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9/9/2018
1
Beyond Basic Requests: Building Language Skills with
Children who need AAC
Cathy Binger, Ph.D., CCC-SLP
University of New Mexico
(c) Cathy Binger 2018
Disclosures
• I have received funding from the National Institutes of Health to support this work (R01DC016321).
• I am being compensated for serving as your speaker today.
(c) Cathy Binger 2018
Current Project: Actively Recruiting!
(c) Cathy Binger 2018 3
Families must come to UNM for visits
Families receive a $20 gift card for each visit
Length of study = ~ 5 months/child
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Overview
• Early language development model & AAC
• Applying a Developmental Model: AAC Case study
• Integrating Approaches: Challenges and Opportunities
• AAC as a Tool
• Language Goals for Children who use AAC
• Dynamic Assessment
• Intervention techniques to Improve Expressive Communication
(c) Cathy Binger 2018 4
Communication Silos
Even AAC specialists fall into the trap of aligning themselves with particular approaches for preliterate AAC communication
(c) Cathy Binger 2018 5
“This district is really focused AAC iPad apps”
“I think activity displays provide
the best supports for students”
“We use PECS with all of our students
with autism”
“Approach X is great for most children who
need AAC”“I would never use
Approach Y”
(c) Cathy Binger 2018 6
• The evidence does not support any of these kinds of statements• No “one size fits all”
• We do have lots of evidence about how children learn language
How many of you have heard some version of this?
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We still have a long way to go!
• We must stop arguing with each other over which approach is “better”• Each approach has something to offer
• We must objectively – and dispassionately – examine each approach to see what the strengths and weaknesses are
• Every approach has strengths
• Every approach has weaknesses
• Then – and only then – can we move the field forward, toward more cohesive approaches to building language skills via aided AAC
(c) Cathy Binger 2018 7
https://www.socialana.com/face-your-weaknesses-to-find-your-strength/
Model of Typical (Early) Language Development
(c) Cathy Binger 2018 8
Why Use a Typical Language Development Model for Children who are not Typical?• All children deserve the opportunity to achieve their maximum
linguistic potential
• This provides us with a way to examine• How well each AAC approach promotes full language development
• Where the weaknesses lie• All AAC approaches have areas of weakness
• What gaps we need to fill in with additional approaches
• We must strive, as a field, to develop new, integrated approaches that better mimic typical language development
(c) Cathy Binger 2018 9
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Language Domains
Semantics
SyntaxMorphology
(c) Cathy Binger 2018 10
Pragmatics
• Communicative functions
(c) Cathy Binger 2018 11
Commenting
• We need lemons/boiled eggs/etc.
• It’s very cold
• Daddy, I got some muffins
Asking questions • Can I carry pretzels?
Commanding • Let’s go!
Directing Attention • Dad!
(Requesting) • (Can I have X?)
(Rejecting) • (I don’t want pineapples)
Pragmatics
Consider what his communication would be like without • Core vocab (Marvin et al., 1994)
• Fringe vocab
(c) Cathy Binger 2018 12
• Lemon, milk, spaghetti, cereal, peanuts, basket, etc.Nouns
• We, I, you, your, itPronouns
• Got, get, go, like, see, need, carryVerbs
• Cold, boiled, circle (cheese)Adjectives
• VeryAdverbs
• A, the, someArticles/ Determiners
• In (your basket)Prepositions
• Oops-a-daisy! Whoa!Interjections
Semantics
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Simple subject-verb-object statements
We need lemons
Embeddings
Put it in the shopping cart
Questions using intonation
Got some spaghetti?
Questions with inverted auxiliary
verbs
Can I carry cereal?
Imperatives/ commands
Let’s go
Put it in the shopping cart
(c) Cathy Binger 2018 13
Syntax
Grammatical Markers
• Plurals
• Blueberries, pretzels, eggs
• Prepositions• In
• Likely present or emerging• -ing (19 mo.)
• Possessive ’s (26 mo)
• -ed (26 mo.; boiled)
Contractions
• Let’s
• It’s
• Here’s
• I’ll
(c) Cathy Binger 2018 14
Morphology
What’s the Point?
• Even a child as young as two has AMAZING language skills!
• Within all language domains
• Our job is to maximize gains in all areas
• We can use our knowledge of normal language development to ensure that our objectives are supporting all domains
(c) Cathy Binger 2018 15
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Applying a Developmental Model: Case Study
(c) Cathy Binger 2018 16
Henry: Five-Year-Old with Autism
• Attends preschool 5 days/week
• Receives SLP services at school• Is using a PRC device
• Receives additional SLP services in a private clinic
• Speech is highly unintelligible• Single word intelligibility with context = 3%
• Language sample with repeated listening = 32%
• MacArthur CDI: 109 words expressively• Almost certainly affected by speech intelligibility
(c) Cathy Binger 2018 17
Henry’s Test ResultsTest Percentile Age Eqiv.
PPVT-IV 53 5;2
TACL-3VocabularyGrammatical Morphemes
Elaborated Phrases & Sentences
39377516
4;9
Leiter-R (non-verbal IQ) 70
Vineland: Communication 10
Mullen: Receptive Language 37 4;1
Mullen: Expressive Language
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Receptive Language Age of 4;9
This tells us that Henry…
(c) Cathy Binger 2018 19
…needs access to far MORE language than
Beckett!
What Language Expectations Should We Have for Each Domain?
Semantics
SyntaxMorphology
(c) Cathy Binger 2018 20
Pragmatics
Pragmatics
What Language Expectations Should We Have for Each Domain?
• Reject
• Request
• Make choices
• Show affection
• Greet people
• Offer & share
• Direct attention
• Answer yes/no questions
• Ask questions
• Name things/people
• Make comments (Communication Matrix)
(c) Cathy Binger 2018 21
Typical 2-year-olds are doing all of these
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Semantics
What Language Expectations Should We Have for Each Domain?
• >2,000 word expressive vocabulary
• All parts of speech & subcategories (e.g., all types
of pronouns)
(c) Cathy Binger 2018 22
Age 3 = ~1,000 wordsAge 4 = ~1,500 wordsAge 5 = ~2,100 words
Syntax
What Language Expectations Should We Have for Each Domain?
• Grammatically complete sentences• All semantic-syntactic relations
• Compound sentences• Complex sentences
• Use of auxiliary verbs in statements and questions
• Clausal conjoining and embedding
(c) Cathy Binger 2018 23
Brown’s Stage = Post V
Morphology
What Language Expectations Should We Have for Each Domain?
• -ing
• plural –s
• possessive ’s
• in, on
• determiners
• regular past tense
• irregular past tense
• third person singular –s
• auxiliary verbs
• Etc.
(c) Cathy Binger 2018 24
Brown’s Morphemes = ALL
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School-Based ApproachUnity/Core Vocab
• Vocab is frequently used & highly flexible
• “Unity 60 Sequenced”• Multiple selections required to
access each word• Allows for access to wide range of
vocab• Selected to promote long-term
language growth• Can hide icons so he’s not
overwhelmed
(c) Cathy Binger 2018 25
(Another Example of Core Vocab)
(c) Cathy Binger 2018 26
Current Functioning: Unity 60 Sequenced on an “Accent”• Has had device for ~ 1 year
• Can locate ~40 words independently (mostly core); can learn more but supports are limited
• Readily learns how to access some fringe (animals, food)• Understands the taxonomic categories
• Uses single-word utterances; gets frustrated when asked to do more
• Seldom seeks out device when communication breakdowns occur (says it’s “Too hard”)
(c) Cathy Binger 2018 27
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Private SLP’s Approach Activity Displays
• In keeping with WHO-ICF
• Activity-based; focused on what’s motivating
• Can readily locate ~35 symbols on a display
• Many parts of speech available + grammatical morphemes
(c) Cathy Binger 2018 28
Current Functioning: Activity Displays• Just started using these with new private SLP
• ~8-10 displays, each one used for a motivating, preferred activity• Ex: playing with vehicles, reading favorite stories
• Started putting 2- and 3-word sentences together in a single session
• If he doesn’t remember what a symbol is for, he simple selects it
• Obviously happy during sessions
• Readily initiating and imitating sentence productions
(c) Cathy Binger 2018 29
Activity Display Core/ Unity
Use Today • Range of functions • Range of functions• Difficulty locating items to make
choices
Build for Tomorrow
• Full range of functions; can be modified to grow with thelearner
• Full range of functions; can grow with the learner without modifications
(c) Cathy Binger 2018 30
Contrast with PECS
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Activity Display Core/ Unity
Use Today • Wide array of vocabulary available on each display
• Easy to locate/ access
• Vocab to build grammar available
• Easy to access motivating vocabulary
• Wide array of vocabulary available on device
• Challenging to locate/ access
• Vocab to build grammar available
• Difficulty to access motivating vocabulary
Build for Tomorrow
• Storing thousands of words is challenging
• Limited # of words per display
• Thousands of words already stored
• Essentially unlimited vocab
(c) Cathy Binger 2018 31
Contrast with PECS
Activity Display Core/ Unity
Use Today • Easy to create grammatically complete messages
• Can include many semantic relations on one display for easy sentence-building
• Can create compound & complex sentences
• Challenging to create grammatically complete messages initially
• Challenging to access wide range of semantic relations for sentence-building
• Challenging to create compound & complex sentences
Build for Tomorrow
• Challenging to produce novel, decontextualized sentences
• Designed to support productions of novel, decontextualized sentences
(c) Cathy Binger 2018 32
Activity Display Core/ Unity
Use Today • If included, grammatical morphology and other early morphemes are easy to access
• Not available on Sequenced 45• Easy to access with more
complex arrays: Sequenced 60 & 84
Build for Tomorrow
• Challenging to include all grammatical morphology on a single display
• Grammatical morphology will remain in same location over time
(c) Cathy Binger 2018 33
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So…What Does This Mean for Henry?
• Neither approach is fully meeting Henry’s language needs
• Combined, these two approaches provide a solid approach for face-to-face communication
• All language domains for today• All language domains for tomorrow
• Major missing piece is LITERACY• Must look at other solutions for this!• This is Henry’s path to full,
independent communication
(c) Cathy Binger 2018 34
Full Language System
Literacy-based
solutions
Unity: Core + Fringe
Activity Displays
Integrating Approaches: Challenges and Opportunities
(c) Cathy Binger 2018 35
Other Learners = Different Solutions“Henry” was just an example…
(c) Cathy Binger 2018 36
Full Language System
NOVA Chat 10:
On-screen keyboard
NOVA Chat 10: Core +
Taxonomic
NOVA Chat 10: Activity Displays
Full Language System
Manual Signs
PODD for Low Tech
WordPower: Taxonomic +
Literacy
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Other Learners = Different Solutions
(c) Cathy Binger 2018 37
Maximal Language Potential
Visual Scene
Displays
iPad app: Comments,
Asking Questions
PECS
Maximal Language Potential
Literacy Solutions
Language in all Domains for TOMORROW
Language in all Domains for TODAY
Challenges & Opportunities
• Each person who uses AAC is unique
• We have varying levels of support for some approaches • All focus on particular domains and particular points in development
• No evidence supports the use of any single approach that• Cohesively, simultaneously builds language in all domains
• Meets learners’ need for both today and tomorrow
(c) Cathy Binger 2018 38
Challenges & Opportunities
• We need new, better integrated approaches
• Until children who need AAC are communicating in like Beckett, we’re not there yet
(c) Cathy Binger 2018 39
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In the Meantime….
• We must use language development to guide us• Ensure supports in all language domains today
• Ensure supports in all language domains tomorrow
All learners deserve the opportunity to reach their full language potential
(c) Cathy Binger 2018 40
AAC as a Tool, Not a Goal
(c) Cathy Binger 2018
(c) Cathy Binger 2018 42
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AAC as a Tool
◦ Augment = to supplement
◦ Alternative = to replace
◦ AAC = Using ANYTHING other than speech to communicate
(c) Cathy Binger 2018 43
Facial expressions
Gestures
Manual signs
Objects (whole or partial)
Miniature objects
Remnants
Graphic symbols (line drawings, photos)
Electronic devices (high end and low end)
AAC is a TOOL, Not a Goal
◦ GOAL◦ Improved daily life communication
◦ TOOL◦ AAC
◦GOAL ≠ AAC
AAC is about COMMUNICATION
(c) Cathy Binger 2018
What are the Outcomes?
Increase/Improve
Participation
Academic/ employment
outcomes
Social skills
Language skills
(c) Cathy Binger 2018
AAC use is never an outcome in and of itself
Devices cannot accomplish anything in and of themselves◦ Nothing magical about
using AAC◦ “What app is that?” is not
the central question
Devices are TOOLS to reach the same goals as clients who rely on speech
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(c) Cathy Binger 2018
Language Goals for Children using AAC
(c) Cathy Binger 2018
Focus, Goals, & Context of Communication
• Improving daily life communication Focus
• Very similar to non-AAC clients; e.g.,
• Improve spoken syntax
• Expand expressive vocabulary, etc. Goals
• We will discuss AAC devices within the context of communication
• NOT the features of each device in isolationContext
(c) Cathy Binger 2018
AAC is much less intimidating when viewed this way!
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Language Goals for Children who use AAC
Pragmatics
• Turn-taking, commenting, asking questions
• NOT just requesting!
Semantics
• Vocabulary size & diversity
Morphology
• Grammatical morphemes
Syntax
• Message length and complexity
• Early language rules
(c) Cathy Binger 2018
Differences between the Videos
• What are the differences between the first video compared with the last two?
• What questions do you have about this child’s abilities that can assist with goal-setting?
• What are some viable goals we might set for this child?
(c) Cathy Binger 2018
Example Goals
• José will indicate that he needs to use the restroom using an appropriate mode of communication at least once per day during a 3-day period
Severe disabilities
• Jasper will take at least three commenting turns with his peers during free play time using an appropriate communication mode (e.g., using pre-programmed phrases such as “That car is fast”)
Preschool
• Margarite will use grammatical morpheme markers appropriately when preparing & giving oral presentations in science class (core curriculum)
Elementary school
(c) Cathy Binger 2018
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Background on Children who use AAC
(c) Cathy Binger 2018
Risks to Development for Children who use AAC
• All aspects of language (e.g., Binger & Light, 2008)
(c) Cathy Binger 2018
Pragmatic Semantic SyntacticMorpho-
logical Narrative
Historically more focus on improving pragmatics and early semantics
More focus recently on other areas
Contributing Factors
Intrinsic factors
• e.g., cognitive/ motor/ motor-speech/ language impairments
Extrinsic factors
• e.g., lack of communication opportunities, lack of access to appropriate AAC solutions
(c) Cathy Binger 2018
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Extrinsic Factors
• We have more control over the extrinsicfactors
• Can help children make rapid progress when we tackle extrinsic factors
• Main focus of today’s talk
• Can help compensate for some intrinsic factors, too
• Expectant delay: increases processing time
(c) Cathy Binger 2018
Characteristics: Children who use AAC
• Communication Characteristics of many Children who use AAC (e.g., Light, Collier, & Parnes, 1985):
(c) Cathy Binger 2018
Are passive communicators
Exhibit challenging behaviors
Initiate few interactions
Respond infrequently
Produce a limited number of
communicative functions
Use restricted linguistic forms
Characteristics: Communication Partners
• Communication Characteristics of many
Communication Partners (e.g., Light, Collier, & Parnes, 1985):
(c) Cathy Binger 2018
Take the majority of conversational
turns
Provide few opportunities for communication
Ask predominantly Yes/No questions
Interrupt individuals using
AAC
Focus on the technology, instead
of the individual
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Receptive vs. Expressive Language Gaps & Receptive Language vs. Speech Gaps
Often, we still misdiagnose children with expressive language disorders when they have severe speech impairments Poor speech masks underlying expressive
language competence
Children with large gaps (Tend to) make rapid progress with expressive
language
May have a WIDE range of disabilities
Have severe motor-speech disorders
Lack the tools to communication linguistically
NOT THE ABILITY!(c) Cathy Binger 2018
Language
Cognitive
Gross motor
Fine motor
58
Gaps & Testing: General Considerations
• Test receptive language formally whenever possible• May need to make adaptations for physical limitations
• New evidence from our lab (unpublished pilot data) that receptive language strongly predicts expressive potential
(c) Cathy Binger 2018
Gaps & TestingStandardized Testing
• Use standardized, normed tests that require NO verbal output from child; e.g.,
• PPVT
• TACL (Test of Auditory Language Comprehension)
• CASL (Comprehensive Ax of Spoken Lang)
• CELF-P (some sections)
• TOLD-P (Test of Language Devp – Primary)
• (Some tests contain items that require spoken output)• (PLS, Mullen Scales of Early Behavior)
(c) Cathy Binger 2018
9/9/2018
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Gaps & Testing: Parent Report Instruments
• Vineland Adaptive Behavior Scales• Communication subtest
• Receptive language scores significantly correlated with early AAC sentence-building outcomes in our most recent work
• Additional subtests• Daily Living, Social Communication, Motor Skills,
and Maladaptive Behavior
• MacArthur-Bates Communication Development Inventory
• Parent checklists• Translated into over 90 languages• Determine MLU3 (when appropriate)
• Have parents write down the 3 longest utterances they’ve ever heard the child say
• For children with some speech, this is an indicator of expressive potential
(c) Cathy Binger 2018
Gaps & Testing: Age Equivalent Scores
• Determine age-equivalent score on standardized tests
• Use this as an expressive aim. Example: • Child’s age = 5;0
• Receptive age = 3;0
• Expressive expectations = ???
• What are your expressive language expectations for language for a child who is 3 years old?
(c) Cathy Binger 2018
Relationship between Gaps & Expectations
• We frequently underestimate expressive capability
• Many children simply lack
• The tools to do more expressively
• The expectation that they can do
more expressively
• There are (many) exceptions, of course
• Low level symbolism; pre-symbolic communicators
(c) Cathy Binger 2018
9/9/2018
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Intervention Techniques to Improve Expressive Communication
(c) Cathy Binger 2018
Intervention Techniques to Improve Expressive Communication (e.g., Binger, Kent-Walsh et al., 2008, 2010, 2017; Binger & Light, 2007; Tonsing et al., 2014)
Prompts
• Aided AAC Modeling
• Expectant Delay
• Open-Ended Question Asking
• Direct Verbal Prompting
• (Physical prompting)
Responses
• Contingent responses
• Imitations
• Recasts
• Can be spoken and aided (or unaided)
(c) Cathy Binger 2018
Sample Communication Board: Locatives and Attributes
(c) Cathy Binger 2018
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Sample Communication Board: Possessives and Agent-Action-Object
(c) Cathy Binger 2018
Intervention Sessions: 3-Symbol Locatives • Note in the videos:
• Motivating contexts for communication• Adequate time allowed for responses• Aided models of targets• Grammatically complete spoken models• Corrective feedback• Encouraging correction of errors
• Ix Play Session 1
• Ix Play Session 2
• Ix Play Session 3
(c) Cathy Binger 2018
Intervention Sessions: Grammatically Complete Locatives • Note in the videos:
• How much FUN this can be!• Same techniques as original videos• Encouraging use of grammatical markers• Speed of learning to use the markers• Impossibility of producing such sentences without AAC
• Ix Play Session 1a with markers
• Ix Play Session 1b with markers
• Ix Play Session 2 with markers
(c) Cathy Binger 2018
1 ChildH_Loc_Ix1_CP1_7-23-13.mp42 ChildH_Loc_Ix2_CP2_7-25-13.mp43 ChildH_Loc_Ix3_CP3_7-30-13.m2ts4 ChildH_Loc_markers_Ix1_Play1_10-1-13.mp45 ChildH_Loc_markers_Ix1_Play1_10-1-13 5 word production.mp46 ChildH_Loc_markers_Ix2_Play2_10-3-13.m2ts
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Challenge your Clients
• Provide them with the communication solutions they need
• Motivating contexts
• Appropriate vocabulary
• Expectation for success
• Expect them to keep improving
• Increase expectations every time they improve
(c) Cathy Binger 2018 70
Summary
Remember that we are SLPs: Focus on the Language!
AAC is a TOOL, not a goal
Goals for children using AAC should be very similar as those for children who do not use AAC
Children using AAC tend to be passive; it’s up to us to provide opportunities for communication
Dynamic assessment can be used to help set reasonable SHORT-TERM expectations
Intervention techniques for children who require AAC are the same as for children who rely on speech
(c) Cathy Binger 2018
Questions?
Contact info: [email protected]
(c) Cathy Binger 2018 72
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References: Various AAC Approaches
• Low Language Expectations• Hustad, K. C., Keppner, K., Schanz, A., & Berg, A. (2008). Augmentative and alternative communication for preschool
children: Intervention goals and use of technology. Seminars in Speech and Language, 29, 83–91. http://doi.org/10.1055/s-2008-1080754
• Building Evidence-Based Practice in AAC Display Design for Young Children• http://www.tandfonline.com/doi/abs/10.3109/07434618.2015.1035798
• Activity displays• Binger & Kent-Walsh intervention research; e.g.,
• http://journals.sagepub.com/doi/abs/10.1177/1525740116655804
• http://ajslp.pubs.asha.org/article.aspx?articleid=2109135
• Full articles available here: https://www.researchgate.net/profile/Cathy_Binger/publications
• AAC Intervention Meta-analyses• AAC & Autism (including PECS, iPads, SGDs):
• http://www.aaiddjournals.org/doi/abs/10.1352/1944-7558-119.6.516?code=aamr-site
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5036660/
• http://www.tandfonline.com/doi/abs/10.3109/07434618.2015.1047532
• iPads & Autism: https://link.springer.com/article/10.1007/s40489-014-0018-5
• Core vocab (Note: I could not locate any peer-reviewed intervention research)• http://praacticalaac.org/strategy/teaching-core-vocabulary/
• http://praacticalaac.org/praactical/5-misconceptions-about-core-vocabulary-in-aac/
(c) Cathy Binger 2018 73
Key References of Our WorkBinger, 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. Augmentative and Alternative Communication, 24(323-338).
Binger, C., Kent-Walsh, J., Ewing, C., & Taylor, S. (2010). Teaching educational assistants to facilitate the multi-symbol message productions of young students who require AAC. American Journal of Speech-Language Pathology, 19, 108-120.
Binger, C., Kent-Walsh, J., & King, M. (2017). Dynamic assessment for three- and four-year old children who use augmentative and alternative communication: Evaluating expressive syntax. Journal of Speech, Language, and Hearing Research, 60, 1946-1958.
Binger, C., Kent-Walsh, J., King, M., & Mansfield, L. (2017). Early sentence productions of three-and four-year-old children who use augmentative and alternative communication. Journal of Speech, Language, and Hearing Research, 60, 1930-1945.
Binger, C., Maguire-Marshall, M., & Kent-Walsh, J. (2011). Using aided AAC models, recasts, and contrastive targets to teach grammatical morphemes to children with developmental delays who use AAC. Journal of Speech, Language, and Hearing Research, 54, 160-176.
Kent-Walsh, J., Binger, C., & Malani, M. (2010; invited). Teaching partners to support the communication skills of young children who use AAC: Lessons from the ImPAACT Program. Early Childhood Services, 4 (3), 155-170.
Kent-Walsh, J., & McNaughton, D. (2005). Communication partner instruction in AAC: Present practices and future directions. Augmentative and Alternative Communication, 21, 195-204.
King, M., Binger, C., & Kent-Walsh, J. (2015). Using dynamic assessment to evaluate the expressive syntax of five-year-old children who use augmentative and alternative communication. Augmentative and Alternative Communication, 31, 1-15. DOI: 10.3109/07434618.2014.995779
(c) Cathy Binger
201874
http://www.tandfonline.com/doi/abs/10.3109/07434618.2015.1035798http://journals.sagepub.com/doi/abs/10.1177/1525740116655804http://ajslp.pubs.asha.org/article.aspx?articleid=2109135https://www.researchgate.net/profile/Cathy_Binger/publicationshttp://www.aaiddjournals.org/doi/abs/10.1352/1944-7558-119.6.516?code=aamr-sitehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5036660/http://www.tandfonline.com/doi/abs/10.3109/07434618.2015.1047532https://link.springer.com/article/10.1007/s40489-014-0018-5http://praacticalaac.org/strategy/teaching-core-vocabulary/http://praacticalaac.org/praactical/5-misconceptions-about-core-vocabulary-in-aac/