Running Head: I HAVE SOMETHING TO TELL YOU

“I Have Something to Tell You”
The Augmentative and Alternative Communication Project
Lisa Barrett
Clarion and Edinboro Universities

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Abstract

A social-learning group was used to train caregivers of school-age augmentative and
alternative communication (AAC) users. Training was aimed at the caregiver of emergent AAC
users and occurred in the home and community settings using a modeling strategy. Instruction
was primarily delivered in three 15-minute training sessions using Facebook. In addition to
social media instruction, the caregiver-child teams met with other participants to practice and
implement newly learned skills during community activities. Meetings were approximately 1hour in length and included coaching and feedback. A single subject AB design was used to
evaluate the effects of community instruction on caregiver AAC modeling. Frequency of
caregiver modeling is the dependent variable measured by direct observation. Module
development utilized behavior skills training techniques consisting of (a) instruction (b)
modeling (c) practice (d) feedback and coaching in the community setting.
Keywords: Developmental Disabilities, Autism, Augmentative and Alternative
Communication (AAC), nursing, modeling, aided-language stimulation, behavioral skills
training, single subject design, community, communication partner

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ACKNOWLEDGMENTS
I would like to thank my family who provided love and support during my academic
journey. I appreciated the growth and positivity provided by my advisor, Dr. Meg Larson. I
valued the feedback from my committee members, Dr. Brandy Gustavus and Dr. Meghan
Ferraro who challenged my thinking and my process. In addition, I would like to express
gratitude to my students, Natalia Adharsingh, Natera Austin, and Angela Gomez who
volunteered to assist with the data collection process adding to their already hectic school
schedule. Jessica Irish, Meghan King and Leigh Czerwinski, I am grateful for the time you spent
reviewing materials for best practices. Without you, I could never have reached this milestone.
Thank you.

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Table of Contents
Abstract ............................................................................................................................... 2
ACKNOWLEDGMENTS .................................................................................................. 3
Chapter 1 ............................................................................................................................. 7
Introduction ......................................................................................................................... 7
Background and Significance of the Problem ................................................................ 8
Research Question ........................................................................................................ 11
Hypotheses .................................................................................................................... 11
Concepts ........................................................................................................................ 12
Definitions of Terms ..................................................................................................... 13
Need for the Study ........................................................................................................ 15
Nurses’ role. ........................................................................................................................................ 16
Outreach. ............................................................................................................................................. 16

Assumptions.................................................................................................................. 17
Chapter 2 ........................................................................................................................... 17
Review of Related Literature ............................................................................................ 17
Perceived Efficacy and Module Design ........................................................................ 18
Online Instruction Modules .......................................................................................... 20

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Community Setting ....................................................................................................... 20
Modeling Intervention .................................................................................................. 22
Theoretical Frameworks ............................................................................................... 24
Bioecological Model Application ................................................................................. 25
Chapter 3 ........................................................................................................................... 30
Methodology ..................................................................................................................... 30
Recruitment ................................................................................................................... 30
Participants .................................................................................................................... 30
Characteristics. .................................................................................................................................... 32
Type of device..................................................................................................................................... 32
Motivation. .......................................................................................................................................... 32

Design ........................................................................................................................... 34
Rationale for SSD ......................................................................................................... 34
Intervention Materials ................................................................................................... 35
Procedure ...................................................................................................................... 37
Baseline. .............................................................................................................................................. 37
Intervention. ........................................................................................................................................ 38

Interobserver Agreement and Reliability ...................................................................... 40
Quantitative Data Collection......................................................................................... 41
Qualitative Data Collection........................................................................................... 41
Chapter 4 ........................................................................................................................... 42
Results ............................................................................................................................... 42

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Models Per Minute ........................................................................................................ 42
Home and Community Practice .................................................................................... 43
Modeling and Vocalization ........................................................................................... 43
Facebook participation .................................................................................................. 47
Post-intervention Participation Feedback ..................................................................... 47
Chapter 5 ........................................................................................................................... 48
Discussion, Limitations, and Recommendations .............................................................. 48
Discussion ..................................................................................................................... 49
Self -efficacy and motivation .............................................................................................................. 49
Modeling strategy ............................................................................................................................... 50
Vocalizations....................................................................................................................................... 50
Community modeling ......................................................................................................................... 51
Modules............................................................................................................................................... 53
Program. .............................................................................................................................................. 54

Limitations .................................................................................................................... 55
Conclusion .................................................................................................................... 57
Future Recommendations ............................................................................................. 57
References ......................................................................................................................... 59

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Chapter 1
Introduction

Autism is a developmental disability (DD) that affects 1 in every 58 children (Baio, et al.,
2018). There is no cure for autism. Children living with autism spectrum disorder (ASD) are
the most common group of individuals with communication challenges. This socialcommunication disorder leaves 25-40% of children affected in need of augmentative alternative
communication (AAC). AAC describes methods of communication used to supplement or
replace oral communication for individuals who cannot speak or have difficulty speaking. It can
take the form of pictures, gestures, sign language or robust technologies such as iPad
applications.
Since communication and social-emotional deficits are the defining characteristics of
ASD, any intervention that mitigates these difficulties becomes a critical priority (Prizant,
Wetherby, Rubin, & Laurent, 2003). While ASD is the most common DD it is not the only
disability resulting in communication. One in six children in the United States are diagnosed
with a developmental disability (Boyle et al., 2011). Cerebral palsy (CP) is a disorder that
affects an individual’s ability to control muscle movement including the muscles used to speak
clearly. The prevalence of CP is one out of 323 children. Recent studies have shown the
occurrence of ASD among children with CP is 6.9% (Christensen et al., 2014). A co-morbidity
of ASD and Down syndrome (DS) has also been identified with a higher prevalence of 37%.
While the prevalence of DS and ASD co-occurrence is higher, the prevalence of DS occurs less
with one in every 691 births affected (Barbosa, et al., 2018; Davis, Spriggs, Rodgers, &
Campbell, 2018). Every individual with a DD exhibits uniquely different qualities. However, the
speech, communication, and social deficits are a common thread regardless of ASD comorbidity.

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Background and Significance of the Problem
Research has shown that the economic and emotional burden of life-long care for
children living with autism is significantly higher than any other disability. Specialized services
such as education, language and occupational therapy contribute to a $2.4 million lifetime cost to
support a child living with autism. In addition are costs such as loss of parental productivity,
caregiver burden, medical and residential care continue through the lifespan (Buesher et al.,
2014). Medicaid spends six times more money per year to provide medical care for those with
ASD. This figure does not include behavioral services which can add approximately an
additional cost of $40,000 per year (Long, 2018). Due to speech and language impairments, most
children living with developmental disabilities will require daily, life-long care from family
members who make large investments of time, money, and energy to provide such care.
Ultimately, parents just want their child to have a happy and meaningful life (McNaughton, et
al., 2008).
The Report of the Surgeon General (1999) states applied behavioral analysis (ABA) is an
effective method for increasing functional communication and learning through motivating
interventions. The most common, and most qualified, professional to initially assist with
language impairments and initiation of appropriate augmentative and alternative communication
is a speech-language pathologist (SLP).
Children with complex communication needs (CCN) frequently use speech generation
devices (SGD) and other tools known as augmentative alternative communication. While
technology has provided extraordinary benefits in helping children communicate, providing a
child with technology alone will not give children the skills required to have functional
communication or meaningful relationships with others (Cockerill, et al., 2014; Light, &

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McNaughton, 2014). Learning to use AAC requires a multidisciplinary team working together
to reach common goals.
Typical children learn language through hearing it in everyday life. For most children,
language develops naturally through experience. It is estimated that typically developing children
hear 125,000 words per week; while children with complex communication needs who use AAC
experience approximately 1600 words per week. In a literature review by Sennott, Light, and
McNaughton (2016) modeling was deemed the best methodology and the cornerstone to AAC
intervention.
Despite the limited amount of exposure to language that children with CCN experience,
modeling has proved extremely effective in teaching communication pragmatics, grammar and
language. Although the efficacy of modeling communication to AAC users is well researched in
the clinical setting, it has not been sufficiently implemented in practice (Light & McNaughton,
2015).
Establishing communication partners to provide meaningful demonstrations of language
skills is necessary. Parents, teachers, and children require support in navigation and use of
assistive technology to maintain meaningful interactions and promote communication
independence (Kaiser & Roberts, 2013; Light, 1989; Sanders, 2017; Senner & Baud, 2016).
Having a child with a communication disorder does not make the parent an expert in technology
any more than providing a child with technology ensures development of communication
(Cockerill, et al., 2014; Light, & McNaughton, 2012). Because communication (not just speech
alone) is a building block to literacy, it is important to provide children with the opportunity to
develop these skills early (Light, & McNaughton, 2012). When children experience
communication deficits, brain development and cognitive ability is dramatically impaired and

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can lead to educational and social isolation as well as difficulties with future employment (Topia
& Hocking, 2012).
A lack of qualified AAC providers in schools and clinics is a barrier to ensuring children
with complex communication needs (CCN) develop communication competence (Crisp,
Draucker & Ellett, 2014; Sanders, 2017; Senner and Baud, 2017). When communication
services are provided, a service gap exists in promoting carry over of services from the school
or clinic setting to the home and community. In addition, skills are usually taught in isolation
making generalization outside of therapy difficult (Cockerill, et al.; 2014; Granlund, BjorckAkesson, Wilder & Ylen, 2008). True communication competence involves the use of
communication for multiple functions. Not only is communication used to meet basic needs,
but to develop closeness with others (Light, 1989). Lack of support prevents caregivers from
facilitating the use of their child’s communication device, becoming skilled communication
partners, or developing closeness with their child (Crisp et. al., 2014; Mandak, O’Neill, Light &
Fosco, 2017; Sanders, 2017; Senner & Baud, 2017).
A study conducted by Sanders (2017) found the majority of parents request support to
assist their child in using AAC, yet 52% were offered less than 3 hours of support. Some parents
were unable to access support at all. When asked to rank the most critical areas for support,
parents overwhelmingly wanted assistance with navigation and learning ways to help their child
use AAC. Furthermore, parents reported in-person support far superior to Skype, email, or
phone support. Parents also found online video tutorials helpful. When AAC is not adequately
supported, abandonment of AAC is common and communication remains stunted with negative
long-term consequences (Crisp et. al., 2014; Granlund et al., 2008; Anderson, Balandin,
Stancliffe, & Layfield, 2014). Many children can make 1-2 simple requests with AAC quickly.
However, becoming a competent ACC user requires approximately two years of coaching and

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practice; the longer the child goes without training the longer acquisition takes (Ballin, Balandin,
Togher, & Stancliffe, 2009). This contributes to development of challenging behaviors such as
screaming, crying, hitting, biting, wandering, and self-injury (Andzik, Chung, & Kranak, 2016;
Fragale, Rojeski, O’Reilly & Gevarter, 2016; Hall & Graft, 2010), device abandonment
(Johnson, Inglebret, Jones & Ray, 2006), and lack of skill development for employment and
independence in adulthood (Prizant et al., 2003).
Research Question
More than half of children using AAC are non-proficient in their communication (Andzik
Schaefer, Nichols & Chung, 2018; Bellomo, 2016). Teaching caregivers to model the use of
AAC to their child is one way to increase communication competency. The National Joint
Committee on the Communication Needs of Persons with Severe Disabilities Members (2016)
found 96% of individuals with profound intellectual and developmental disabilities were able to
advance their communication skills with proper intervention. The purpose of this study was to
determine if participation in a social-learning group affects the caregivers’ frequency of using
their child’s AAC device to communicate with their child.
Hypotheses
For caregivers of children who use AAC devices:
1. Participation in a social-learning group will increase the caregiver’s frequency of
modeling using their child’s AAC device in the home when compared to baseline.
2. Participation in a social-education group will increase the caregiver’s frequency of
modeling using their child’s AAC device in the community when compared to baseline.

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Concepts
Bioecological system. A system of multiple environmental subsystems which together
influence human development over time (Bronfenbrenner, 1986). Changes in one system affect
changes in the other systems (Topia & Hocking, 2012).
Communication competence. The ability of an individual who uses AAC to develop
effective and efficient communication in four interrelated domains (a) linguistic, (b) operational,
(c) social, and (d) strategic. Communication competence also encompasses psychosocial
influences such as motivation, confidence, and listener support (Light, 1989). It is essential for
meeting one’s needs, participating in society and to share experiences with others. Therefore, the
inability to communicate has a detrimental effect on happiness and well-being (Topia &
Hocking, 2012).
Happy and meaningful life. Defined by the ability to participate fully in education,
employment, family and community activities that are social, political and recreational in nature.
These activities provide enjoyment and contribute to health and well-being. Participation implies
active engagement or to join in an activity as opposed to simply being present or attending (Light
& Mc Naughton, 2015). What makes a person experience a happy and meaningful life is unique
for all individuals but largely determined by culture and society (Bronfenbrenner, 1986). In the
treatment of disabilities, there has been a recent paradigm shift from disease-oriented
intervention to performance enhancement, health and well-being (Topia &Hocking 2012).
Families of children with disabilities want their children to have happy and meaningful lives
(Light & Mc Naughton, 2015).
Level of independence. The highest level of functioning in which a person can perform a
task without the help of another person. Level of independence that is supported by adaptive
devices and use of adaptive supports increases an individual’s level of independence that could

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not be achieved without the support. In contrast, support from another person decreases level of
independence even if the individual is able to complete more activities with personal assistance.
An individual may have multiple levels of independence. For example, a person may be able to
independently make a bed using a visual schedule. The visual schedule enables a high level of
independence for this task. However, the same individual may require the help of another person
to cross the road safely. This example illustrates a lower level of independence in road crossing
behaviors because of the need for personal assistance to complete the task.
Definitions of Terms
Augmentative and alternative communication. The use of technology (written, computer
software, signing etc.) to supplement spoken language or aid in understanding language when a
child or adult has speech and/or language impairments. Augmentative communication is a
method of communication that supplements spoken language. Alternative communication
replaces spoken language for a person with no intelligible speech. AAC technology is referred to
as (a) no technology, (b) low technology, (c) high technology. Examples of AAC technology are
provided in appendix A (American Speech-Language-Hearing Association, 2018).
Approximations. Vocalizations or attempts to vocalize words that sound almost correct
but not exact.
Autism spectrum disorder. A group of disorders characterized by deficits in social
communication and repetitive or restrictive behaviors that interfere with daily living. Deficits
and behaviors range from mild to severe (Harstad, Fogler, & Barbaresi, 2015).
Behavioral skills training (BST). An Evidence-based teaching strategy that includes five
steps: (a) instruction (b) modeling (c) practice (d) feedback and coaching (Parsons & Rollyson
& Reid, 2012).

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Cerebral palsy. A disorder affecting motor movement and control of the body including
communication and behavior (Christensen et al., 2014).
Communication. A behavior that involves the exchange of information between at least
two people. The most basic form of communication is functional communication. A person
communicates basic needs such as, “help,” “I need to use the bathroom,” “I want to eat,”
(ASHA, 2018). Communication is a basic human right (Brady et al., 2016).
Communication partner. A communication partner can be the receiver or giver of
information in a conversation with the AAC user or act as a facilitator. A facilitator makes
communication easier for the AAC user by assisting the AAC user in conveying or exchanging
messages, or seeking information to another receiver (Granlund et al., 2008).
Community. An environmental system in which a person lives and interacts daily. It
includes the physical location as well as other people that may be present in the location. Places
may include school, home, work, businesses, places of worship and recreation (Bronfenbrenner,
1986). People in a community usually have similar interests and participate in similar activities.
Community setting. A place accessible to the general public. This is the context in which
the modeling intervention is embedded (Granlund et al, 2008).
Complex communication needs. The needs of an individual with severe communication
difficulties including individuals living with autism, cerebral palsy, down syndrome and those
who use AAC. The impairment may affect speaking, understanding language, and motor ability
to form words. Individuals with complex communication needs cannot meet daily needs with
speech. (Beck, Stoner & Dennis, 2009).
Down syndrome. A disorder caused by trisomy of human chromosome 21. It causes
physical and intellectual impairments including language and communication (Barbosa, et al.,
2014).

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Language. A system of symbols organized by rules to convey information (ASHA,
2018).
Modeling. Teaching an activity by using demonstration.
Participation. An active engagement in education, employment, family and community
activities that are social, political and recreational in nature. “Communication is the simple form
of participation” (Chan, cited in Topia & Hocking, 2012).
Perceived self-competency. Individuals’ belief to perform a particular task (Bandura,
1977).
Social-learning group. A group of people with similar interests who gather to perform an
activity and learn information pertinent to the interests of the group.
Speech. Communication using voice.
Need for the Study
Approximately 90% of SLPs provide direct services to children with ASD in the school
setting while providing indirect consultation to special education teachers who teach children
with ASD (Sanders, 2017; Mandak & Light, 2018). However, not all SLPs have received
specialized training in AAC. This has created a shortage of expert practitioners in geographical
locations. Not only do families of children with ASD and other developmental disabilities report
problems coordinating and securing support (Mandak & Light, 2018), but frequently receive
service from multiple disciplines including, occupational therapy, applied behavior analysis, and
speech-language therapy. It is important for all practitioners serving non-verbal children to be
adequately trained in AAC strategies to promote future development of communication after
initial evaluation and acquisition of AAC. Practitioner education should include training in
family support strategies related to AAC intervention.

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Nurses’ role. Advanced Practice Nurses (APN) are increasingly filling the gaps with
specialization in caring for the family living with DDs. Nurses are usually the first point of
contact for families with children having DDs, and excellent choices as primary providers and
long-term coordinators of care. APNs have a strong educational background in collaboration,
advocacy, and case management. Collaboration with an APN ensures integrity of treatment
programs across disciplines necessary to meet communication goals.
Family-centered services are important since the family will spend the greatest amount of
time with the child (Bellomo, 2016; Mandak et al., 2017). A child’s lack of functional
communication is a contributing factor to the family’s social isolation, productivity losses,
caregiver stress and financial burden which continue through the lifespan (Buescher, Cidav,
Knapp & Mandell, 2014; Mandak et al., 2017; Van Tongerloo, Van Wijngaarden, Van der Gaag,
& Lagro-Janssen, 2015). Research shows that interventions to support communication can be
taught in the classroom and at home, however, few studies have been conducted on teaching
communication in the community (Logan, Lacono & Trembath, 2017; Senner & Baud, 2017,
Stadskleiv, 2017). APNs are skilled at developing and sustaining therapeutic relationships with
patients, families and communities (American Association of Colleges of Nursing, 2006). These
attributes allow the APN to pioneer delivery models such as a social-learning group to foster
development of communication skills for children using (AAC) and their caregivers.
Outreach. Light and McNaughton (2015) stressed the need to create real-life
communication opportunities in the community with families as these were seldom targets in
AAC education. Creation of social groups led by practitioners allow greater distribution of
services in areas where a shortage of providers exists. In addition, when students of health
professions, such as nursing students, occupational and speech therapy students, are also
included in outreach, resources become exponentially more plentiful. Innovation then creates an

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interactive way for caregivers to access support and decrease isolation where little opportunity in
the community currently exists. Children will benefit from development of social language skills
required for making friends and becoming independent. Caregivers will benefit from an
opportunity for meaningful participation in their child’s care, fostering potential relationships,
increased advocacy skills, and specialist care at minimal cost (Hall & Graft, 2010).
Assumptions
1. Families want their children to experience a happy and meaningful life.
2. Children using AAC want to participate in their environment.
3. Children using AAC have something to tell.
4. Families want to extend the circle of communication partners for their child though
AAC use.
5. Families desire independence and communication competence for their child.
6. Families have limited resources and/or access to support services which foster
communication.
7. Families desire social outlets.
8. Families value the use of technology for education delivery and support.
9. People learn best through education, practice and feedback models.
10. Modeling is effective at increasing AAC use among AAC users.

Chapter 2
Review of Related Literature
Despite the body of research supporting the use of modeling in AAC, children and
families struggle to effectively and efficiently use it (Andzik, et al., 2018; Bellomo,2016, Logan,
et al., 2017). A lack of qualified AAC providers is a barrier for children with CCN to develop

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the skills for effective communication (Crisp et al., 2014; Sanders, 2017; Senner & Baud, 2017).
Given the importance of communication for independent functioning later in life, a review of
the research was undertaken to determine whether a social-learning group would be
beneficial. This section reviews studies that examined perceived efficacy, evaluated methods
for promoting communication skills of AAC users, or generalized competence across settings.
Studies were evaluated to determine content, delivery, and evaluation methods for
communication partner training in the community setting. In addition, Bronfenbrenner’s
Bioecological Systems Model is presented as a framework for this study.
Perceived Efficacy and Module Design
The term parental efficacy is a term frequently confused with competence. Efficacy is
the belief that one can be successful performing an activity. Therefore, efficacy is both the
knowledge and belief that the action can be completed. (Bandura, 1977). Competency differs
from efficacy because competency refers only to the ability of task completion. (Wittkowski,
Garrett, Calam, & Weisberg, 2017). Perceived self-efficacy (PSE) is a predictor of parent
functioning. Steca, Bassi, Caprara and Fave (2011) evaluated PSE of 130 parents and their
adolescent children using 25 items from the Perceived Parental Self-Efficacy (PPSC) Scale.
When comparing parent self-ratings, children of parents with high PPSE scores were more
motivated to perform in academics and develop independence in associated tasks. In contrast,
adolescents with parents who had low PPSE were less motivated to engage in academic
activities. Therefore, efforts to increase parental PSE may be valuable in developing
communication competence in children who use AAC.
According to Bandura (1977) several factors contribute to the perception of selfefficacy, including one’s previous mastery with a task and watching others in a similar
situation. In order to perform successfully, the skills of the task must be understood (Gist &

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Mitchell, 1992). This framework supports parent participation in knowledge-based
interventions to support AAC users. Senner and Baud (2017) conducted a study examining
the use of an eight-step instructional model to train school staff in modeling. The model
resembled BST consisting of (a) instruction (b) modeling (c) practice (d) feedback (e)
coaching (Miltenberger & Roberts, 1999). Behavior skills training not only includes
acquisition of knowledge necessary to perform modeling but also includes practice and
coaching. Senner and Baud (2017) successfully used these steps to increase the frequency of
teachers modeling AAC in the classroom environment. Applying Bandura’s theory and BST
can be used to create a social-learning module for a group of parents.
Parent perceived efficacy is not the only valuable perception. Tönsing and Dada (2016)
employed a mixed method design to measure teacher perceived competence with AAC.
Teachers rated their ability to support users with a 4-point Likert scale resulting in a mean
score of 2.5. Despite feeling somewhat competent, more education in supporting AAC users
was desired by 92% of the respondents. Lack of knowledge was identified as a barrier to
supporting AAC user by SLPs, parents, and teachers (Anderson et al., 2014; Bellomo, 2016;
Crips et al., 2014; Clifford & Minnes 2013, Sanders, 2017; Stadskleiv, 2017).
A participatory observational study by Stadskleiv (2017) noted parents of children
with AAC devices are unfamiliar with device programming and usage. This researcher
launched a support group for six families whose children participated at a pediatric AAC
habilitative unit. One of the aims of the study was to assist parents to develop competence and
confidence with AAC. Both parents and professionals participated in group discussions. Field
notes from this study revealed six themes that commonly occur in AAC literature: (a) child
characteristics, (b) general development, (c) communication devices (d) AAC, (e) language
development (f) policy. In concert with Bandura’s framework, providing knowledge support

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to a group of parents enhanced parental competence through shared experience with others in
similar situations. Evidence was drawn from reciprocal participation and development of
community initiatives by the parents. Results of this study cannot be solely contributed to the
support group. History and maturation must be considered in this five-year study.
Online Instruction Modules
Bellomo (2016) administered the Usage Rating Profile-Intervention Revised (URSPIR) to measure self-efficacy of parents of children who use AAC and learned modeling
technique from online multimedia training materials. The URSP-IR is a 5-point Likert scale
questionnaire consisting of 40 questions. The pre-test and pos-test format revealed increased
knowledge in effective communication strategies led to increased parental self-efficacy of
modeling techniques. This demonstrates efficacy is increased with knowledge and that online
education is viable method for parent training in modeling techniques. Similarly, Clifford and
Minnes (2013) utilized an online format to provide emotional support to parents of children
with autism. Satisfaction surveys of the participants found the format to be acceptable as a
method to provide support despite lack of statistical significance in measures parenting stress
or positive perceptions between the support group and control. Similarly, Sanders (2017)
found that parents preferred receiving AAC support in person meetings or online training
videos as opposed to phone or email. Research indicates that parenting a child with language
disorders is extremely stressful (Buesher et al., 2014; Clifford & Minnes, 2013), and parent
support groups can be helpful to families (Bellomo, 2016; Clifford &Minnes, McNaughton, et
al., 2008).
Community Setting
A systematic review by O’Neill, Light, and Pope (2017) identified partner modeling,
long-term communication ability as well as intensity of intervention as research priorities in

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the area of AAC. Researchers screened 731 records for the review. Only 3 of 28 included in
the review involved teaching modeling in a group, one of which included interventions in the
community. Further research is necessary to determine how communication skills learned
during the school years support independent living after graduation.
A child’s communication competence cannot be delegated to one person. Parents,
teachers, and providers must support language development of AAC users across activities,
settings and people (Bronfenbrenner, 1986; Mandak et al., 2017; Stadskleiv, 2017). Seven
parents of individuals with CP who used AAC devices participated in a focus group study to
examine the challenges of learning with ACC. Six themes emerged from the online discussion
including opportunities for use in the community setting (McNaughton, et al, 2008). Parents
reported struggling with communication in the community setting. One parent stated,
“Although it is quite portable, she rarely uses it out of the house…” (McNaughton et. al.,
2008, p 50). In addition, parents expressed the lack of friendships with peers and activities
available in the community created barriers to communication by leaving nothing interesting
to talk about. While there are limited studies examining AAC use in the everyday setting
(Logan et al., 2017), the body of research is steadily growing in the school realm for children
under age 12 and their communication partners.
Many studies involving preschoolers have used playtime activities either at school or
in the home to create natural opportunities for language, but rarely generalized to the
community setting (Kasari et al., 2014; Kent-Walsh, Binger, & Hasham, 2010; Romski et al.,
2010). Dada and Alant (2009) evaluated modeling during arts and crafts as well as food
preparation activities providing more hopeful potential for generalization toward independent
living skills. While participants in this study were upper elementary age children, few have
studied AAC intervention in adolescents and adults.

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Parents are not the only group struggling in creating communication opportunities. A
study by Anzik, Chung and Kranak (2016) reported in a study of 23 students ages 6-11, were
presented with approximately 17 communication opportunities per hour during the school
day. While this may seem like a lot, when the opportunity was presented the student only had
access to their AAC device about half the time and the majority of the interactions were
presented by adults. Creating opportunities for students with AAC to develop communication
competence must be deliberate and planned (Kent-Walsh, Murza, Malani & Binger, 2015).
Modeling Intervention
There are several methodologies used to promote and develop communication skills in
children who present as non-verbal. The most common methods for promoting communication
of AAC users are aided language stimulation (modeling).
Typical children learn to speak by hearing language spoken. Children who use AAC need
to have the same symmetry between language taught and language produced. Modeling is the
visual demonstration of language by a communication partner (Sennott et al., 2016).
Studies have shown that communication attempts of an AAC user increase when
modeling is part of the treatment package (Beck, et al., 2009; Dada & Alant, 2008, Kasari et al.,
2014, Rosa-Lugo, & Kent-Walsh et al., 2010; Kent-Walsh, Binger & Buchanan, 2015; Romski et
al., 2010; Solomon-Rice & Soto, 2014) or when used alone ( Dada & Alant, 2009; Drager,
Postal, Carrolus, Castellano, 2006; Harris & Reichle 2004; Hughes et al., 2000; Romski et al.,
2010). The number of times a communication partner should provide a model to be effective
remains unclear. Researchers have measured the frequency of modeling by both percentage of
opportunities (Dada & Alant, 2009) or number of times per session (Binger, Kent-Walsh, Ewing,
&Taylor, 2010; Drager et al, 2006; Binger & Light, 2007) as well as acquisition of target
vocabulary (Drager et al., 2006, Dada & Alant, 2009; Romski et al., 2010; Soloman-Rice &

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Soto, 2014), or number of communicative turns (Beck, et al., 2009; Sennot et al., 2013).
Systematic reviews (Sennott et al., 2016; Lynch, McCleary, & Smith, 2018) and meta-analyses
(Kent -Walsh, et al., 2015; O’Neill et al., 2017) examined 35 different studies providing
modeling effectiveness. Visual inspection of data shows most studies involve children ages 3-12
and occur in school or a research room. Story book reading is the most common activity used to
either provide direct intervention or teach communication partners how to model. Multiple
studies have shown success with teaching modeling to teachers (Binger et al., 2010; Senner &
Baud, 2017; Chung & Carter, 2013) parents or caregivers (Beck et al., 2009; Bellomo, 2016;
Kent-Walsh et al., 2010; Rosa-Lugo & Kent-Walsh, 2010) and peers (Hughes, et al., 2000;
Trottier, Kamp & Mirenda, 2011; Lilienfeld& Alant, 2005) as communication partners.
Studies have shown variability in the amount of pre-service training partners need to
perform modeling effectively (Bellomo, 2016; Binger et al., 2010; Binger, Kent-Walsh,
Berens, Del Campo, & Rivera, 2008; Chung & Carter, 2013; Senner & Baud, 2017). The
minimum amount of pre-service training delivered to peer communication partners was 45
minutes, however, due to lack of results additional training was necessary (Chung & Carter
2013). Two separate parent training programs provided approximately 2.4 hours of training
(Binger et al, 2008 & Binger et al., 2010), while a third provided almost 6 hours of parent
training (Rosa-Lugo & Kent-Walsh 2010) to demonstrate successful gains. Bellomo (2016)
provided 1.5 hours of online training and measured parental knowledge and PSC increases.
However, this study lacked direct measurement of the learned skills. Senner and Baud (2016)
demonstrated modeling technique in the classroom during the course of normal ongoing class
activities. During the normal classroom activities, the researchers provided coaching and
feedback to successfully increase the frequency of modeling of teachers and
paraprofessionals. There was no special preparation of materials. Applying a similar method

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of coaching and feedback in the community combined with instruction via social media,
suggests that modeling can be taught to caregivers in a similar fashion.
Theoretical Frameworks
Research suggests that family-centered services are needed to successfully support
development of communication skills in AAC users (Fraenkel, 2006; Granlund et al., 2008;
Mandak, et al., 2017; McNaughton et al., 2008). In addition, there is little research examining
the best way to target communication skills in the community through the lifespan (Light &
McNaughton, 2015).
Despite the recognition by professionals of the need for collaboration and familycentered services, a lack of a specific framework and support continuum for delivering
services continues to be a barrier (Mandak et al., 2017). Beukelman and Mirenda (2013)
created the Participation Model for Augmentative and Alternative Communication, which
highlights the importance of environmental supports and barriers of optimal AAC use.
Despite this model’s inclusion of the family and environment as essential, the focus of AAC
intervention continues to focus on the individual rather than the family unit (Light &
McNaughton, 2015). In addition, the International Classification of Functioning, Disability,
and Health (ICF) provides a common language for describing function, and marries social and
restorative functions. It is both a classification system and conceptual framework. Despite
early adoption by American Speech-Language Hearing Association (ASHA) few
professionals have adopted this model. ICF is considered a bioecological model. While the
model takes into account personal factors such as life experiences, social, education, and age
etcetera, they are not included in the classification system. This may contribute to the lack of
adoption (Blake Huer, & Threats, 2016).

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In addition to guiding areas of future research, application of a theoretical model can
provide a purposeful direction for community interventions. The theoretical framework of this
study is based on a bioecological systems approach developed by Bronfenbrenner (1986).
Similar to social-learning theory (Bandura, 1977), ICF Model (WHO, 2001) and behaviorism
(Skinner, 1974), this model attributes learning and development to environmental influences.
Four foundational concepts imbedded in the bioecological model include: process, person,
context and time. Together, these four interconnected systems influence human development
(Tudge et al, 2016). Human development encompasses development of communication and
independence.
Bioecological Model Application
Bronfenbrenner (1986) suggests processes are the interactions that occur between
environmental objects and other people in the environment. The primary focus of this study is
examining the reciprocal processes that occur during interactions between a family and the child
while using the AAC device in the community. The concept of person refers to individual
characteristics and experiences that may motivate a person or family to respond or participate in
daily activities (Bronfenbrenner, 1986; Bandura, 1977). A non-verbal child’s inability to have
basic needs met without an AAC method exemplifies both motivations and characteristics shared
by all participants in this study. Likewise, a family’s inability to understand the child affects the
child’s development and the family’s motivation to learn AAC.
Environmental subsystems represent the natural contexts in which children and families
live. There are three environmental subsystems (a) microsystem, (b) exosystem and (c)
macrosystem (Bronfenbrenner, 1986). For example, the home is considered a microsystem where
a child spends the most time interacting with immediate family members, extended family

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members and possibly other caregivers. Each environment encompasses different motivating
factors that encourage or discourage use of AAC by the family or the child.
Exosystems are systems that influence the child even though the child may not be present
at the time an interaction is occurring (Bronfenbrenner, 1986). The school is an example of an
exosystem. During school, the child learns literacy, social skills and how to access AAC. While
at home or in the community, the teacher is not present; however, the daily learning that occurs
at school influences the child’s social actions and use of AAC. The same is true for the
professional environment. The professional environment may consist of doctors, nurses, SLP,
occupational and physical therapists, as well as behaviorists. Therapies and care provided in
professional settings influence the child’s development at home, school and the community even
though the practitioner is not present. Because each exosystem exerts influence on another
exosystem, they are represented by overlapping circles in the diagram representation (see Figure
1).
Mesosystem, represented by the grey, circular, arrow, overlay illustrates the continuous
multi-directional relationship that occurs between multiple settings or systems. For example,
professionals interact with the family, school, and community by providing appropriate supports
to foster communication development. The school setting interacts with the family,
professionals, and the community to achieve the same goal. The relationship between the family
microsystem and the school exosystem, the community and school exosystems is multidirectional.
The community is a group of people who gather outside the home setting and share
similar interests and activities. A parents’ work place and social supports reside in the
community. Applying Bronfenbrenner’s model, community can be viewed as a both a
macrosystem and exosystem. Place of employment, recreation opportunities, social or religious

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gatherings and local businesses are examples of exosystem contexts that affect a child’s
adaptation. However, societal norms and values in regard to disability awareness, access, and
prejudices can also affect these opportunities. In the United States, the American Disabilities Act
(1990) promotes inclusion, however, similar laws may not be present in other countries or
cultures. In this context the community is viewed as a macrosystem. A social-learning group that
meets at a restaurant represents an exosystem. When a family and a child with AAC patronize a
restaurant the family microsystem moves into the community exosystem. The restaurant design,
other patrons, service and previous experience affect the success or failure of the child’s
interaction within that system. The restaurant as a macrosystem is exemplified by the ability of
the child to access the menu whether in print or pictures. Willingness of staff to allow sufficient
wait-time for the child to formulate an order on the AAC device, eye contact and directing
questions toward the child instead of the parent when the order is placed. While such actions are
seemingly normal for most, societal norms are actually responsible for attitudes toward
individuals with disabilities and represent the macrosystem affecting communication
development. Services and therapies should be designed to provide the families of AAC users
the necessary supports to develop communication competence and independence to children who
use AAC.
The final system in the framework is a chronological system. Time is a chronological
system that occurs both within and across subsystems as well as though the lifespan. As time
passes, there is a directional process of development. Development can move forward, remain
stagnant or regress. Health, learning and level of independence also move along a continuum
with the progression of time. The corners of the triangle represent the chronological continuum.
For example, a child may experience a level of independence with communication in school, but
not the community. Likewise, level of communication once obtained may regress if the child

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experiences a change in health, educational placement or family disruption such as a divorce or
moving to a new home. The double-headed arrow represents the passage of time within
subsystems and though the lifespan. When regression occurs, time is considered “lost”.
Typically, this model is represented by concentric circles. While continuous in nature, a
circle has no end and no beginning. Communication goals have a clear beginning and end; it is
how progress is measured. Therefore, the triangle is a better representation of the processes
involved in growing communication competence. Communication competence, is the apex of a
pyramid requiring a strong foundation of support in health and learning. Coordination of goals
through all systems creates a synergy toward independence and communication competence.
Application of the bioecological systems model recognizes that a child cannot be
separated from the family unit and the family unit is affected by all the feelings, interactions, and
roles of other family members. Together the family unit interacts with each other and subsystem
contexts such as work, school, and the community (Mandak, et al. 2017). In turn, these
interactions foster development of communication competence across time for the entire family.
While communication development is concurrently occurring and being supported in other
subsystems, the focus of this study is only the community subsystem.

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Figure 1. Theoretical Structure adapted from Bronfenbrenner’s Bioecological Model
This section reviewed research studies conducted with the aim of increasing
communication partners effectiveness in modeling AAC to children with communication
challenges. Modeling was found to be an effective intervention for increasing a child’s AAC
skills and communication ability. Methods for disseminating information were also examined.
Online instruction was found to be an emerging method for teaching communication partners.
Finally, Bronfenbrenner’s Bioecological Model was explained. Applying bioecological concepts
can guide interventions for families and children with AAC allowing participation in their
communities to the highest level possible.

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Chapter 3
Methodology
This section will describe the sample, methods, and design for the study. This section
defines a social-learning group as the independent variable in this pilot study. In addition, the
measurement of the dependent variable is also identified.
Recruitment
After Institutional Review Board (IRB) approval, a convenience sample of three families
was obtained from a Northeast Florida Community. Participants were recruited from email,
social media sites, as well as already established local public schools’ notification system, local
children’s hospital departments’, private special needs schools’, and private therapists’ email
distribution lists and flyers. All participants met the inclusion criteria: (a) live within 45 miles of
Jacksonville, Florida, (b) have the physical ability to participate in activities such as bowling, art,
and eating at a restaurant (c) be free from behaviors of self-injury, aggression toward others, and
property destruction. (d) have access to AAC, (e) be engaged and present for the entirety of the
group (f) provide informed consent or assent (g) legal guardian of the child who uses AAC.
Excluded were persons whose children had age appropriate language skills, younger than six
years or older than 13 years.
After consent, assent, and HIPAA authorizations were obtained, demographic
information about the parents and their child AAC user was collected by the researcher using a
survey and personal interview (see Appendix B).
Participants
Demographic information was collected in the participants home with children present.
Interviews lasted between 30 and 40 minutes. The following information was collected at the

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initial interview; parent’s age, child’s age, number of years using current device, type of device,
parents gender, child’s gender, child’s diagnosis by parent report, child’s grade, parent’s highest
level of education, parents judgement of child’s estimated mental age and prior exposure to AAC
training (Terry, 2015). Demographics for the child participants are displayed in a Table 1.
Demographics for the caregiver participants are displayed in Table 2 (Sylvia & Terhaar, 2014).
Participants are identified by alias to maintain confidentiality.

Table 1. Demographics for children participants.
Gender

Diagnosisa

Age

Estimated
Age

Time with
current device

Type of
school

ASD, CP
DS
ASD

11y 3 m
11y 1m
13y 4m

2
6
4

<1y
<1y
>3y

Public
Public
Public

Child alias

Katie F
Tonya F
Tyler M
a

ASD: Autism Spectrum Disorder; CP: Cerebral Palsy; DS: Down Syndrome

Table 2. Demographics for caregiver participants.
Gender

Agea

Ethnicityb

Education

Received
training

Uses
at home

Takes
in public

F
F
F
M

40
50
30
40

W
AA
W
A

College Graduate
Some College
College Graduate
Graduate School

Yes
No
No
No

Some
Never
Seldom
Never

Seldom
Never
Never
Never

Caregiver
alias
Katie’s Mom
Tonya’s Mom
Tyler’s Nanny
Tyler’s Dad

a

30: 30-40 years old, 40:40-50 years old 50:50-60 years old
W: White; AA: African American A: American

b

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Characteristics. Three caregiver(s) and children teams with children age 11 to13 who
use a speech generation device (SGD) as their primary method to communicate agreed to
participate in the study. The caregivers consisted of the biological mother for two children, and
the biological father and nanny for the other child.
All of the children attended public schools. Two children attended schools as same-age
typically developing peers, but were in self-contained special education classrooms. The other
child attended a center school, specially designed to educate only students with special education
needs. The public school suggested and provided an AAC device to one of the children. The
other two children were provided devices through private speech therapist evaluations and
treatment. Two of the children made some word approximations understood by the family, but
not understood by people unfamiliar with the child. One child made sounds but no
understandable word approximations.
Type of device. All of the children used speech generation AAC on a portable electronic
device (iPad or Windows tablet) and spoke English. Each of the children’s devices ran different
communication applications. The following applications were in use: Saltillo TouchChat-HD
with WordPowerTM with 108 icons on the display, AssistiveWare® Proloquo2Go® with 8 icon
display, and tobiidynavox Snap + Core First for Windows, with 4 icons visible (un-hidden) on
the home screen. All device vocabulary contained mostly single words or single words and
symbols organized with core words on the home page. Vocabulary was also color-coded to
identify parts of speech (verb, noun, adjective). Snap + Core First for Windows contained more
pre-programed phrases than the other two devices.
Motivation. The interview ended with an open-ended question asking the caregiver to
describe any training received about their child’s communication device. This question prompted
participants to express their motivation for responding to the study.

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Tonya’s mom who had no training with the device stated she did not know how to use
Apple products. Tonya’s mom stated, “She [Tonya] seems to know how to use it, she’s used it
once or twice to ask.” Although Tonya’s mom can understand her daughter’s approximations,
she stated the school suggested the device because Tonya is difficult to understand. Tonya’s
device was provided by the school.
Katie’s mom has previously participated in a study for fostering communication. The
study was conducted by a university to evaluate a picture exchange method and did not use an
SGD; however, the intervention could be considered as a prerequisite skill to acquiring SGD.
On a separate occasion last fall, she also completed a device trial with SGD from a device
loan program. Loan programs allow AAC users to trial devices prior to purchase to ensure a
proper match with the user’s abilities. The device had nine programmable buttons and stored up
to 45 messages. Paper templates could be inserted into the device to change the meanings of the
nine program button options. The parent reported that for the first time Katie was very
responsive to AAC. In just a few weeks she could ask for highly preferred items, however, it
was cumbersome and limiting for the family. Her mom stated, “We don’t want the device to tell
us what she can do.” The family had to return the loaned device at the end of the loan period and
chose not to purchase it.
Katie’s mom is familiar with some concepts of modeling, but does not currently use it.
Katie received her current device approximately one month before the study began. Her mother
reported that Katie does not locate the device and use it to communicate. The family is able to
understand her body language for meeting her basic needs. Participation in the study stemmed
from an interest in learning how to use the device in the community and “How to get her to bring
it to us, or let us know she wants to use it to communicate or what we are going to do with it,” as
stated by Katie’s mother.

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Tyler’s nanny has cared for him after school for 5 years. She agreed to participate in the
study when approached by the parent because she would like to learn how to help him
communicate better.
She states that Tyler typically uses the device to ask for food. Often, he will point and
make vocalizations, but is not understood. She reported no previous training in AAC. When his
nanny first began working for the family, she was shown by the parent how to navigate to the
food page and simple activities that Tyler may ask for. The family also requested she take the
device on outings. While she does take the device in public with him, he does not use it. She
stated he used it at the zoo one time when she asked, “What animal is that?”
Design
A mixed method design was used to determine if participation in a social-learning group
affects the frequency of the communication partners’ modeling (Hitchcock, Nastasi, &
Summerville, 2010; McDougall, Hawkins, Brady, & Jenkins, 2006). A single-subject
experimental A-B design (SSD) provided quantitative data for intervention effectiveness while
non-experimental qualitative methods yielded descriptive phenomenologic data. In the SSD,
each individual participant served as his/her own control. Graphing of data allowed visual
analysis as a measure of comparison from week to week, as well as relationships between the
baseline and experiment conditions over time (Cooper, Heron, & Heward, 2007; Hitchcock et al.,
2010). Social media comments and posts as well as postintervention satisfaction survey provided
data for qualitative analysis.
Rationale for SSD
Given the low incidence of the population being studied, determining a sample size for a
population study would be impractical (Balasubramanian, Shetty, TS, & Mani, 2017). Survey
answer options are too restrictive and would not reveal details. Additionally, a SSD was chosen

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because the subject serves as its own control across time when the treatment phase is applied
(Hitchcock et al., 2010). Classic changing criterion design was considered as appropriate for
evaluating the effects of teaching modeling expected to in a therapeutic direction is expected
(Klein, Houlihan, Vincent, & Panahon, 2017; McDougall, et al., 2006), however, the length of
the intervention would not allow enough data collection points to ensure stability (McDougall et
al., 2006). In addition, modeling behavior is likely to develop through shaping. Changing
criterion designs are not appropriate for shaping successive approximations of behavior (Cooper
et al., 2007).
Using the multiple baseline design (MBD) for demonstrating experimental control is
another way to demonstrate effectiveness of an intervention. However, MBD requires extended
baseline data and participants to begin the intervention in a staggered fashion. Because the
intervention being tested involved a social group, all participants must begin the intervention
together. One person cannot be social without other participants. In addition, because the
intervention is educational, one cannot unlearn material taught. This makes true reversal designs
such as a single subject ABAB design impossible (Cooper et al., 2007; McDougall et al., 2006).
Intervention Materials
Before implementation of the social-learning group, several steps were taken to ensure
the content validity and feasibility of the online learning materials. Three content expert
reviewers who work with children and families using AAC were chosen from the disciplines of
special education, speech language pathology, and applied behavioral analysis to review
intervention materials. Each reviewer had a minimum of 5 years’ experience in his respective
field. Each reviewer was paid a $10.00 gift card upon completion of his review. Reviewers
received content outlines for each week of the study via Facebook (Fb) Messenger. Each week
included (a) written learning materials (b) video links (c) description of community activities and

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(d) an invite to access the Fb page. No instructions were provided in regard to how to access the
content on the Fb page. Reviewers did not have difficulty accessing the content and were able to
view and “like” content without explicit instruction. Had the reviewers needed additional
instruction, it would have been provided.
After reviewing the materials, experts completed a 10-question Likert scale survey
developed by the researcher to facilitate and promote consistency of evaluation (see Appendix
C). A mean score from all three experts established the quality of the materials (CastilloMontoya, 2016). All experts “agreed” or “strongly agreed” the materials were appropriate and no
revisions to the materials were recommended. One reviewer neither agreed nor disagreed to
whether the community activities would provide sufficient modeling opportunities. This
response was not surprising as it is the basis of the study. In addition, the use of the word
“sufficient” in the question may have been too subjective considering the number of times a
partner should model remains uncertain (Beck et al., 2009; Binger et al., 2008; Dada & Alant,
2009; Drager et al, 2006).
Written instructional material was provided by AssistiveWare® who is a leading pioneer
in the field of augmentative and alternative communication (AAC) and assistive technology
software. The company’s mission is to help build a world without communication barriers, thus,
granted copyright permission to use and adapt their teaching materials for this study (see
Appendix D).
Videos links included in the training were accessible through YouTube. Videos were
chosen to enhance explanations and demonstrate techniques explained in the written learning
materials. Links were presented in the Fb unit material for each week. When a reviewer clicked
on the link, a separate window opened and played the video. Videos included multiple exemplars

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of modeling demonstrations from both professional and families in a variety of settings and
devices.
Community activities were chosen for ease of accessibility and age appropriateness. The
activities chosen for this study included: selecting and reading a book at the public library,
making microwave mug cakes in a separate activity room at the public library, and attending an
children’s exhibit at the museum of science and history (MOSH). Due a scheduling conflicts,
session two was conducted in the participant’s home.
Procedure
After the participants were identified, the researcher met with the family in their home to
complete consent and assent to participate. After consents were obtained, parent interviews were
conducted in the home with the child present to collect demographics and baseline data.
Baseline. Participants chose a time in which they are normally home with their child.
During the interview, participants were told to go about their normal routine. The researcher
collected baseline data by documenting the number of times the caregiver used the AAC device
with the child. At the conclusion of the interview if the participant had not interacted with the
child using the AAC device, the researcher asked the caregiver the following question, “Can you
use AAC to read a book to your child?” If the caregiver read a story, frequency data on the
number of models provided during the interaction was recorded and reported as rate. If the
caregiver was unable, a second request was made, “Show me an activity other than reading that
you might be able to do with your child and their AAC”. If the caregiver was unable, the
researcher provided an empathetic statement, “I am excited you have decided to join the study,”
and concluded the interview. None of the participants were able to demonstrate the skill of
modeling. A leave behind folder was provided to the participants with the start date of the study,

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instructions to log in to the Fb study page, a copy of the signed papers as well as a contact
number to reach the researcher.
Intervention. After the collection of baseline data, participants were invited to a closed
group Fb page to access written and video training materials. The secret mode in Fb was applied
to ensure confidentiality of the group. All caregivers gained access to the Fb group at the same
time. Instructions for accessing the educational material on Fb, posting and research procedures
were verbally explained and provided in writing to the parent at the initial interview. Caregivers
were provided opportunities at the initial interview and subsequent weeks to ask questions,
clarify information and withdraw from the study if they choose to do so.
Each week, on Sunday, participants were expected to access Fb to view new learning material.
Training caregivers to perform the skill of modeling followed the protocol for conducting BST.
The first step in BST is providing the participant with a written description of the skill. Step two
includes demonstrating the target skill. Steps one and two were posted on the Fb page.
Participants accessed the unit section to receive written instructions about modeling on AAC
devices. Then, demonstrations of the skill were performed by the researcher or other AAC users
in videos posted on YouTube. Links to videos demonstrating how to model AAC were
embedded into the learning units. Learning units were designed to take less than 15 minutes to
view.
The third step in BST requires the learner, or caregiver in this case, to practice the skill.
After viewing the learning units in Fb, participants were asked to practice the new techniques at
home or in the community with their children between group meetings. Each week parents were
asked to subjectively report if the learned information increased the number of times modeling
was utilized at home or in the community. This was measured by asking the parent to compare
the use of their child’s device to the previous week using a Likert scale with participant as “1” no

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more use, “3” same use and “5” a lot more use. Engagement statistics automated by Fb were
examined as a method to gauge parent participation as well as attendance at social group
meetings.
Step four in BST requires the trainer, or researcher in this case, to provide feedback and
coaching to the participant during practice. Once a week for three weeks, teams met to practice
the new skills in the presence of the researcher. Prearranged, one-hour, community activities
included reading, cooking, and visiting the MOSH. Data were collected on the caregiver’s
frequency of modeling during the first 10 minutes of the session. This was done because
behavior and attention of children with disabilities can be unpredictable in an uncontrolled
environment. Next, feedback and coaching were provided to the participants. Additional data
were collected on the caregiver’s frequency of modeling at subsequent meetings. During weeks
two and three, the participants were exposed to addition information that was intended to
improve modeling skills. Goals, methods and assessments for each week of the study are
contained in the intervention module plan in appendix E. Each week followed the same
procedure: view information on Fb, individual practice, group activity practice, data collection,
feedback and coaching.
Using direct observation by trained data collectors and digital cameras, event recording
was used to capture the frequency of modeling (Johnston & Pennypacker, 2009). Frequency was
measured using tally counters. The researcher had active direct participation and provided
coaching to foster use of modeling during the group activity. Tyler’s AAC system had
RealizeLanguageTM data logging capabilities (Prentke Romich Company, 2014). Katie’s AAC
system had Snap + Core First data logging feature and was activated through
mytobiidynovox.com on day seven of the study. Usage reports indicate when users are most

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engaged with their AAC, and the most frequently used messages. This allowed triangulation of
data to assure validity.
Interobserver Agreement and Reliability
When repeated measures of the same event yield the same results, it is said to be a
reliable measure. For example, if the same observer counts the number of caregiver models
today, as counted in the video recording of the same event a week later, then reliability is
established. Interobserver agreement (IOA) refers to the degree of which two or more
independent observers report the same counts when measuring the same event. A high degree of
agreement between observers ensures the target behavior definition is clear and that the data is
believable and trustworthy (Cooper et al., 2007).
Data collectors were students recruited from a private, accredited, associate degree,
nursing program. Release from clinical time was given as compensation. After completing the
Human Subjects Researcher Course, observers were trained in data collection procedures.
Because human error is the biggest threat to accuracy and reliability of data, observers received
systematic training and practice (Cooper et al., 2007). Training lasted approximately two hours.
Observers were trained to measure modeling behavior of the caregiver. They were provided a
definition of what modeling is and what it is not. Multiple exemplars of modeling were provided
by the researcher and through the use of videos. Videos demonstrated modeling in various
settings with multiple AAC (SGD and static). Observers practiced and discussed modeling
observations as a group during the training. One week later, IOA data were collected. IOA was
pre-determined at 80%. Observers independently watched a series of six videos demonstrating
modeling. They were instructed to record the number of models observed in each video. Once
viewing was competed, IOA was compared between observers 1 and 2; 2 and 3;1 and 3 (See
Appendix F).

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For this study, the total count-per-interval IOA and mean count-per-interval IOA were
greater than 93%. Each observer used the same observation code and measuring system.
Observers were paired with a participant team. Observers independently measured the same
participant at each event. Observer measurements were compared to 20% of the audio and video
recordings by the researcher for accuracy.
Quantitative Data Collection
The first day of Fb access marked the beginning of the intervention phase. Participants
came to the first activity having already viewed the educational materials on Fb 5 days prior.
The independent variable was participation in a social-learning group. A social-learning group is
a group of participants who meet for a social activity in the community while concurrently
receiving education about their child’s communication device. In this study, participation was
measured when the participant viewed educational materials presented in Fb in addition to
attending weekly community outings with their child over a three-week period. Caregiver
modeling was the dependent variable in this study. Caregiver modeling occurs when the
caregiver activates one or more key words in a spoken phrase on the child’s SGD during an
interaction with the child. An operational definition of modeling can be found in appendix G.
In addition, participants were asked to rate how often modeling was used at home and in
the community each week. Subjective data were collected from the participants using a Likert
scale (Appendix H). Participant collected data assist in providing social significance of the
intervention.
Qualitative Data Collection
A 16-question, 5- point Likert scale post-intervention survey was used to generate
qualitative data regarding modeling in a community setting. Participants were asked to evaluate
the usefulness and quality of teaching via Fb and social group sessions. Survey data were

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collected at the end of the last session. Questions one through twelve were rated by the
participant as “1” strongly disagree, “3” neutral and “5” strongly agree (See Appendix I).
Descriptive analysis for each of the 14 questions was reported by a mean score taking in to
consideration reverse scoring for items 7 and 11 (Bandura, 2006). Questions 15 and 16 posed
open questions which were analyzed and common themes reported.
Method triangulation using direct and video recorded observation, post-intervention
surveys, device data logging and Fb posts was performed. Data triangulation identified
convergence of data by cross referencing the satisfaction survey and Fb conversations with the
single subject data. This added credibility of the design which does not have an extensive
baseline or reversal phases (Carter, Bryant-Lukosius, DiCenso, Blythe, & Neville, 2014; Fusch
& Ness, 2015).
This section examined a meso-level and micro-level description of the sample. The
setting and procedures for quantitative and qualitative elements of the research design were
described. Intra-observer agreement thresholds were discussed along with methods for
evaluating validity and feasibility of the learning materials.
Chapter 4
Results
This chapter will discuss the analysis of data from quantitative and qualitative measures.
The purpose of this pilot study was to determine the feasibility of social-learning group and its
effects on caregivers of AAC users modeling techniques in both the home and community
setting.
Models Per Minute
Measurements of caregiver modeling which included both home and community settings
showed an increase in frequency over the course of the three-week study. Figure 2 presents the

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number of models per minute each caregiver performed during a planned observation. Overall,
modeling in the home environment was higher than in the community environment. Dad did not
attend any community groups. Nanny averaged 1 model per minute playing a boardgame. After
feedback was provided, she increased to 3 models per minute. She maintained a rate of 3 models
per minute in the Library. All participants increased the number of models per minute when
feedback was provided.

Figure 2. Number of models per minute in both community and home settings. Community
settings included the Museum of Science and History (MOSH) and the public library.
Home and Community Practice
All participants rated using their child’s AAC device “some more” or “a lot more” each
week compared to “no more,” a “little more,” or “same as,” the previous week in the home.
Using the same scale participants rated community use of their child’s device in the community
as “no more” than the previous week. All the participants reported they had not taken the device
in the community setting the previous week.
Modeling and Vocalization
Transcriptions of the recorded sessions allowed comparison of the caregiver’s modeling
and child vocalized output (see Figure 3). During session one, Nanny modeled 20% of her
phrases during a boardgame. Tyler vocalized words that were modeled on the SGD 82% of the

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time compared to 50% of vocalizations of unmodeled phrases. After Nanny was provided with
feedback, she improved her modeling to 42%. When Nanny improved modeling, Tyler improved
his vocal approximations. After feedback, 63% of Nanny’s modeled words elicited clear
vocalizations (spoken words) from Tyler. Unclear approximations that previously occurred
without modeled words decreased to less than 1%. Tyler’s verbal approximations following
modeled SGD output were clearly articulated and understood by unfamiliar people.
Vocalizations occurring with non-modeled phrases or questions consisted of initial sounds or
prosody of syllables and were difficult to understand even by familiar people.
During session two, 18% of phrases were modeled by Nanny and 77% of these models
evoked clear vocalizations. Similarly, 16% of unmodeled phrases or questions that yielded
approximations were not understood.
Tyler

Figure 3. Percentage of Tyler’s vocal approximations compared to percentage of
modeling.

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Table 3. Sample of Tyler’s word approximations during session one.
Modeled
Not modeled
Not modeled
Bird
Not modeled
Not modeled
Butterfly

Nanny’s Verbal Phrases
Do you want to read or play in the sand?
What do you see?
It comes from a bird.
What is it?
What is that?
It’s a butterfly.

Vocalizations
Gu gu
Di di
Bird
No vocalization
No vocalization
Butterfly

During a home observation (session two), Katie’s mom modeled 39% of her phrases.
Forty-seven percent of her phrases were statements and the remaining phrases were questions.
Katie used her AAC to respond to 15% of the questions without a prompt including immediate
presence of a model prompt. Katie’s responses were one word (62%) and two words (37%).
Katie did not verbalize, she did laugh, squeal with excitement and protest at times. Nanny
modeled 54% of phrases as statements and the remaining 43% were questions (see Figure 5).

Katie

Figure 4. Percentage and type of Katie’s AAC responses to modeled questions.

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Modeled
Katie’s mom’s Verbal Phrases
AAC responses
Not modeled
Do you want to play with me yes or no?
(no)Yes
Here, well I want to play with you.
(yes)+
Not modeled
Which toy do you want?
(violet)Your turn
Here your turn.
No response
Not modeled
Make her sing?
No response
Your turn
There, your turn.
No response
Not modeled
Sit up.
No response
Not modeled
What is that?
(go)- (car)Not modeled
Let’s do it together.
No response
Car
Car.
No response
Not modeled
Can you do car.
(car) +
Table 4. Sample of Katie’s AAC responses during session two. Physical or gestural prompted
words are indicated with a (+) sign. Unprompted words are represented by (–) sign.
When comparing samples from session two, Katie’s mom modeled more. However, when
comparing the types of phrases modeled, Nanny modeled more statements and Katie’s mom
modeled more questions. Interestingly, Katie responded independently using AAC to nonmodeled questions whereas Tyler vocalized more clearly when modeled statements were
provided.
Nanny and Katie’s mom

Figure 5. Percentage of modeled phrases and percentage of statements versus questions in
chosen phrases from session two.

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Facebook participation
Four participants accepted the Fb email invite to the online social-learning group. During
week one, there was one learning module to complete, two encouragement posts and a Fb event
invite to the community event at the library. Automated engagement statistics indicated all posts
were seen by all participants. Dad read all posted learning modules but did not attend community
events. The remaining three participants responded to the invite by selecting the “going” button.
Tonya’s mom did not attend the community outing. After two attempts to reach her by phone
and failure to access the Fb group during week two, she was removed from the study. The Fb
page received a total of 13 “likes”, four comments and six event responses. Katie’s mom
participated the most with five “likes” and four comments. No other participants posted
comments. All participants made at least one “like” including Tonya’s mom.
Participants Post-intervention survey (n=3) rated the Fb page as “very good” (4/5) when
all scores were averaged. When asked, participants “strongly agreed” (5/5) that they would
attend an AAC social group if there was no instruction from a facilitator. Participants rated
understanding of how to use modeling (4.3/5), and neither “agreed” or “disagreed” (3.6/5) the
information was new or they had time for modeling in everyday life. All participants “strongly
disagreed” that they would not use the intervention in the future (1/1 reverse scored), and would
attend a follow-up or advanced workshop on the same subject (4.6/5).
Post-intervention Participation Feedback
Participants were asked about the quality of the program in a post-intervention survey.
The results are displayed in table 4. Overall program quality was rated excellent.

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Table 5. Quality of program.
Question
I will recommend the program to others
The program was well paced within the allotted time
The material was presented in an organized manner
The amount of record keeping was reasonable
I have seen my child’s communication improve
Home-School communication is necessary to be successful
How useful were videos
Rate the quality of the videos
Rate the Handouts
Rate the type of activities
Rate the coaching/assistance

Mean (n=3)
5
5
5
4.6
4
5
4.6
4.6
4.3
4.6
4.6

Additionally, two open ended short answer questions asked participants to describe the
best component and areas of program improvement. All participants stated a preference to
increase the length of the study. One participant stated the weekly presentation of information
was a good pace. One participant stated videos were the most helpful as well as being
accountable to someone. One participant stated practicing in the community was the most
beneficial.
Overall, this pilot study supports the use of community-based social-learning groups for
caregiver’s of AAC users. While a community-based social-learning group was effective in
getting caregivers out in the community with a facilitator, it did not increase the independent use
of their AAC in the community. Despite the lack of independent community use of AAC,
participants did increase the use of AAC in the home, independent of a facilitator.
Chapter 5
Discussion, Limitations, and Recommendations
The purpose of this pilot study was three part. First, would participation in a sociallearning group will increase the parent’s frequency of modeling using their child’s AAC device
at home and second would it also increase use in the community. The final part was to examine

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the feasibility of a community-based social-learning program. This section will discuss the
results of the intervention as well as the implementation of a program.
Discussion
Self -efficacy and motivation. Interestingly, both Tyler’s and Katie’s devices were
acquired privately. This could be attributed to motivation of the parents. Both children who are
non-verbal, should have been provided communication devices by the public school but were
not. Public schools are required by the Individuals with Disabilities Education Act (IDEA) to
assess children for assistive technology. It was disappointing to see that all three of the
participants in this study had delayed or no access to communication devices through the publicschool system. Katie’s mom was somewhat familiar with modeling but was not using it. She
stated she was interested in the study to hold her accountable to modeling and specifically get
practice using it in the community, which she does not do. This is consistent with studies that
state watching others in similar situations assist with the perception of our own ability to perform
a skill or task (Bandura, 1977; Gist & Mitchell, 1992)
Tonya’s device was provided by the public school, but not until she was 11 years old.
When Tonya’s mom made the effort to start the study, she demonstrated motivation, however,
she did not complete the remainder of the study after the first week. The researcher attempted to
call her to offer individual support, but did not receive a return phone call after two attempts.
Any attempt to explain her lack of participation would be speculation. It is possible that after she
was added to the Fb group, she felt the information or the group would not provide the support
she was looking for. It is unlikely that her full-time work schedule was a reason, as she stated her
availability on the day and times of the study during the consent to participate. More
concentrated recruitment efforts could help create a larger and more diverse group for caregivers.
Consistent with other studies, lack of knowledge and or confidence is a barrier to supporting

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families using AAC (Anderson et al., 2014; Bellomo, 2016; Sanders 2017; Stadkleive, 2017).
Regardless of parent advocacy and motivation, AAC support should always be offered and
provided.
Modeling strategy. The results demonstrate caregivers improved their modeling in both
the home and community. However due to the limited number of replications in both home and
community, stability of the increase is not established. For example, both Katie and Nanny
increased their models per minute at home, but then, the rate decreased the following week in the
community setting. Even at rate of two models per minute the caregiver was able to model above
the minimum recommended 20 times per hour. Dad was out of town for work during most of the
study and only demonstrated modeling in the home. While his performance increased in the
home, given the current data, community performance for Dad cannot be predicted. In addition,
data does not demonstrate whether or not the results can be sustained over an extended period of
time without continuous support. Increasing the length of the study and including a maintenance
phase should be considered in future studies. In addition, it would be worth investigating if
correlations exist between the amount of AAC use to amount of AAC of the child.
Vocalizations. Since the aims of this study were focused on caregiver modeling, Tyler’s
vocalizations were an unexpected finding. During session two, it was noted that Tyler made
some clear vocalizations. This prompted a review of the session one and two videos for
comparison. When modeling focused on statements rather than questions, Tyler vocalized almost
all of the words modeled as opposed to questions that were not modeled. The increase in clarity
of Tyler’s vocalizations was consistent with findings that have found AAC supports acquisition
of natural speech (Bishop, 2017; Millar, Light, & Schlosser, 2006; Oommen, & McCarthy,
2015).

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In contrast, Katie’s use of AAC was in response to questions as opposed to statements.
While Tyler did use his AAC to respond to some questions, AAC requires more effort than
speech. Often, he preferred to attempt vocal approximations in response to questions. Again,
because the children were not the focus of the study, it is difficult to draw conclusions from these
differences. It is possible that one child has developed more receptive language skills and
therefore has the ability to answer questions. However, Since Tyler’s vocalizations are not easily
understood, it is difficult to know whether is expressive vocalizations were answering questions.
Community modeling. Similar to Senner and Baud (2016), the modeling technique was
successful in the natural environment without special preparation. However, instead of teaching
educators in the classroom, this study teaches caregivers in the community. It is not surprising
that the rate of modeling in the community decreased when compared to home or that it
decreased from the library to the MOSH. Taking care of a child with DD requires a caregiver to
juggle multiple tasks. Children with DD have a tendency to elope or require extra equipment to
navigate in the community. The addition of a communication device adds to the equipment to
handle. In Katie’s situation, her communication device is a Windows tablet with minimal
protection from damage, and no handle or strap to make carrying easier. Charging the device was
also difficult because it was a computer versus a tablet. Tyler’s device was an iPad in a rugged
carrying case with both a shoulder strap and handle. Tyler’s device was easy to charge on the go.
Katie’s mom quickly realized that to go in the community, she would need to look into different
case options. Sitting and reading a book at the library is easier to model than walking around and
talking about a museum exhibit because it is familiar, predictable and stationary. Many families
have experience reading books to their children but few have experience taking children a
museum. Katie’s mom also said staring by others and slow speed of communication with the
device were deterrents to venturing into the community alone which was consistent with other

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research findings (Mc Naughton, et al., 2008). The challenges Katie’s mom experienced suggests
the value of community groups as a method for fostering AAC use in the community by building
skill and confidence with coaching and feedback. The caregivers’ ability to model during story
book reading is consistent with other studies (Binger et al, 2010; Rosa-Lugo & Kent-Walsh,
2010; Senner & Baud, 2016).
Also consistent with other studies, using behavioral skills training was a successful
strategy for teaching caregivers’ modeling skills (Parsons et al., 2012; Senner & Baud, 2016).
From a provider perspective, providing individual feedback in the community group setting
was difficult. The participants were spread out during activities, sometimes in different
rooms. Fleeting attention and repetitive behavior of the children made it difficult to provide
feedback in the moment. When a caregiver modeled and the child listened, feedback would
interrupt the momentum and seemed counterproductive. Therefore, feedback was limited to
simple suggestions at the end of the session or in the home at an individual observation.
Often, effects of the feedback were observed at the next session. In individual sessions,
feedback was easier, less intrusive and easier to record. Facebook provided an effective way
to provide group feedback and instruction for common errors witnessed during the activities.
Despite the difficulty of providing individual feedback in a group, the activities were still
effective. One of the aims of the study was to meet the increased demand and supplement
services where there is a lack of providers. Community-based social-learning groups appear to
be an option.
Providing community activities for parents to receive coaching and feedback across
environments was intended to increase successful implementation of modeling as well as provide
caregiver a support network. The online support was intended to be beneficial for caregivers who
might otherwise be unable to attend educational or support groups in real-time (Bellomo, 2016;

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Clifford & Minnes 2013). Participants utilized Fb as evidenced by their comments and “likes”
on posts. Unfortunately, the small number of participants made Fb ineffective as a social support.
Resources were provided to the participants to encourage them to join existing groups with a
large member base to continue learning, interaction and online support after the study ended.
Modules. Online modules have been previously used by researchers as a method for
disseminating modeling strategies to families (Bellomo, 2016). However, success of the
intervention was based on the parents’ knowledge of modeling and not the demonstration or use
of the technique. Katie’s mom is an example of a caregiver who had knowledge of the technique
but did not use it until she participated in the study. In addition, once participants demonstrated
the technique in real-life situations, they encountered challenges. For example, during activities,
feedback often involved statements that were presented in the Fb posts such as “model key
words, not sentences,” “make comments, rather than always asking questions,” “accept all forms
of communication.” This could may have resulted from distractions while learning the material
or simply illustrate, multiple repetition’s and practice are needed for communication partners to
learn new skills (Kent-Walsh & McNaughton, 2005; Parsons et al., 2012).
Due to Facebook’s accessibility, videos and material could easily be viewed while
waiting in the school pick-up line, and be viewed multiple times for better understanding. Video
clips were rated as one of the most valuable components of the program.
It is difficult to examine any long-term benefits of parent modeling in developing
communication competence in the community. Caregivers successfully used AAC in the
community during the study. Clearly, since none of the caregivers increased their independent
use of AAC in the community, extended practice in this area may have improved this outcome.
Modeling is just one skill in a dynamic and complex hierarchy of communication education for
AAC users (Kent-Walsh & McNaughton, 2005; Ballin et al., 2009). Participants all agreed that

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the length of the intervention should be longer. This supports that families both want and need
more education about their child’s AAC and desire education that includes use in the community
(Crisp et al., 2014; Sanders, 2016). Even though modeling increased, the ratio of modeled
phrases to unmodeled phrases was approximately 20:80. Extending the length of the intervention
could produce a higher ratio of modeling of 80:20 as recommended by Dada and Alant (2008).
Information provided during the three-week intervention was intended and rated by the
participants as introductory. Despite this, participants were not able to apply all of the
information. When the study ended the participants were given several resources for continuing
their education about modeling including other online Fb groups and product support for their
specific device. It is hoped that in the absence of another group, that more advanced materials
will be sought out. All the participants stated they desired more education and advanced AAC
strategies. Overall, the high rating of the group and quality of materials suggest, that community
groups are wanted by families.
Program. The quality of the program was rated high by participants. Videos
demonstrating modeling were necessary in order to provide demonstrations of modeling in
multiple environments by multiple people. Videos are also necessary to allow asynchronous
learning of skills. One of the challenges in creating this program was the availability of quality
videos of modeling. Most modeling videos were found to include prompting or expectation of
the AAC user to respond. Thus, videos were created specifically for this study to ensure that
multiple exemplars were available in addition to the few found on Youtube.com.
Although Fb is feasible for delivery of information, ensuring a group large enough to
provide parent to parent support, diversity and feedback is a challenge. Active ongoing
recruitment would be necessary to build and sustain an interactive group. Although the study was
designed to examine the effect of minimal intervention, it became clear that a moderator was

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needed to stimulate active Fb engagement. The first week of the study, participants read the
material and liked some of the content, but none posted comments or questions. During week
two, additional questions and suggestions were posed to the participants through Fb posts. This
elicited some comments. No participants took pictures or volunteered ideas they had tried unless
solicitated. For example, Katie’s mom started family reading time before bed. This allowed her
spouse to read the book to the children while she modeled on Katie’s device. She also enlisted
Katie’s little brother in peer modeling. Neither were shared on the Fb page. Nanny played a
boardgame and talked about a TV program they were watching together, but also did not share
on the Fb page. It is important that a moderator helps connect members to gain the greatest
benefit from the group.
This social-learning group only focused on three components of modeling (a) motivation
(b) core word (c) waiting and expanding. Training on prompting was not provided but would be
a logical next module if the program was extended. Handouts were created for the distribution at
the community events, but not given out because it seemed overwhelming. Instead, the
information in the handouts was converted to Fb comments that were posted throughout the
week. This helped encourage engagement in the Fb group.
Limitations
The first limitation of this study is use of a single subject design. While single subject
designs (SSD) are frequently used in applied fields of education and behavioral studies the
results lack generalizability outside the study (Hitchcock et al., 2010). The advantage for using a
SSD in this study was the ability of the participant to serve as its own control. This is particularly
beneficial in low incidence populations such as AAC users that would prevent well- powered
randomization of participants. Due to the number of participants, generalization of the results of
this study are limited.

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The participation criteria for this study specified that the child must already have access
to an AAC device. This limitation excludes several children who may require modeling
intervention but have not been properly identified by providers for AAC. It is possible that
children who already acquired AAC devices have parents who are stronger advocates. Therefore,
the same parents may have been more motivated to volunteer for participation in a sociallearning group exaggerating any potential benefits from the intervention.
Similarly, since the parents self-report home use of the device, the desire for success may
create observer bias when recording data (Cooper et al., 2007). Using the data logging programs
on each device demonstrated that the caregivers were using the devices at home as they reported.
However, the capabilities of the data logging are limited. For example, both programs can show
usage time of day, however, the RL program cannot distinguish between caregiver modeling
verses user activation. Snap + Core data logging only showed most frequently used words but
the modeling feature can be turned on and off to distinguish between modeling and user. For
both users, it could be assumed that high usage times were when modeling occurred as usage
patterns throughout the remaining times of days were much lower.
Another limitation of this study was the lack of experimental control for confounding
variables that are present when research is conducted in the natural environment (Senner &
Baud, 2017). One of the unique features of this study was to identifying effective methods of
increasing AAC use in the community. Each week of the study was conducted with a different
activity. Even in the home environment each activity varied based on the creativity of the
caregiver or the mood and willingness of the child to participate.
Because the study utilized social media for the delivery of learning material, the
researcher could not control the environment in which the participant accessed the learning

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material. Consequently, the study included a social media component. Families without the
means to access social media may not have had equitable access to this form of intervention.
Time of year could have been a barrier to caregivers’ participation. Families have more
time in their schedules during the summer. In the fall, children are going back to the school
leaving little time for extra activities. The school district suggested recruiting at the end of the
school year if the study was repeated. While the school district expressed interest in the study
and distributed recruitment flyers, participants reported public schools need to take more active
rolls in fostering AAC use. Beginning community groups and access to AAC in early
intervention and preschool could make a significant impact on independence.
Conclusion
This study is unique and adds to the current knowledge base because it measured use of
modeling technique after online instruction, in a nurse-lead community activity. Using Fb as a
way to provide information about modeling was proven to be feasible for families of AAC users.
In addition, families can be successful in using AAC in the community when coaching and
feedback support is provided. Caregivers want more community opportunities to use AAC with
their children and require multiple exemplars. Interventions should include written instructions,
video demonstration and community activities for more than three weeks.
Future Recommendations
Because caregivers face more challenges with modeling in the community than at home,
consideration should be given to prepare specific directives for caregivers to practice in the
community. When using Fb groups as a social-learning tool, moderators should provide frequent
posts that encourage participants to respond and practice skills.
During the recruitment process, several private behavioral schools reported having no
students using SGD. This suggests more interdisciplinary collaboration is necessary for non-

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verbal children. A few private speech therapists stated they had a younger population using
devices. This was encouraging since the earlier students are provided speech devices the better
their chances to have communication competency. Despite this, nurses should partner with
school to take a more active role in developing communication partners for AAC users. This can
be accomplished by including caregivers in community-based instruction.
In summary, future research should focus on both long-term, community-based, AAC
interventions. Identifying the types of community activities that are best suited for fostering
AAC skills should also be evaluated. In addition, motivating factors as well as barriers for
caregiver participation in and the AAC user’s communication plan should also be explored.
Community programs are of critical importance in supporting the independence of this growing
non-verbal population. If the programs are not socially significant, they are useless.

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References

American Association of Colleges of Nursing. (2006). The essentials of doctoral education for
advanced practice nursing. Washington, DC: Author.
American Speech-Language-Hearing Association. (1982). Language [Relevant Paper]. Available
from www.asha.org/policy.
American Speech-Language-Hearing Association. (2018). Definition of communication and
appropriate targets. Retrieved from: https://www.asha.org/NJC/Definition-ofCommunication-and-Appropriate-Targets/
American Speech-Language-Hearing Association (2018). Augmentative and alternative
communication (AAC). Retrieved from:
https://www.asha.org/public/speech/disorders/AAC/#types
Americans With Disabilities Act of 1990, Pub. L. No. 101-336, 104 Stat. 328 (1990).
Anderson, K. L., Balandin, S., Stancliffe, R. J., & Layfield, C. (2014). Parents’ perspectives on
tele-AAC support for families with a new speech generating device: Results from an
Australian pilot study. Perspectives on Telepractice, 4(2), 39–70.
https://doi.org/10.1002/pro.2529
Andzik, N. R., Chung, Y.-C., & Kranak, M. P. (2016). Communication opportunities for
elementary school students who use augmentative and alternative communication.
Augmentative and Alternative Communication, 32(4), 272–281.
https://doi.org/10.1080/07434618.2016.1241299
Andzik, N. R., Schaefer, J. M., Nichols, R. T., & Chung, Y. C. (2018). National survey
describing and quantifying students with communication needs. Developmental
Neurorehabilitation, 21(1), 40–47. https://doi.org/10.1080/17518423.2017.1339133

I HAVE SOMETHING TO TELL YOU

60

Assistiveware (2019). Start Modeling. Retrieved from: https://www.assistiveware.com/learnaac/start-modeling
Baio, J., Wiggins, L., Christensen, D. L., Maenner, M. J., Daniels, J., Warren, Z.,
& ...Pettygrove, S. (2018). Prevalence of autism spectrum disorder among children
aged 8 years – Autism and Developmental Disabilities Monitoring Network, 11 Sites,
United States, 2014. MMWR Surveillance Summaries, 67(6), 1-23. Neurorehabilitation,
21(1), 40–47. https://doi.org/10.1080/17518423.2017.1339133
Balasubramanian, N., Shetty, A. P., TS, S. R., & Mani. (2017). Power analysis computed to
determine sample size for an evaluative study of video assisted teaching module
(VATM) on home care of schizophrenic patients developed for primary
caregivers. International Journal of Nursing Education, 9(2), 163–166. https://doiorg.proxy-clarion.klnpa.org/10.5958/0974-9357.2017.00056.3
Ballin, L., Balandin, S., Togher, L., & Stancliffe, R. J. (2009). Learning to use augmentative and
alternative communication (AAC): Is there a mentoring role for adults experienced in
using AAC? Journal of Intellectual and Developmental Disability, 34(1), 89–91.
https://doi.org/10.1080/13668250802676038
Bandura, A. (2006). Guide for constructing self-efficacy scales. Self-Efficacy Beliefs of
Adolescents, 307–337.
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psych Rev,
84(2), 191–215.
Barbosa, R. T. de A., de Oliveira, A. S. B., de Lima Antão, J. Y. F., Crocetta, T. B., Guarnieri,
R., Antunes, T. P. C., … de Abreu, L. C. (2018). Augmentative and alternative
communication in children with Down’s syndrome: a systematic review. BMC
Pediatrics, 18(1), 160. https://doi.org/10.1186/s12887-018-1144-5

I HAVE SOMETHING TO TELL YOU

61

Beck, A. R., Stoner, J. B., & Dennis, M. L. (2009). An investigation of aided language
stimulation: Does it increase AAC use with adults with developmental disabilities and
complex communication needs? AAC: Augmentative and Alternative Communication,
25(1), 42–54. https://doi.org/10.1080/07434610802131059
Bellomo, N., (2016). Increasing the augmentative and alternative communication knowledge and
self- efficacy of parents of children with autism spectrum disorders: Using multimedia
training materials. An Applied Dissertation (Unpublished dissertation). Nova Southeastern
University, Fort Lauderdale, Florida.
Binger, C., Kent-Walsh, J., Ewing, C., & Taylor, S. (2010). Teaching educational assistants to
facilitate the multisymbol message productions of young students who require augmentative
and alternative communication. American Journal of Speech-Language Pathology, 19(2),
108–120. https://doi.org/10.1044/1058-0360(2009/09-0015)
Binger, C., Kent-Walsh, J., Berens, J., Del Campo, S., & Rivera, D. (2008). Teaching latino
parents to support the multi-symbol message productions of their children who require
AAC. AAC: Augmentative and Alternative Communication, 24(4), 323–338.
https://doi.org/10.1080/07434610802130978
Binger C, & Light J. (2007). The effect of aided AAC modeling on the expression of multisymbol messages by preschoolers who use AAC [corrected] [published erratum appears in
AAC AUGMENT ALTERN COMMUN 2007 Jun;23(2):188-9]. AAC: Augmentative &
Alternative Communication, 23(1), 30–43.
Bishop, S. K., "Increasing Novel Vocalizations for Individuals with ASD Using a Voice Output
Communication Aide" (2017). Master's Theses. 294.
https://aquila.usm.edu/masters_theses/294
.

I HAVE SOMETHING TO TELL YOU

62

Blake Huer, M., & Threats, T. T. (2016). Shared responsibilities for full participation in society:
planning further integration of the ICF into AAC. Perspectives of the ASHA Special
Interest Groups, 1(12), 83–93.
Boyle CA, Boulet S, Schieve LA, Cohen RA, Blumberg SJ, Yeargin-Allsop M, et al. Trends in
the prevalence of developmental disabilities in US children, 1997–2008. Pediatrics.
2011; 127(6):1034–1042. 10.1542/peds.2010-2989
Brady, N. C., Bruce, S., Goldman, A., Erickson, K., Mineo, B., Ogletree, B. T., Paul, D.,
Romski, M., Sevcik, R., Siegel, E., Schoonover, J., Snell, M., Sylvester, L., & Wilkinson,
K. (2016). Communication services and supports for individuals with severe disabilities:
Guidance for assessment and intervention. American Journal on Intellectual and
Developmental Disabilities, 121(2), 121-138.
Bronfenbrenner, U. (1986). Ecology of the family as a context for human development.
Developmental Psychology, 22(6), 723–742.
Buescher, A. S., Cidav, Z., Knapp, M., & Mandell, D. S. (2014). Costs of autism spectrum
disorders in the United Kingdom and the United States. JAMA Pediatrics, 168(8), 721728. Doi:10.1001/jamapediatrics.2014.210
Cockerill, H., Elbourne, D., Allen, E., Scrutton, D., Will, E., McNee, A., … Baird, G. (2014).
Speech, communication and use of augmentative communication in young people with
cerebral palsy: The SH&PE population study. Child: Care, Health and
Development, 40(2), 149–157. https://doi.org/10.1111/cch.12066
Carter, N., Bryant-Lukosius, D., DiCenso, A., Blythe, J., & Neville, A. J. (2014). The use of
triangulation in qualitative research. Oncology Nursing Forum, 41(5), 545–547.
https://doi.org/10.1188/14.ONF.545-547

I HAVE SOMETHING TO TELL YOU

63

Castillo-Montoya, M. (2016). The qualitative report preparing for interview research: The
interview protocol refinement framework. The Qualitative Report, 21(1), 811–831.
Retrieved from: http://nsuworks.nova.edu/cgi/viewcontent.cgi?article=2337&context=tqr
Christensen, D., Van Naarden Braun, K., Doernberg, N. S., Maenner, M. J., Arneson, C. L.,
Durkin, M. S., … Yeargin, A. M. (2014). Prevalence of cerebral palsy, co-occurring autism
spectrum disorders, and motor functioning – Autism and Developmental Disabilities
Monitoring Network, USA, 2008. Developmental Medicine & Child Neurology, 56(1), 59–
65. https://doi.org/10.1111/dmcn.12268
Chung, Y.-C., & Carter, E. W. (2013). Promoting peer interactions in inclusive classrooms for
students who use speech-generating devices. Research and Practice for Persons with Severe
Disabilities, 38(2), 94–109. https://doi.org/10.2511/027494813807714492
Clifford, T., & Minnes, P. (2013). Logging on: Evaluating an online support group for parents of
children with autism spectrum disorders. Journal of Autism and Developmental Disorders,
43(7), 1662–1675. https://doi.org/10.1007/s10803-012-1714-6
Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied behavior analysis (2nd ed.).
Columbus, OH: Merrill Publishing Co.
Crisp, C., Draucker, C. B., & Ellett, M. L. C. (2014). Barriers and facilitators to children’s use of
speech-generating devices: A descriptive qualitative study of mothers’ perspectives. Journal
for Specialists in Pediatric Nursing, 19(3), 229–237. https://doi.org/10.1111/jspn.12074
Dada, S., & Alant, E. (2009). The effect of aided language stimulation on vocabulary acquisition
in children with little or no functional speech. American Journal of Speech-Language
Pathology, 18(1), 50–64. https://doi.org/10.1044/1058-0360(2008/07-0018)
Davis, M. A. C., Spriggs, A., Rodgers, A., & Campbell, J. (2018). The effects of a peer-delivered
social skills intervention for adults with comorbid Down syndrome and autism spectrum

I HAVE SOMETHING TO TELL YOU

64

disorder. Journal of Autism & Developmental Disorders, 48(6), 1869–1885.
https://doi.org/10.1007/s10803-017-3437-1
Drager, K. D. R., Postal, V. J., Carrolus, L., Castellano, M., & Al, E. (2006). The effect of aided
language modeling on symbol comprehension and production in 2 preschoolers with
autism. American Journal of Speech -Language Pathology, 15(2), 112–125.
https://doi.org/10.1044/1050360(2006/012)
Fraenkel, P. (2006). Engaging families as experts: Collaborative family program development.
Family Process, 45(2), 237–257. https://doi.org/10.1111/j.1545-5300.2006.00093.x
Fragale, C., Rojeski, L., O’Reilly, M., & Gevarter, C. (2016). Evaluation of functional
communication training as a satiation procedure to reduce challenging behavior in
instructional environments for children with autism. International Journal of
Developmental Disabilities, 62(3), 139–146.
https://doi.org/10.1080/20473869.2016.1183957
Fusch, P. I., & Ness, L. R. (2015). Are we there yet? Data saturation in qualitative research. The
Qualitative Report, 20(9), 1408–1416. https://doi.org/1, 1408-141.
Gist, M. E., & Mitchell, T. B. (1992). Self-Efficacy: A theoretical analysis of its determinants
and malleability. Academy of Management Review, 17(2), 183–211.
https://doi.org/10.5465/AMR.1992.4279530
Granlund, M., Björck-Åkesson, E., Wilder, J., & Ylvén, R. (2008). AAC interventions for
children in a family environment: Implementing evidence in practice. AAC: Augmentative
and Alternative Communication, 24(3), 207–219.
https://doi.org/10.1080/08990220802387935

I HAVE SOMETHING TO TELL YOU

65

Hall, H., & Graff, J. (2010). Parenting challenges in families of children with autism: A Pilot
Study. Issues in Comprehensive Pediatric Nursing, 33(4), 187-204.
Doi:10.3109/01460862.2010.528644
Harstad, E. B., Fogler, J., & Barbaresi, W. J. (2015). Comparing diagnostic outcomes of autism
spectrum disorder using DSM – IV – TR and DSM – 5 Criteria, 1437–1450.
https://doi.org/10.1007/s10803-014-2306-4
Hitchcock, J. H., Nastasi, B. K., & Summerville, M. (2010). Single-Case designs and qualitative
methods: Applying a mixed methods research perspective. Mid-Western Educational
Researcher, 23(2), 49–58.
Hughes, C., Rung, L. L., Wehmeyer, M. L., Agran, M., Copeland, S. R., & Hwang, B. (2000).
Self-Prompted communication book use to increase social interaction among high school
students. Research and Practice for Persons with Severe Disabilities, 25(3), 153–166.
https://doi.org/10.2511/rpsd.25.3.153
Johnson, J. M., Inglebret, E., Jones, C., & Ray, J. (2006). Perspectives of speech language
pathologists regarding success versus abandonment of AAC. AAC: Augmentative and
Alternative Communication, 22(2), 85–99. https://doi.org/10.1080/07434610500483588
Johnston, J. M., & Pennypacker, H. S. (2008) Strategies and tactics of behavioral research, Third
Edition New York: Routledge.
Kaiser, A. P., & Roberts, M. Y. (2013). Parents as communication partners: An evidence-based
strategy for improving parent support for language and communication in everyday settings.
Perspectives on Language Learning and Education, 20(3), 96.
https://doi.org/10.1044/lle20.3.96
Kasari, C., Kaiser, A., Goods, K., Nietfeld, J., Mathy, P., Landa, R., Murphy, S. & Almirall, D.,
(2014). Communication interventions for minimally verbal children with autism: A

I HAVE SOMETHING TO TELL YOU

66

sequential multiple assignment randomized trial. Journal of American Academy of Child
and Adolescent Psychiatry, 53(6), 635-645. http://dx.doi.org/10.1016/j-jaac.2014.01.019
Kent-Walsh, J., Murza, K., Malani, M. & Binger, C. (2015). Effects of communication partner
instruction on the communication of individuals using AAC: A meta-analysis.
Augmentative and Alternative Communication, (31) 4, 271-284.
DOI:10.3109/07434618.2015.1052153
Kent-Walsh, J. Binger, C. & Buchanan, C. (2015). Teaching children who use augmentative and
alternative communication to ask inverted yes/no questions using aided modeling. American
Journal of Speech-Language Pathology, (24) 222-236.
Kent-Walsh, J.K., Binger, C., and Hasham, Z. (2010). Effects of parent instruction on the
symbolic communication of children using augmentative and alternative communication
during storybook reading. Communication Disorders Quarterly, 30(1), 49–61.
https://doi.org/10.1177/1525740108320353
Klein, L. A., Houlihan, D., Vincent, J. L., & Panahon, C. J. (2017). Best practices in utilizing the
changing criterion design. Behavior Analysis in Practice, 10(1), 52–61.
https://doi.org/10.1007/s40617-014-0036-x
Light, J. (1989). Toward a definition of communicative competence for individuals using
augmentative and alternative communication systems Toward a Definition of
Communicative Competence for Individuals Using Augmentative and Alternative
Communication Systems, 4618. https://doi.org/10.1080/07434618912331275126
Light, J., & McNaughton, D. (2012). Supporting the communication, language, and literacy
development of children with complex communication needs: State of the science and
future research priorities. Assistive Technology, 24(1), 34–44.
https://doi.org/10.1080/10400435.2011.648717

I HAVE SOMETHING TO TELL YOU

67

Light, J., & McNaughton, D. (2014). Communicative competence for individuals who require
augmentative and alternative communication: A new definition for a new era of
communication? 30(January), 1–18. https://doi.org/10.3109/07434618.2014.885080
Light, J., & McNaughton, D. (2015). Designing AAC research and intervention to improve
outcomes for individuals with complex communication needs. AAC: Augmentative and
Alternative Communication, 31(2), 85–96.
https://doi.org/10.3109/07434618.2015.1036458
Lilienfeld, M., & Alant, E. (2005). The social interaction of an adolescent who uses AAC: The
evaluation of a peer-training program. AAC: Augmentative and Alternative Communication,
21(4), 278–294. https://doi.org/10.1080/07434610500103467
Logan, K., Iacono, T., & Trembath, D. (2017). A systematic review of research into aided AAC
to increase social-communication functions in children with autism spectrum disorder.
Augmentative and Alternative Communication, 33(1), 51–64.
https://doi.org/10.1080/07434618.2016.1267795
Long, B., (2018). Autism Basics. Division of Birth Defects, National Center on Birth Defects and
Developmental Disabilities, Centers for Disease Control and Prevention. Retrieved
7/14/18 http://www.dcc-cde.ca.gov/af/afbasic.htm
Lynch, Y., McCleary, M., & Smith, M. (2018). Instructional strategies used in direct AAC
interventions with children to support graphic symbol learning: A systematic review. Child
Language Teaching and Therapy, 34(1), 23–36. https://doi.org/10.1177/0265659018755524
Mandak, K., & Light, J. (2018). Family-centered services for children with ASD and limited
speech: The experiences of parents and speech-language pathologists. Journal of Autism
and Developmental Disorders, 48(4), 1311–1324. https://doi.org/10.1007/s10803-0173241-y

I HAVE SOMETHING TO TELL YOU

68

Mandak, K., O’Neill, T., Light, J., & Fosco, G. M. (2017). Bridging the gap from values to
actions: a family systems framework for family- centered AAC services. Augmentative
and Alternative Communication, 33(1), 32–41.
https://doi.org/10.1080/07434618.2016.1271453
McDougall, D., Hawkins, J., Brady, M., & Jenkins, A. (2006). Recent innovations in the
changing criterion design. The Journal of Special Education, 40(1), 2–15.
https://doi.org/10.1177/00224669060400010101
McNaughton, D., Rackensperger, T., Benedek-Wood, E., Krezman, C., Williams, M., & Light, J.
(2008). “A child needs to be given a chance to succeed”: Parents of individuals who use
AAC describe the benefits and challenges of learning AAC technologies. AAC:
Augmentative and Alternative Communication, 24(1), 43–55.
https://doi.org/10.1080/07434610701421007
Millar, D. C., Light, J. C., & Schlosser, R. W. (2006). The impact of augmentative and
alternative communication intervention on the speech production of individuals with
developmental disabilities: A research review. Journal of Speech, Language, and Hearing
Research, 49(2), 248–264. https://doi.org/10.1044/1092-4388(2006/021)
Miltenberger, R. G., & Roberts, J. A. (1999). Training and generalization of sexual abuse
prevention skills for women with mental retardation. Journal of Applied Behavior
Analysis, 32(3), 385. https://doi-org.proxy-clarion.klnpa.org/10.1901/jaba.1999.32-385
O’ Neill, T., Light, J., & Pope, L. (2017). Effects of interventions that include aided
augmentative and alternative communication of individuals with complex communication
needs: A meta-analysis. Journal of Speech Language and Hearing Research, July 2018
(61), 1743–1765. Doi:10.1044/2018_JSLHR-L-17-0132

I HAVE SOMETHING TO TELL YOU

69

Oommen, E. R., & McCarthy, J. W. (2015). Simultaneous natural speech and AAC interventions
for children with childhood apraxia of speech: Lessons from a speech-language pathologist
focus group. AAC: Augmentative & Alternative Communication, 31(1), 63–76.
https://doi.org/10.3109/07434618.2014.1001520
Parsons, M. B., Rollyson, J. H., & Reid, D. H. (2012). Evidence-based staff training: a guide for
practitioners. Behavior analysis in practice, 5(2), 2–11. Doi:10.1007/BF03391819
Prentke Romich Company (2014). RealizeLanguage [Computer Application]. Retrieved from:
https://realizelanguage.com/info/about
Prizant B. M, Wetherby A. M, Rubin E., & Laurent A. C. (2003). The SCERTS Model: a
transactional, family-centered approach to enhancing communication and socioemotional
abilities of children with autism and spectrum disorder...Social Communication, Emotional
Regulation, and Transactional Support. Infants & Young Children: An Interdisciplinary
Journal of Early Childhood Intervention, 16(4), 296–316 21p.
Romski, M., Sevcik, R. a, Adamson, L. B., Cheslock, M., Smith, A., Barker, R. M., & Bakeman,
R. (2010). Randomized comparison of augmented and nonaugmented language
interventions for toddlers with developmental delays and their parents. Journal of Speech,
Language, and Hearing Research, 53(April), 350–364. https://doi.org/10.1044/10924388(2009/08-0156)
Rosa-Lugo, L., I., & Kent-Walsh, J. (2008). Effects of parent instruction on communicative turns
of Latino children using augmentative and alternative communication during storybook
reading. Communication Disorders Quarterly, 30(1), 49–61.
https://doi.org/10.1177/1525740108320353
Sanders, H. (2017). Extension of school augmentative and alternative communication services to
home: A national survey, (April). Retrieved from

I HAVE SOMETHING TO TELL YOU

70

https://kuscholarworks.ku.edu/bitstream/handle/1808/25826/Sanders_ku_0099M_15238_D
ATA_1.pdf?sequence=1&isAllowed=y
Senner, J., & Baud, M. (2016). Pre-Service training in AAC: Lessons from school staff
instruction the need for pre-service training in AAC. Perspectives of the ASHA Special
Interest Groups, 1(Part 2), 24–31. Retrieved from
http://pubs.asha.org/ss/rights_and_permissions.aspx
Senner, J. E., & Baud, M. R. (2017). The use of an eight-step instructional model to train school
staff in partner-augmented input. Communication Disorders Quarterly, 38(2), 89–95.
https://doi.org/10.1177/1525740116651251
Sennott, S. C., Light, J. C., & McNaughton, D. (2016). AAC modeling intervention research
review. Research and Practice for Persons with Severe Disabilities, 41(2), 101–115.
https://doi.org/10.1177/1540796916638822
Solomon-Rice, P. L., & Soto, G. (2014). Facilitating vocabulary in toddlers using AAC: A
preliminary study comparing focused stimulation and augmented input. Communication
Disorders Quarterly, 35(4), 204–215. https://doi.org/10.1177/1525740114522856
Skinner, B.F. (1974). About behaviorism. New York: Knopt; [distributed by Random House].
Stadskleiv K. (2017). Experiences from a support group for families of preschool children in the
expressive AAC user group. Augmentative and Alternative Communication (33) 1, 3-13.
http://dx.doi.org/10.1080/07434618.2016.1276960
Steca, P., Bassi, M., Caprara, G. V., & Fave, A. D. (2011). Parents’ self-efficacy beliefs and their
children’s psychosocial adaptation during adolescence. Journal of Youth and Adolescence,
40(3), 320–331. https://doi.org/10.1007/s10964-010-9514-9
Squires M. E., & Tourangeau A., (2009). The missing data dilemma. Canadian Journal of
Cardiovascular Nursing, 19(4), 33–36.

I HAVE SOMETHING TO TELL YOU

71

Sylvia, M. L., & Terhaar, M. F. (2014). Clinical analytics and data management for the
DNP. New York, NY: Springer.
Terry, A. (2015). Clinical research for the doctor of nursing practice
(2nd ed.). Burlington, MA: Jones & Bartlett.
Tönsing, K. M., & Dada, S. (2016). Teachers’ perceptions of implementation of aided AAC to
support expressive communication in South African special schools: a pilot investigation.
AAC: Augmentative and Alternative Communication, 32(4), 282–304.
https://doi.org/10.1080/07434618.2016.1246609
Topia, M., & Hocking, C. (2012). Enabling development and participation through early
provision of Augmentative and Alternative Communication. New Zealand Journal of
Occupational Therapy, 59(1), 24–30.
Trottier, N., Kamp, L., & Mirenda, P. (2011). Effects of peer-mediated instruction to teach use of
speech-generating devices to students with autism in social game routines. AAC:
Augmentative and Alternative Communication, 27(1), 26–39.
https://doi.org/10.3109/07434618.2010.546810
Tudge, J. R. H., Payir, A., Merçon-Vargas, E., Cao, H., Liang, Y., Li, J., & O’Brien, L. (2016).
Still misused after all these years? A reevaluation of the uses of Bronfenbrenner’s
bioecological theory of human development. Journal of Family Theory and Review, 8(4),
427–445. https://doi.org/10.1111/jftr.12165
U.S. Department of Health and Human Services (1999). Mental Health: A Report of the Surgeon
General. Rockville, MD: U.S. Department of Health and Human Services, Substance
Abuse and Mental Health Services Administration, Center for Mental Health Services,
National Institutes of Health, National Institute of Mental Health.

I HAVE SOMETHING TO TELL YOU

72

Van Tongerloo, M. A. M. M., Van Wijngaarden, P. J. M., Van der Gaag, R. J., & Lagro-Janssen,
A. L. M. (2015). Raising a child with an autism spectrum disorder: “If this were a partner
relationship, I would have quit ages ago.” Family Practice, 32(1), 88–93.
https://doi.org/10.1093/fampra/cmu076
Wittkowski, A., Garrett, C., Calam, R., & Weisberg, D. (2017). Self-report measures of parental
self-efficacy: A systematic review of the current literature. Journal of Child and Family
Studies, 26(11), 2960–2978. https://doi.org/10.1007/s10826-017-0830-5
World Health Organization. How to use the ICF: A practical manual for using the International
Classification of Functioning, Disability and Health (ICF). Exposure draft for comment.
October 2013. Geneva: WHO

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Appendix A

Types of AAC
(a) No tech or unaided AAC refers to using one’s own body to communicate. Examples of
unaided AAC would include pointing or leading, American sign language, facial
expressions or body language.
(b) Low technology or aided AAC refers to the use equipment. Examples of low technology
AAC would include pen and paper, pointing to pictures or word typically on a static
display board. Sometimes words or pictures are laminated and placed on a key ring to
make them easily portable.
(c) High technology is also considered aided AAC. The equipment is more sophisticated
then paper and pencil. Letters words or pictures are displayed on equipment such as an
iPad. High technology devices may have speech generation activated by touching the
word or picture.

American Speech-Language-Hearing Association (2018). Augmentative and Alternative
Communication (AAC). Retrieved from:
https://www.asha.org/public/speech/disorders/AAC/#types

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Appendix B

Demographic Survey
Completion of the survey indicates your willingness to take part in this study and that you are at
least 18 years old. If you have any additional questions about your rights as a research
participant, you may call Lisa Barrett 904 994 0747. Please complete this survey to the best of
your ability and return it to the researcher before leaving.
Participant Name ________________________________________
Age of parent  20-30
 50-60

 30-40

 40-50

 Over 60

What is your (Parent) highest level of education?
 some high school

 high school

 college graduate

 graduate school

Actual age of your child

 some college

___________ years __________ months

Estimated mental age of your child ___________ years
How many years has your child has this communication device?
 less than one

 1 year

 2 years

 3 years

 Over 3 years

What type of communication device and software does your child use? ____________________
What is your child’s diagnosis? ___________________________________
What grade is your child in? _________
What race or ethnicity do you and your family most identify with? ____________________
Did you receive training for using the device yes

no

Do you currently participate in a Facebook support/resource forum? yes

no

How often do you take or use your child’s communication device in the community?
 Never

 Seldom

 Sometimes

 Usually

 Almost always

Describe briefly any type of training you had for your child’s communication method.
Type or write answer here

Thank you! Please return this form to the researcher before leaving

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Appendix C

Content Review by Experts
You have agreed to review the content for a proposed training module to teach parents of augmentative
alternative communication users how to use modeling techniques to facilitate their child’s communication
skill development in the community setting. Modeling is also referred to in the literature as Aided
Augmented Input and Aided Language Stimulation. Please read through the content outline and view the
embedded videos. Then, rate the material using the scale below. Please mark the response that best
represents how much you agree or disagree with each statement.

1. The training addressed key components of modeling strategies. (Content)
 Strongly Agree
 Agree
 Neither Agree or Disagree
 Disagree
 Strongly Disagree
2. The material in the training is well organized. (Design)
 Strongly Agree
 Agree
 Neither Agree or Disagree
 Disagree
 Strongly Disagree

3. Facebook will provide an online format that is easy for parents to access (Pedagogy)
 Strongly Agree
 Agree
 Neither Agree or Disagree
 Disagree
 Strongly Disagree
4. The use of video clips will increase the parents’ ability to implement modeling. (Content)
 Strongly Agree
 Agree
 Neither Agree or Disagree
 Disagree
 Strongly Disagree

5. The information is current practice. (Content)
 Strongly Agree
 Agree
 Neither Agree or Disagree
 Disagree
 Strongly Disagree

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6. The video quality is sufficient to demonstrate real life use. (Content)
 Strongly Agree
 Agree
 Neither Agree or Disagree
 Disagree
 Strongly Disagree
7. The 15 minutes to complete the material is sufficient (Design)
 Strongly Agree
 Agree
 Neither Agree or Disagree
 Disagree
 Strongly Disagree

8. The community activities chosen for group meetings will provide sufficient modeling
opportunities. (Pedagogy)
 Strongly Agree
 Agree
 Neither Agree or Disagree
 Disagree
 Strongly Disagree

9. The program is applicable to all learning styles.
 Strongly Agree
 Agree
 Neither Agree or Disagree
 Disagree
 Strongly Disagree

Comments/Recommendations:

76

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Appendix D

Copywrite permission for use of AssistiveWare materials.

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Appendix E
Intervention Module Plan

AAC User/Communication Partner Plan

AAC Communication Partner outcomes
By the conclusion of the group, the communication partner will be able to:
1.
Identify motivating activities to promote communication opportunities
2.
Demonstrate effective modeling of communication using preferred method of AAC in two separate settings
a.
Home setting
b.
Community setting
3.
List five “Do and Don’t” of AAC communication.
4.
Give examples of re-casting and expanding using language stages
5.
Recognize the importance of “wait time”
6.
Develop and evaluate self-goals as a Communication Partner
AAC User Outcomes
By the conclusion of the group, the AAC users will be able to:
(with or without assistance of communication partner depending on baseline competence)
1. Respond (physically, verbally or using AAC) to familiar people and motivating activities
2. Increase utilization of AAC at home and community setting
3. Access AAC communication to communicate with an additional communication partner (requesting, commenting,
directing)
4. Utilize AAC communication to comment on the group activity
5. Express multiple word utterances (+1 greater than base line) using AAC

I HAVE SOMETHING TO TELL YOU
Communication
Partner Goal

AAC User Goals

Facebook post:
Identify motivating
activities to promote
communication
opportunities (1)

Attend (physically,
verbally or using AAC)
to familiar people and
motivating activities (1)

Weekly
session
Number
1

79
Method

Discussion
Facebook post:
Brainstorm motivating activities the kids like to do.
Explain no expectation for child to reciprocate
Constant access to AAC, praise ALL communication
Session 1 hand out:
Becoming a communication partner
Post Document: AssistiveWare Week post 1- What is modeling?
Video (to watch at home via closed Facebook group):
https://www.youtube.com/watch?v=NdaEabODlh8
I cook (:15)
https://youtu.be/LKsxfedOOZY
The word “You” (4:06)
https://www.youtube.com/watch?v=UZSwwbhyExE&index=3&list
=PLfn9UI5ZGNPzHK14pr-OOck0IR8KR4ZZq&t=80s
(3:18) -Phillip Go, modeling go while brother reads
https://www.youtube.com/watch?v=QmuBaL-xWfw
(1:47) playing a game, put it in,
Explain no expectation for child to reciprocate
https://www.youtube.com/watch?v=qys640DKD0Q
(8:04) No, David
https://www.youtube.com/watch?v=VnDkdvIXObg
(5:09) watch with your child, piranhas don’t eat bananas
Easy to model with reading. This is advanced, but you don’t model
every word.
Group Activity: Library
Review group purpose
First 10-15min. shared reading activity caregiver-child
No coaching or feedback
Second 10 mins with if child behavior tolerates (sensory/ interest
toys)
Simple one-word modeling (wow, go, ball, down, again, more, turn,
get etc.) any words on the home page.

Assessment of Learning

Active Participation
Weekly Number of views on
video and Facebook group
(secret-closed) login

Data collection tool
Parent data collection tool

I HAVE SOMETHING TO TELL YOU

Communication
Partner Goal
List five “Do and
Don’t” of AAC
communication.
(don’t expect a
response) (4)

AAC User Goals

Utilize AAC
communication to
comment on the group
activity (4)

Access AAC
Recognize the
communication to
importance of “wait communicate with an
time” (6)
additional partner
(requesting,
commenting, directing)
(3)
Create exciting
stories to share or
talk about what you
are doing, going to
do or did (3)

Increase utilization of
AAC at home and
community setting (1)

Weekly
session
Number
2

80

Method

Assessment of Learning

Discussion:
Facebook Post: How the week went, barriers, successes, Explain
and demonstrate modeling. Brainstorm in the replies a morning and
afternoon activity for modeling for their unique situation. What are
they already communication non -verbally?
Session handout: Modeling key words, tips

Active Participation

Post: AssistiveWare What are core words?
Video: Examples of modeling everyday situations
https://www.youtube.com/watch?v=oE5qLy2LABk
It is hot (:21)
https://www.youtube.com/watch?v=xkX9aPFiFSY
(:45) Halloween
https://www.youtube.com/watch?v=UG5JeH2H_OY
(2:36) Rachael, core vs. fringe
https://www.youtube.com/watch?v=Nz1jVfQOXAE
(1:46) Core words with a peer
https://www.youtube.com/watch?v=VnDkdvIXObg
(5:09) watch with your child, piranhas don’t eat bananas go back and
see she mostly models the core words
Wednesday
https://www.youtube.com/watch?v=kGFqjhKajdM&list=UUknkKgD_7DldLeMXvsGpcg
Cookies and make 2:13
https://www.youtube.com/watch?v=YcjTq6v6ZQg
rollercoasters 2:26
Group Activity: YMCA room
First 10” Making mug cup cakes
Begin coaching and feedback
Core words: more, on, get, want, it, that, go, see, pour, mix, stir, hot,
put, in, out
Fringe: tableware and ingredients

Data collection tool

Weekly Number of views on
video and Facebook group
(secret-closed) login

Parent data collection tool

I HAVE SOMETHING TO TELL YOU

Communication
Partner Goal
Give examples of
re-casting and
expanding using
language stages (5)
Demonstrate
effective modeling
of communication
using preferred
method of AAC in
two separate
settings (Model)
Home setting
Community
setting (2)
Develop and
evaluate self-goals
as a Communication
Partner (Coaching)
(7)

AAC User Goals

Express multiple word
utterances (+1 greater
than base line) using
AAC

Weekly
session
Number
3

81

Method

Discussion: How the week went, barriers, successes, Demonstrating
with enthusiasm.
Explain Expanding and expectant pause. Model Directing and
talking as if you are the kid (use of “I” vs “you”). Model expectant
pause by looking eagerly at child 45 secs after a request, direction or
question
Session handout: Post intervention survey
Post: More Response strategies, expanding, recast waiting.
Video:
https://www.youtube.com/watch?v=FE1BzN7ncl4
(5:34) prompting expanding, waiting
https://www.youtube.com/watch?v=AV-q9TlpLSQ
(3:00) Expanding
Group Activity: MOSH. Let’s do “this action” No requirement to
use device.

Phone follow-up
Connect with other resources and meeting place if group wants to
continue to meet on own.

Assessment of Learning

Active Participation
Weekly Number of views on
video and Facebook group
(secret-closed) login

Data collection tool
Parent data collection tool

I HAVE SOMETHING TO TELL YOU

82
Appendix F

Interobserver Agreement
Calculation of total and mean count-per-interval interobserver agreement (IOA) for
frequency of modeling. While watching a video of a partner and AAC user modeling, the
observers independently tally the number of times modeling behavior occurred in each video.
Once event recording is complete, the smallest count divided by the larger count and multiplied
by 100. This was done for total and individual intervals. (Cooper, Heron, & Heward, 2007).
Observer 1 & 2, 2&3, and 3&1 were compared for IOA.

Video

Observer Observer
1
2

Observer
3

Observer Observer Observer
1&3
2&1
2&3

Mean count
per interval
IOA

1
2
3
4
5
6
Mean
Total Count
Agreement

Mean count per interval IOA=
Total count IOA=

Running head: I HAVE SOMETHING TO TELL YOU

83

Appendix G
Data Collection Tool
Definitions:
1. Modeling: Occurs when a communication partner activates one or more key words in a
spoken phrase on the child’s SGD during an interaction with the child while speaking the
words immediately before, during or after activation A production of a model begins
when the communication partner is with in arms reach of the user and touches the device
to generate word and ends with a pause following completion of the last audible or
thought or sentence output regardless if the AAC user (child) walks away from the
partner while modeling. ). Individual words of a sentence are counted as one thought
regardless of the length of pause in between navigation or words. Repeated words and
phrase count as individual interactions when the partner uses the icon and not the
message bar to activate the device.
2. Modeling Does Not Occur When: User touches the device but does not produce verbal
output, or if the user touches the device for navigation purposes (such as back, clear or
page forward). Individual words of a sentence are counted as one thought regardless of
the length of pause in between navigation or words. Repeated words and phrase count as
individual interactions.
Directions: Use the table below to record whether modeling was used during an interaction.
Partner Name:

AAC user age and gender:

Date of observation:

Observation Activity:

Time of observation:

Length of observation:

Time:
Modeling occurred

10 minutes pre- coaching and feedback

Additional observations:

10 minutes pre- coaching and feedback

I HAVE SOMETHING TO TELL YOU

84
Appendix H

Caregiver Data Collection Tool
Sample: Kelli Miller
Date 11/23/18 Time: 6:10pm
Compared to last week how much more did you use your child’s communication device to communicate
with him/her at home (do not include time spent in the group activity)

No more

A little more

Same as

Some more

A lot more

Name: _________________
Date ______ Time: _______
Compared to last week how much more did you use your child’s communication device to communicate
with him/her at home (do not include time spent in the group activity)

No more

A little more

Same as

Some more

A lot more

Compared to last week how much more did you use your child’s communication device to communicate
with him/her in the community (do not include time spent in the group activity)

No more

A little more

Same as

Some more

A lot more

I HAVE SOMETHING TO TELL YOU

85
Appendix I

Postintervention Participant Feedback
Thank you for you and your family for participating in this important study. We hope you have enjoyed
this Communication support group and it has been beneficial to everyone involved. In order to provide
the best service to more families in our area, please answer the questions below about your experience
with this group.

1. I understand how to use modeling

Strongly
disagree
1
2

3

Strongly
agree
4
5

2. This information was new to me

1

2

3

4

5

3. I will recommend this program to others

1

2

3

4

5

4. The program was well paced within the allotted time

1

2

3

4

5

5. I have time to use modeling in everyday life

1

2

3

4

5

6. The material was presented in an organized manner

1

2

3

4

5

7. I would not use this intervention in the future

1

2

3

4

5

8. I would be interested in attending a follow-up, more
advanced workshop on this same subject
9. The amount of record keeping was reasonable

1
1

2
2

3
3

4
4

5
5

10. I have seen my child’s communication improve

1

2

3

4

5

11. Home-School communication is necessary to be
successful

1

2

3

4

5

2

3

4

5

12. I would attend an AAC social group if no teaching
from a facilitator was provided

1

13. In your opinion, was this program: ❑ a. Introductory ❑ b. Intermediate ❑ c. Advanced
14. Please rate the following:
Excellent Very Good Good
Fair
Poor
a. Facebook page
❑
❑
❑
❑
❑
b. Video usefulness
c. Video quality
❑
❑
❑
❑
❑
d. Handouts
❑
❑
❑
❑
❑
e. Type of activities
f. Coaching/assistance
❑
❑
❑
❑
❑

I HAVE SOMETHING TO TELL YOU

15. What did you most appreciate/enjoy/think was best about the program?

16. What can we do better next time?

Thank you!
Please return this form to the researcher before leaving

86