Piagetian assessment to learners
with disabilities. They concluded that, in general, learn-
ers with disabilities appeared to progress through the
stages of sensorimotor development in an ordinal fash-
ion, much as nondisabled learners do. That is, they
acquire skills at one stage of performance before be-
coming able to succeed at the next stage within each
behavioral area. However, Karlan and Lloyd (in press)
also reported that there does not appear to be as much
congruence across behavioral areas for the learners
with disabilities as there was for nondisabled children.
That is, the learners with disabilities appeared to show
more variability by functioning at early stages in some
behavioral areas and later stages in other behavioral
domains. They hypothesized that differences in expe-
rience and task variables contributed to this reduced
congruence for learners with disabilities. Karlan (1980)
reported that he obtained widely different develop-
mental assessment results for individuals with severe
cognitive impairment when he compared their perform-
ance using standard items or using individually pre-
ferred items. Whatever the cause for variable perform-
ance in individuals with disabilities, it clearly casts doubt
on the practice of assigning a single stage description
of development. Indicating that an individual is function-
ing a sensorimotor stage 5 or stage 6 has little meaning
unless the specific measures, procedures, and nature
of the materials used to determine that stage are also
reported.
Several researchers (Cardoso-Martins, Mervis, &
Mervis, 1985; Cunningham, Glenn, Wilkinson, & Sloper,
1985; Smith & vonTelzchner, 1986) have reported that
there appears to be a significant delay of language
abilities with respect to cognitive development for indi-
viduals who have Down syndrome. For at least this one
population of individuals it would seem that cognitive
development does not predict linguistic ability in the
same way as it does for nondisabled children. Clink et
al. (1986) reported that cognitive level and improvement
in a language intervention program were only moder-
ately correlated for children with language delay. Al-
though the specific reason for this phenomenon is not
known, it is clear that for a significantly large number
of individuals with developmental delay measures of
cognitive abilities do not predict the development of
language abilities to the same degree that they do for
nondisabled learners. This suggests that prevention of
more severe communication deficits may be an appro-
priate goal for communication intervention for individ-
uals with developmental delay.
As Karlan and Lloyd (in press) point out, Piaget’s
explanation of how the child develops through these
cognitive stages relies heavily on the child’s interactions
with his environment. Indeed, the very name of the
developmental period which has been of greatest inter-
est to the study of language development, the senso-
rimotor period, is derived from the observation that the
child is using sensory input and motor skills to explore
and understand the environment. For individuals with
disabilities, their early experience with the world is
altered by their disabilities. The difference for children
with physical disabilities is obvious; they are limited in
their abilities to explore and to act on their surround-
ings. Likewise, it is easy to see that children with
sensory impairments have an altered experience with
the environment. What is not so obvious, however, is
how this will affect their early cognitive development.
Children who have cognitive deficits, even with good
motor skills and sensory abilities, may also have an
altered experience with the world. These children may
not engage in the same exploration of their environ-
ment, they might not attend to and organize sensory
perceptions in the same way, and their parents may
behave somewhat differently toward them. Thus, in
using a theory which relies heavily on experience, we
must be very cautious about extending our assump-
tions from normally developing children with normal
experiences to learners with disabilities who may have
very different experiential opportunities.
The question of extending our assumptions becomes
even more critical as we talk about older individuals
who still may not be showing the early cognitive skills
we expect from young normally developing individuals.
Karlan and Lloyd (in press) recommend caution in inter-
preting data from such assessments with adults. They
noted the scarcity of data on Piagetian assessment
tasks with older individuals and, in particular, they
raised a question of test-retest reliability with this pop-
ulation. Calculator (1988) also questioned the efficacy
of applying norms derived from child development to
the communication assessment of adults with mental
retardation.
Very little data are available to demonstrate the re-
lationship of cognitive measures to communication abil-
ities for adults and adolescents with severe disabilities.
Snyder-McLean, Etter-Schroeder, and Rogers (1986)
reported data from three groups of adolescents and
 Cognitive Prerequisites
adults with severe disabilities. They found that the
communication level was a poor predictor of perform-
ance on sensorimotor assessment scales. Although in
general there was some correlation, and the more
verbal individuals usually scored higher than individuals
who were nonverbal (meaning nonlinguistic in any sym-
bol system), there were many contradictory scores in
both directions.
Application to Nonspeech Symbol Sets
Regardless of the individuals involved, we must also
ask if the cognitive abilities related to the use of verbal/
vocal symbols (i.e., spoken words) are also necessary
for the use of other symbols. The symbols used in
nonspeech communication methods are not a direct
substitute for speech, and there are problems in draw-
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ing direct parallels between components of different
symbol systems (Harris & Vanderheiden, 1980; Rom-
ski, Lloyd, & Sevcik, 1988; Romski & Sevcik, 1988;
Romski, Sevcik, & Joyner, 1984; Vanderheiden &
Lloyd, 1986). Each symbol system has its own char-
acteristics and has a different effect on overall interac-
tion patterns. Several authors (Fristoe & Lloyd, 1979;
Musselwhite & St. Louis, 1988; Silverman, 1980) have
reported, for example, that for many individuals manual
signs are easier to learn than spoken words, and they
may not have the same cognitive demands. There are
several reports which indicate that children who are
acquiring American Sign Language in an environment
where it is used in a natural communicative manner
obtain early language skills at younger ages than chil-
dren learning spoken language. According to these
reports, first signs emerge as early as 8 months of age
and sign combinations occur as early as 10 months of
age (McIntyre, 1977; Schlesinger, 1978). Also, the total
number of signs acquired by children learning signs
exceeds the average vocabulary of spoken words re-
ported for children learning speech, at least until the
age of 2 years (Holmes & Holmes, 1980; McIntyre,
1977; Orlansky & Bonvillian, 1984; Schlesinger, 1978).
This suggests that signs may not have the same cog-
nitive-developmental demands as spoken words.
Graphic symbols differ from speech and manual sign
in that they are fixed or static, and the user relies on
recognition memory to select a graphic symbol, not
recall of the symbol (Romski, Lloyd, & Sevcik, 1988;
Romski et al., 1984; Vanderheiden & Lloyd, 1986).
Reichle and Yoder (1985) demonstrated labeling skills
using a communication board could be taught to a child
who had not reached the 12 month developmental level.
Romski, Sevcik, & Pate (1988) reported that their sub-
jects with severe mental retardation were able to learn
arbitrary graphic symbols to request specific food
items. These subjects later learned additional symbols
to request nonfood items and generalized the use of
the symbols to labeling, comprehension, and initiation.
Although the evidence is scant, these reports do sug-
gest that for some AAC symbol systems, the cognitive
skills correlated with learning the symbols may be dif-
215
ferent than those correlated with learning spoken
words.
In summary, there are many reasons to question the
earlier assumptions which led clinicians and teachers
to either wait for prerequisite skills to develop or to
teach cognitive prerequisites before beginning to teach
the use of AAC techniques for individuals with severe
disabilities. There is considerable doubt as to the true
nature of the relationship between cognition and lin-
guistic development for normally developing children. It
has been suggested that even if that relationship were
better understood, we must carefully examine the ex-
tent to which that relationship would hold true for
individuals who are disabled and for learning linguistic
symbols other than speech. These issues support a
position that there are no empirically supported reasons
to wait for cognitive prerequisites to develop before
beginning a communication program. But are there
compelling positive reasons for early intervention?
Implications for Early Intervention
Questions of when to initiate language intervention
have previously been asked with regard to initiating
signing for very young deaf children. In summarizing
the arguments and research in this area, Wilbur (1987)
makes reference to information regarding the develop-
ment of the brain and the establishment of synaptic
patterns. This development of the central nervous sys-
tem is most rapid up until the age of 5 or 6 years, and
so the time from birth to age 6 is viewed as the most
critical for language learning. It should be stressed that
this argument refers to a physiological development
that is related to chronological age, and thus the same
critical period could be expected to be important for a
child who is cognitively delayed. This is consistent with
Alpert’s (1980) report that for children with autism there
is a greater chance for improved social development if
speech is present by age 5.
Many authors have concluded that the use of AAC
may have a facilitative effect on communication abilities.
Reichle and Karlan (1985, 1988), Romski, Lloyd, and
Sevcik (1988) Romski and Sevcik (1988), and Romski
et al. (1984) suggest that AAC may facilitate compre-
hension skills. Fristoe and Lloyd (1979) conclude that
signing facilitates production of vocal/verbal reper-
toires. They further report that teaching sign has no
adverse effect upon acquisition of vocal communica-
tion. There are many reasons why the use of AAC
systems may have a facilitating effect on speech (Fris-
toe & Lloyd, 1979; Musselwhite & St. Louis, 1988;
Romski, Lloyd, & Sevcik, 1988; Silverman, 1980).
Among these possible reasons are the reduced pres-
sure for verbal speech, the static nature of many of the
aided symbols used, and the development of input/
output modes other than the traditional auditory-vocal
channel. Romski and Sevcik (1988) discussed the po-
tential importance of augmented communicative input
in the development of communication. We might also
assume that successful communication will help to
 216 Kangas and Lloyd
encourage the individual and to develop more appro-
priate interaction patterns.
Harris and Vanderheiden (1980) and Scheifelbusch
(1980) advocate early communication intervention for
children with severe disabilities. They point out that
communication begins at birth and many skills are
achieved before the child begins to use symbolic com-
munication. There is an extensive body of literature that
describes normal child language development, including
many sources which describe communication in a
broader context than linguistic skills (Bloom & Lahey,
1978; Brown, 1973; Kearns, 1984; Lewis & Rosenblum,
1977; Muma, 1986; Ochs & Schieffelen, 1979; Schie-
felbusch & Bricker, 1979; Wood, 1976). Bates and her
colleagues (Bates, 1979; Bates et al., 1977; Bates et
al., 1975) described four communicative behaviors that
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emerged between the ages of 9 and 13 months of age
for the normally developing children they observed, and
which they believe are highly related to the later use of
symbolic, spoken communication. These behaviors
were Showing, Giving, Communicative Pointing, and
Ritual Requests. Bruner (1975a, 1975b) described the
acquisition of formal language as the adoption of con-
ventional means to express communication acts previ-
ously developed within the contexts of joint attention
and joint activity. These observations suggest that
within the domain of communicative development, we
can extend our attention to skills and behaviors which
occur much earlier than the emergence of symbolic
linguistic abilities.
Among the reasons cited by Harris and Vanderheiden
(1980) for early intervention is to help the child to
develop physical and manipulative skills which the child
might later use to access a communication device.
There is a compelling logic here which might again be
related to what we know of normal child development.
If normally developing children use babbling and
thereby gain control of their speech articulators prior to
producing those sounds for meaningful use, it seems
reasonable that a child with disabilities might benefit
from increasing his nonsymbolic and playlike use of
whatever motor patterns he might later access for
communication purposes.
Implications for Goals of Intervention
Authors who support some form of the cognitive
hypothesis of language development make an assump-
tion that normal language development is the most
appropriate reference for the development of interven-
tion programs. These authors frequently recommend
that if cognitive prerequisite skills are not present,
communication intervention programs should be de-
layed or should be directed toward the goal of teaching
or facilitating the prerequisite skills (Chapman & Miller,
1980; Owens & House, 1984; Shane, 1981). The rea-
soning seems to be that there are prerequisite skills
necessary for the development of truly symbolic, rule
based language. Since these authors believe the lan-
guage development is based on the cognitive skills,
they believe no progress in language development will
occur until the cognitive skills are demonstrated. In
addition to the stated cognitive hypothesis, there are
two assumptions implicit in this argument: that there is
no progress unless the client advances in a develop-
mental sequence, and that the communicative needs
of the individual are comparable to the cognitive level
without reference to the chronological age.
Let us first review the assumption that only advances
to higher developmental levels are to be viewed as
progress. This notion assumes that once an individual
achieves a certain level, all of the skills that are com-
parable to that level will be achieved. This idea has
already been partly addressed by showing that there is
a lesser congruence of skills across cognitive areas for
individuals with disabilities than for those who are non-
disabled. It may also be that individuals with disabilities
are more restricted in their applications of skills. As
previously discussed, observations of infant behavior
tell us that from a very early age children engage in a
variety of communication behaviors (Bates, 1976,
1979; Bates et al., 1975; Bates et al., 1977; Bloom &
Lahey, 1978; Bruner, 1975b; Lewis & Rosenblum,
1977; Moerk, 1977; Ochs & Schieffelen, 1979; Schie-
felbusch & Bricker, 1979; Wood, 1976). For example,
a child of 9 or 10 months old may use pointing gestures
to request objects, to show objects or events, or to
continue a showing off routine. These behaviors may
be seen before the child achieves sensorimotor stage
5 or 6 level of development, the levels usually referred
to as prerequisite to language. It may be that the learner
with disabilities who is at the same developmental level
may demonstrate the same pointing behavior, but may
use that behavior in a much more restricted set; for
example, only to request a food which is already
nearby. If the use of that skill can be expanded to a
more frequent and more flexible usage, this in itself
may be an acceptable outcome of intervention. For a
child who is physically disabled, it may be appropriate
to develop a behavior other than pointing, such as eye-
gaze, to substitute for the directed point.
The second assumption which is implicit in accepting
developmental goals in relation only to cognitive devel-
opment is that an individual’s communicative needs are
comparable to those of a normally developing child of
the same cognitive level. Based on this logic, if an adult
with severe cognitive delay displays only the commu-
nication behaviors of a normally developing infant or
toddler, that adult might not be considered for speech
and language intervention nor the possibility of AAC
techniques. However, the needs of an adult with severe
disabilities are very different than those of a young
child. When a child is very young, we expect the ma-
jority of his communication to be with family and highly
familiar care givers, we are very tolerant of interrup-
tions, we accept unintelligible or idiosyncratic words,
and we have little concern for the overall independence
of the child. However, for an adult with developmental
delay, our goals are quite different. We attempt to
establish the highest possible level of independence
 Cognitive Prerequisites
(Bender & Valletutti, 1985; Brown, Branston, Hamre-
Nietupski, Pumpian, Certo, & Gruenewald, 1979; Snell,
1983; Valletutti & Sims-Tucker, 1984). With recent
emphasis on preventing or discontinuing residential
placements and the growth of a variety of community
living arrangements for individuals with disabilities
(Amary, 1980; Gollay, Freedman, Wyngaarden, &
Kurtz, 1978), intervention for communication skills must
place greater emphasis on socially acceptable behavior
and on independent functioning with known and un-
known communicative partners. For example, we may
wish to see the individual be capable of asking for
assistance to locate an item in the grocery store, or to
tell a work supervisor that the work is finished, or to
request the proper shoe size at a bowling alley. The
appropriate selection and teaching of AAC approaches
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will facilitate these goals for some individuals without
advancing the developmental level of either the cogni-
tive or the language abilities.
Specific Goals and Intervention Strategies
There are several communication intervention pro-
grams and descriptions of specific teaching procedures
which would be appropriate for individuals who dem-
onstrate limited cognitive skills. Some of these pro-
grams and procedures are described below. This listing
is not exhaustive of the interventions which have been
described in the literature, nor is it complete with re-
spect to the possible intervention approaches. The
suggestions listed below have been selected as appro-
priate for individuals with limited cognitive abilities, and
as representative of the range of teaching approaches
which are available. This listing should not be miscon-
strued as a sequence or hierarchy of skills to be taught.
The most effective communication intervention will usu-
ally be developed by selecting or adapting several of
these suggestions, and providing an individual with
many different opportunities to develop functional com-
munication.
1. Development of movement patterns to signal spe-
cific activities (Sternberg, McNerney, & Pegnatore,
1985; Sternberg, Pegnatore, & Hill, 1983; Stillman &
Battle, 1984). This three stage program begins with
movement resonance, where the learner and the inter-
ventionist are physically touching and move together.
At this stage, and throughout the program, the inter-
ventionist pauses frequently and allows the learner an
opportunity to signal in some way that the activity
should begin again. From this, coactive movement is
developed, where the two continue to do the same
activity at the same time, but separated in space. The
third stage is imitative movement, where the two imitate
each other and movement signals for the activities are
continued.
One advantage of this approach, is that it is not
necessary to establish visual abilities in order to begin
the resonance phase, and in fact the original program
was developed by VanDijk (cited in Stillman & Battle,
1984) for use with students who were deaf and blind.
217
Once having established a small set of movement sig-
nals, it might be expected that the learner could pro-
gress to acquiring more conventional gestures.
2. Use of a signal to request “more” (Klein et al.,
1981). The first request taught in this program is a
signal for “more.” A high-preference item or activity is
presented, and subsequently withdrawn or interrupted.
The interventionist first pauses to allow the learner to
respond and then, if necessary, prompts the desired
signal. The signal is reinforced by reintroducing the
object or restarting the activity.
This approach is somewhat similar to the develop-
ment of movement signals described above. It also
shares features with Keogh & Reichle’s (1985) program
(described below) in that a single response is trained
and used across several items or activities. In their
discussion, Klein et al. (1981) stress the flexibility of
this approach with respect to selecting the signal to be
taught, as virtually any behavior that the individual can
control could be used as a signal.
3. Use of a generalized symbol to represent “Want”
(Keogh & Reichle, 1985). This program is designed to
teach the use of a single generalized symbol to repre-
sent a request in a contextually appropriate situation.
In the presence of a preferred item, the interventionist
prompts the selection of the Want symbol, and rein-
forces the symbol selection with the desired item.
Although Keogh & Reichle (1985) described this pro-
gram only for use with graphic symbols, it could easily
be adapted for the teaching of manual signs or ges-
tures. They recommended that this program be insti-
tuted concurrently with the program to teach labeling,
described below.
4. Use of specific object names to label salient items
(Keogh & Reichle, 1985). This program teaches the
learner to use object names as a means of expressing
a description or comment communicative function. The
authors recommend teaching the labeling behavior con-
currently with the above described teaching of a gen-
eralized request function.
Keogh and Reichle (1985) stress the importance of
teaching separate vocabulary items for different com-
municative functions in the early stages of communi-
cation intervention. The object names are later com-
bined with the generalized request to form specific
requests for specific objects (i.e., Want + object name).
5. Use of Lexigrams on a computer keyboard to
request specific items (Romski, Sevcik, & Pate, 1988).
In the presence of a communicative need (i.e., food to
be obtained), the learner is prompted to select the
symbol representing that food item on a computer-
based keyboard. Prompts used include pauses, spoken
directions, gestures, and physical prompts. A correct
response is reinforced with the requested item. A re-
quest for a single item is taught to criterion before the
next item and symbol are introduced.
Romski, Sevcik, & Pate (1988) stressed that the
structured teaching methods were the most important
decision in the design of the intervention program.
Although they used arbitrary graphic symbols, Lexi-
 218 Kangas and Lloyd
grams, this teaching approach could be used with any
symbol set, either graphic or manual. Additionally, al-
though the program described used a computer key-
board and a computer activated vending system to
dispense the food in the first stages of the program,
the basic approach could be used without the computer
equipment. As with Keogh and Reichle’s (1985) ap-
proach, this program teaches object names. However,
this program teaches names in a request paradigm,
whereas Keogh and Reichle recommended introducing
object names in a labeling task.
6. Selection of graphic symbols paired with synthetic
speech output to request items (Romski, 1987; Romski,
Sevcik, & Washburn, 1987). Romski and her colleagues
(Romski, 1987; Romski, Sevcik, & Washburn, 1987)
paired synthetic speech output with the selection of the
graphic symbols to request specific items in a commu-
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nication program similar to that described above (Rom-
ski, Sevcik, & Pate, 1988). They reported that the
synthetic speech output appeared to facilitate the sym-
bol learning by their subjects with severe mental retar-
dation. They speculated that the highly consistent na-
ture of the synthetic speech may have contributed to
the subjects’ learning.
Although this technique has only recently been de-
scribed in the literature (Romski & Sevcik, 1988), the
use of voice output communication aids by individuals
with severe mental retardation shows the potential to
be an effective approach to communication interven-
tion.
7. Indication of a choice from an array of two or more
(Klein et al., 1981). The learner is first presented with a
single choice, a highly preferred item. When a signal
has been established to represent that choice, the array
changes to a two choice system, first containing one
highly preferred and one nonpreferred item, and later
containing two highly preferred items.
This program is somewhat similar to Romski, Sevcik,
and Pate’s (1988) program which began with a request
for a single item. These programs differ in that Klein et
al. (1981) primarily discussed nonsymbolic means of
indicating a choice, such as pointing or eye gazing at
the desired item.
8. Indication of protest or rejection (Stremel-Campbell
et al., 1984, Area V Expressive Language, Program
No. 3, pp. 271-272). Physical assistance is provided in
order to teach the learner to push away unwanted
items. This requires an interventionist who can antici-
pate what the individual does not want, or one who is
sensitive to the learner’s indications of displeasure.
The development of the ability to protest or reject
items and activities can be a very powerful skill for an
individual and can be taught concurrently with request-
ing. This ability may help to prevent or reduce negative
behaviors such as tantrums or self-abuse (Donnellan,
Mirenda, Mesaros, & Fassbender, 1984). Once the
behavior of physically pushing away the unwanted item
is established, the action might be abbreviated to a
simple gesture of the hand raised.
9. Use of various communicative functions (Stremel-
Campbell et al., 1984, Area VI Communication Func-
tions, Programs No. 1 through No. 10, pp. 373-391).
This program includes descriptions of procedures to
establish 10 different communicative functions that may
be expressed without the use of language symbols.
The first five are recommended to be taught first, and
they are Protesting & Rejecting; Request for Objects;
Request for Action; Naming Objects for Attention, Con-
firmation, or Reaction; and Call for Attention. When
these are relatively well established, another set of five
are introduced, and these are Offering Objects, Repe-
tition, Requests for Permission, Asking Questions, and
Answering Questions. These communicative functions
are integrated throughout the many individual programs
included in the total curriculum.
The concurrent teaching of several different com-
municative skills is a strength of this program. Keogh
and Reichle (1985) also stressed concurrently teaching
different responses for different functions; however,
they described only two communicative functions. By
focusing on 5 or 10 of the communicative functions as
recommended by Stremel-Campbell et al. (1984), inter-
ventionists will find many opportunities to integrate
communication teaching into a wide variety of activities.
10. Response to touch cues (Stremel-Campbell et al.,
1984, Area IV Receptive Communication, Program No.
5, pp. 205-207). Physical touch cues are paired with
specific spoken directions to improve the receptive
communication for direction following. Physical assist-
ance is initially provided in order to establish pairing of
the behavior with the touch cue, and pauses and re-
duced physical assistance are used to establish com-
pliance with the direction paired with cue in the absence
of other physical assistance.
One important contribution of this program is the
focus on receptive communication. If the selected di-
rections and cues are in the context of functional daily
activities, then the program will directly increase the
learner’s active participation in those activities. Al-
though the examples cited by Stremel-Campbell et al.
(1984) appear to be most appropriate for individuals
who have relatively intact motor skills, the same tech-
niques could be used with individuals who experience
severe physical impairment. For example, one might
increase the extent to which the learner participates in
a dressing routine by teaching the person to begin to
roll onto one side when given a specific spoken direction
and touch cue.
11. Development and use of communication in natural
settings (Fey, 1986; Halle, 1982; Hart, 1985; Hart &
Risley, 1975, 1986; Hart & Rogers-Warren, 1978;
MacDonald, 1985; Warren & Rogers-Warren, 1985).
There are several teaching strategies which may be
loosely grouped under the heading of naturalistic teach-
ing strategies. These include such areas as environ-
mental arrangements to increase the opportunity and
desire to communicate, appropriate cueing techniques
to elicit the appropriate communication behavior, highly
 Cognitive Prerequisites
responsive consequences for communicating, and rec-
ommendations for working with parents, caretakers,
and teachers.
These methods may be an effective adjunct to many
of the specific communication programs described
above. The naturalistic methods may be employed to
establish new behaviors or to facilitate generalization
of behaviors taught in a more structured setting. A
critical feature in the implementation of this approach
is that all people who interact with the individual with
disabilities (e.g., parents, teachers, caregivers, and
work supervisors) are involved in the development of
communication.
Whatever the communication program selected, it is
necessary to carefully differentiate the outward topog-
raphy of the communication from the individual’s use
and understanding of the message. Even when using
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a communication technique that involves language
symbols (e.g., operation of a tape loop which has a
recorded message to request attention, or pointing to
a graphic symbol that represents an item), the individual
may still lack the understanding of the symbols and
therefore be restricted in their use. For example, a tape
loop with a message that calls for attention could be
used in a symbolic manner each time the user desires
some specific form of attention. The symbolic nature of
the use would be suggested by the AAC user’s atten-
tion to whether or not a listener is available, and by the
use of the tape loop in novel situations where attention
or help is necessary. Alternatively, however, it might be
activated as part of a well established routine, such as
going into the bedroom, facing the bed, activating the
call signal, and moving with assistance from a wheel-
chair to the bed. In this case, a communication partner
might over-interpret the usage as symbolic even when
the person requiring assistance does not understand
the nature of the message. The individual’s response,
if attention and help are not immediately forthcoming,
might provide a clue as to the actual understanding. Or
the tape could be activated simply as a response which
has a rich history of reinforcement, but which is not
associated with a specific need for attention nor with
the presence of a potential listener. While any of these
uses may be appropriate at some point in an interven-
tion program, it is important to recognize the extent to
which the AAC user understands the symbolic nature
of the messages in order to determine the most effec-
tive next step in a program sequence.
Throughout this discussion of specific strategies for
intervention, the emphasis has been on functional com-
munication. These strategies are designed to give the
individual some immediate power over the environment
and to provide a means of taking a more active role in
daily activities. The selection of these recommended
approaches to intervention is based on the belief that
all individuals are ready to communicate.
Summary
In summary, questions have been raised as to the
validity of accepting any strict cognitive prerequisites
219
to the development of symbolic communication. The
assumption that such skills are prerequisite to language
learning has impacted on the treatment programs for
learners with severe disabilities and has often led to
delaying or denying the provision of AAC methods. It
appears that there are not sufficient data to support
the view that certain skills, such as attainment of Pi-
aget’s sensorimotor stage 5 or stage 6, are necessary
for the development of language in normally developing
children. Furthermore, caution is suggested when ap-
plying conclusions from the study of normally develop-
ing children to the treatment of individuals with disabil-
ities. It has been shown that there are not sufficient
reasons for delaying the start of communication pro-
grams for individuals with severe disabilities and, in
fact, there are some compelling reasons for beginning
communication intervention at a young age even if
certain cognitive skills have not been attained.
Acknowledgments
The authors wish to thank members of the Purdue
University Augmentative and Alternative Communica-
tion Research Group for their comments on an earlier
draft of this paper. Preparation of this manuscript was
supported in part by Grant No. G008630079 from the
Office of Special Education and Rehabilitation Services
and by a David Ross research fellowship at Purdue
University.
Address reprint requests to: Kathleen A. Kangas,
M.S.P.A., Doctoral Student, Purdue University, Depart-
ment of Audiology and Speech Sciences, Heavilon Hall,
West Lafayette, IN 47907, USA.
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Augmentative and Alternative Communication Fellowship

for
Master’s, Doctoral or Postdoctoral Studies

The president of the Prentke Romich company is pleased to announce a new annual fellowship program for
advanced studies in the area of augmentative and alternative communication. The Prentke Romich AAC Fellowship
provides support for MS-thesis option, PhD, or postdoctoral research studies at Purdue University. The fellowship is
open to individuals of any nationality. Although the fellow would be pursuing studies in either audiology and speech
sciences or in special education, individuals from any discipline applicable to the area of augmentative and alternative
communication are eligible. In addition to coursework and research activities, the fellow will work closely with the
editor of AAC to gain a practical knowledge of manuscript review and processing. For application materials and
further information write: Lyle L. Lloyd, Ph.D., Editor, Augmentative and AIternative Communication, Purdue
University, South Campus Courts— Building E, West Lafayette, Indiana 47907, USA.