JCPSLP Vol 21 No 3 2019

children with severe intellectual disability. With colleagues, I extended this line of research into the benefits of multimodal AAC to include aided symbols in scaffolding language learning by comparing sign+speech with sign+speech+aid (the latter a speech generating device) for children with Down syndrome or developmental delays (Iacono & Duncum, 1995; Iacono, Mirenda, & Beukelman, 1993). Findings indicated either greater learning in the three- compared to the two-modality condition (children with Down syndrome from respective studies) or similar learning across the conditions (one child with developmental delay in the study with Mirenda and Beukelman). These studies demonstrate that providing multimodality options allows children to choose those that best suit their learning strengths and/or modality preferences. to support a person’s communication functioning and development. In one such case study, Garrett, Beukelman, and Low-Morrow (1989) documented the decision-making process in creating a comprehensive and multimodal AAC system for Mike, a 74-year-old man with Broca’s aphasia. The system comprised an alphabet card, writing paper and word dictionary, which were chosen on the basis of his residual skills and preferences, and he was encouraged to use his existing (if often unintelligible) natural speech. A further example is provided by Light, Beesley, and Collier (1988), who documented a 3-year process of providing an adolescent with a head injury with AAC that would meet her current and future needs, while also complementing and facilitating therapy targeting her speech. These case studies demonstrated the multimodal nature of communication. A contrasting, but not unrelated, view of multimodality comes from authors who have referred to it in terms of asymmetry across input and output modes, such as occurs when a person uses AAC for expression, but speech for comprehension when aided input is not provided or required (Martinsen & von Tetzchner, 1996). Lloyd, Loncke, and Arvidson (1999, p. 166), for example, referred to multimodality as ‘the ability and tendency of human beings to combine and integrate different information sources in message reception and message expression. The term refers to the fact that human beings tend to process information in more than one mode’ . Equating multimodal with AAC Referring to AAC as multimodal provides explicit acknowledgement that access to multiple forms of AAC addresses the varied communication needs and preferences of people with complex communication needs (see Iacono, Lyon, West, & Johnson, 2013; Trembath, Iacono, Lyon, West, & Johnson, 2013). The issue is whether all multimodal communication is AAC. Common sense would suggest not, given that communication occurs through multiple channels that combine formal (e.g., print, speech, conventional gestures) and informal (e.g., vocalisations, facial expressions) modes, but only relatively few rely on AAC systems. Yet, there does seem to be evidence in the literature of including as AAC all forms of extant communication (intentional or unintentional) used by a person with complex communication needs. Cress and Marvin (2003, p. 256), for example, stated “Teaching Combining AAC with extant communication modalities AAC research has a rich history of providing detailed case studies that have demonstrated the complex nature of AAC clinical practice and need to consider all available modalities

reported by Kiernan, Reid, and Jones (1982), for example, demonstrated a tendency for schools to adopt either signs (Makaton or Paget Gorman Sign System) or graphic symbol (e.g. Bliss, Rebus) systems, with few introducing both at the school level, let alone for individual students. These choices were often based on recommendations by the school speech therapists. They prescribed AAC systems for a school rather than for individual students (Kiernan et al., 1982), thereby promoting a belief that all students in the same school should either sign or point to graphic symbols on aids (most often communication boards or books). The idea that only one AAC system could meet all of an individual’s communication needs in the absence of functional speech, let alone those of all students in a school, appeared to reflect a concern in the AAC literature. Baumgart, Johnson, and Helmstetter (1990), for example, argued against a tendency to treat AAC decision-making as a process that should result in identifying one AAC system to meet a person’s communication needs. Rather than referring to multimodal systems, they used pluralism to mean “the use of more than one type of system” (p. 8). Similarly, Bloomberg (1991) provided guidance to parents and teachers in choosing an appropriate AAC system for a child who had failed to develop speech, listing the various features and considerations of unaided and aided systems. She stated that “Use of an unaided system does not rule out use of an aided system and vice versa” (p. 38). As the range of AAC systems expanded, particularly with technological advances that resulted in increasingly sophisticated devices, but often with large price tags, the decision-making process in AAC became more complex (Musselwhite & Louis, 1988; Sigafoos & Iacono, 1993). Earlier decision-making guides evolved into feature matching, whereby AAC system components are selected and/or designed according to knowledge of an individual’s capabilities and preferences (Speech Pathology Australia, 2012), but the message increasingly was that no single device would meet all needs, either at one point in time or into the future (Sigafoos & Iacono, 1993). Hence, multicomponent systems (Musselwhite & Louis, 1988) and multiple communication modalities were encouraged. Other early references to the concept of multimodality in the context of AAC use include total communication and simultaneous communication . In early writings, these terms referred to the use of signs for one or more of the main content words while simultaneously speaking all words in a sentence (Kiernan et al., 1982; Konstantareas, Oxman, & Webster, 1977), a practice that continues in Key Word Sign (Speech Pathology Australia, 2012). Total communication, as a term, lost favour in the AAC field because of its specific meaning in the Deaf community and literature as an approach that was considered diametrically at odds with oral communication, whereby students were immersed in speech training without the use of signs (Geers & Moog, 1992). Early AAC studies addressed the effectiveness of simultaneous communication for young children. Konstantareas et al. (1977), for example, demonstrated the benefits of simultaneous communication (sign plus speech) in improving the receptive and expressive (imitative and spontaneous) sign vocabulary of children with complex communication needs associated with severe autism; similar findings were obtained by Kouri (1988) for children with varied aetiologies, including Down syndrome and autism. Remington and Clarke (1993) found that simultaneous communication resulted in improvements in expressive sign as well as speech comprehension for

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JCPSLP Volume 21, Number 3 2019

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