Journal of Speech and Hearing Disorders.

, Volume 49, 18-25, February 1984

DECISION-MAKING PROCESSES IN
AUGMENTATIVE COMMUNICATION

ROBERT E. OWENS, JR. LINDA I. HOUSE

State University of New York at Geneseo

The potential population for augmentative communication is large, yet no objective assessment criteria exist. This article
provides the clinician with a series of matrices designed to facilitate assessment decision making and implementation of
augmentative communication.
The first matrix addresses the appropriateness of augmentative communication. In the matrix the clinician will find an indepth,
systematic decision-making procedure for aiding in the choice of augmentative procedures as primary or complementary methods
of communication. The second matrix provides the clinician with information on modes of augmentative communication. These
modes include manual systems, communication boards, and electronic devices. The third matrix focuses on code information.
Particular attention is given to visual and manual codes. Together, the matrices provide the clinician with an objective procedure
for evaluating and organizing available clinical information on nonspeaking clients.

The American Speech-Language-Hearing Association
Ad Hoe Committee on Communication Processes and
Non-Speaking Persons (1980) reported that there are over
one million nonspeaking individuals as a result of neuro-
logical, physical, emotional, or cognitive disability. The
use of augmentative communication techniques with
these nonspeaking persons has grown rapidly. Several
professionals have reported this growth and have also
noted the lack of objective assessment for augmentative
communication (Bloom & Lahey, 1976; Fristoe & Lloyd,
1978; Silverman, 1980). After reviewing 19 profeSSional
articles on the use of signing, Poulton and Algozzine
(1980) concluded that "the decision to use manual signs
was not based on specific criteria or prerequisite skills...
[but] appeared to occur indiscriminately" (p. 151).
In addition, the ASHA Ad Hoe Committee report iden-
tified several components involved in delivery of speech
and language service to nonspeaking individuals. The
first component, also addressed by Shane and Bashir
(1980), is "assessment to determine the need and appro-
priateness of an augmentative communication system or
systems" (p. '269). The report stated that the second
component is client evaluation for the most effective
modes of communication. The third component relates to
decisions of symbol system selection. Thus, the speech-
language pathologist is reponsible for decision making
relative to election of augmentative communication and
to selection of the appropriate augmentative mode and
code. Currently, there are no objective assessment tools
that can aid in this three-step process.
Much of the content and many of the criteria for making
objective assessments of nonspeaking clients are known.
The decision matrix in this article arranges this informa-
tion in such a fashion as to help the speech-language
pathologist proceed objectively through the three-step
evaluation process outlined by the ASHA Ad Hoe Com-
mittee. The matrix can aid the speech-language patholo-
gist in selection of the most appropriate augmentative
means of expressive communication. In constructing the
matrix, the authors were guided by clinical experience,
relevant research literature, and a survey of residential
clients currently using a variety of augmentative means.
FORMAT
This augmentative communication decision matrix is
comprised of three separate matrices. The Level I matrix,
labeled "To be or not to be augmentative," addresses the
issue of determining augmentative communication ap-
propriateness. Level II and III matrices concern appro-
priate mode and code selection. For ease of use, the
matrices are organized as binary choices. The matrices
are organized for nonspeaking individuals whose hear-
ing, aided or unaided, is adequate for the normal aspects
of communication.
The matrices are a guide to decision making. They are
not meant to dictate the order of evaluation items or to
substitute for the informed clinician. Chapman and
Miller (1980) have summarized the evaluation process as
follows:
The development of an appropriate data base for deciding
who is a candidate and for which nonvocal system is
dependent upon careful evaluation of the child's lan-
guage, cognitive, and communication status. The child's
status will determine: 1) if the ehiid requires augmenta-
tive or a substitute productive system, 9.) if the child has
the necessary prerequisite skills, 3) the nature of the
nonvocal system the child can learn and use, and 4) which
system will meet his future needs. (p. 187)
It is hoped that these matrices will help the speech-
language pathologist organize evaluative data for a more
objective decision.

© 1984, American Speech-Language-Hearing Association 18 0022-4677/84/4901-0018501.00/0

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 OWENS & HOUSE: Decision-Making Processes 19

Level I last two categories concern present intervention proce-

dures and prognosis for speech, and the willingness of the
Level I, found below in (1), attempts to guide the environment.
clinician's decision relative to the appropriateness of Cognitive correlates. Several authors have outlined the
augmentative communication. The first three categories development of correlates to early language and have
deal with presymbolic or early symbolic skills (Chapman suggested presymbolic cognitive skills for assessment
& Miller, 1980). The order of these categories is not and training (Bates, Benigni, Bretherton, Camaioni, &
meant to reflect any developmental bias toward cognitive Volterra, 1977; Bates, Camaioni, & Volterra, 1975; Bloom
over social prerequisites to language. The first three & Lahey, 1978; Bowerman, 1974; Chapman & Miller,
categories screen for individuals for whom symbolic 1980; Kahn, 1975; Morehead & Morehead, 1974; Owens,
communication can become truly functional. The inter- 1982; Piaget, 1952; Reichle & Yoder, 1979). From a
vention goal should not be simple motor imitation but Piagetian view, one would be interested in the develop-
functional symbolic communication. Certain develop- ment of means-ends, motor imitation, object permanence,
mental skills are necessary before an individual can causality, symbolic play, and functional use. Means-ends,
acquire symbolic communication. The next four catego- imitation, and symbolic play appear to be the most highly
ries relate to initial acquisition of speech for those clients correlated with language development (Bates, Benigni,
who possess the presymbolic prerequisites. Finally, the Bretherton, Camaioni, & Volterra, 1979).
Piaget (1952) has theorized that sensorimotor stage 6
abilities are necessary for symbolic thought of which
language is a subset. His explanation of such symbol use
Augmentative Communication Decision Matrix is unclear, however. Stage 6, though, is apparently not
(1) Level I: To be or not to be (augmentative)
required for single-word production relative to present
Cognitive correlates --No--+ Wait. Train cognitive behaviors. referents. Single-word language reportedly begins in late
stage 4 or early stage 5 (Dihoff & Chapman, 1977; Green-
Yes wald & Leonard, 1979; Harding & Golinkoff, 1978;
Miller, Chapman, Branston, & Reichle, 1980). Stage 6
Social/Communicative--No-* Wait. Train social behaviors.
correlates seems to be more closely related to representation of
absent referents and to early multiword communication
Yes (Brown, 1973; Zachary, 1978).
A client who is not functioning at late stage 4 or early
Receptive language --No--+ Wait. Train receptive behaviors.
correlates stage 5 may not have the necessary cognitive abilities to
use single words or signs. In normally developing chil-
Yes dren, this level of functioning occurs at about 11-14
$ months.
Spontaneous 1-2 --Yes-+ Continue speech training. If a The skills present in sensorimotor stage 5 are identified
words history of therapy with little im-
provement or continued unin- by Shane and Bashir (1980) as a prerequisite for augmen-
No telligibility, go to section on tative communication. Successful augmentative commu-
therapy history or at-risk nication programs reported in the professional literature
Imitation of single --Yes ,7 (below) are all with clients at this cognitive level or above
words
(Griffith & l%binson, 1980; Hobson & Duncan, 1979;
No Kohl, 1981; Song, 1979; VanBiervliet, 1977). In an infor-
mal survey of 27 clients in developmental centers, we
Imitation of sounds --Yes ,7 could find no truly functional use of augmentative com-
or oral movements munication by clients functioning below stage 5 or below
No a 12-month developmental level. Assessment materials
$ that would be useful are subtests of the Ordinal Scales of
Oral motor difficulties --No/~ Psychological Development (Uzgiris & Hunt, 1975), De-
k
velopmental Programming for Infants and Young Chil-
Yes
dren (Sehafer & Moersch, 1977), or the Bayley Scales of
Therapy history or at- --No-+ Continue speech training for at Infant Development (Bayley, 1969).
risk least 1 year before implement- Many low functioning individuals prove difficult to test
I ing augmentative training. (Re- for cognitive abilities. Formal tests may be too inflexible
Yes. ceptive augmentative training to be adapted to the limited abilities of such clients.
~, may begin.)
Environment --No--~ Educate those ila the environ- Informal assessments, such as the Ordinal Scales, may be
I ment. more helpful. Obviously, language-based cognitive as-
Yes sessment tools would be inappropriate. In addition, some
initial sign training may enable the client to demonstrate
So far, so good! Go
on to augmentative higher cognitive functioning levels than attained original-
mode decision (Level ly.
II). If the client cannot demonstrate the cognitive corre-

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 20 Journal of Speech and Hearing Disorders
lates for expressive symbol use, then it might be advis-
able to target these presymbolic cognitive skills for train-
ing (Dunst, 1981; Kahn, 1978; Uzgiris & Hunt, 1975).
Augumentative communication training may begin in a
receptive mode if later expressive augmentative commu-
nication is anticipated. If the criterion is met, the clini-
cian should proceed to the second question, social/com-
municative correlates.
Social~Communicative correlates. Several authors have
also identified social and communicative correlates of
functional communication (Bates et al., 1975; Bruner,
1974/75; Freedle & Lewis, 1977; Lewis & Cheery, 1977;
Schaffer, 1977). These skills are more related to commu-
nication than to ability to use symbols meaningfully.
Early social/communicative behaviors have been target-
ed in several early language training approaches (Horst-
meier & MacDonald, 1978; McLean & Snyder-McLean,
1978; Owens, 1982; Russo & Owens, 1982; Schafer &
Moersch, 1977). These skills may include auditory notice,
eye contact, attending, turn taking and gesturing. In
general, the elinieian is interested in (a) client responses
to sounds, to his or her name, and to gestures; (b) client-
attending behaviors; and (c) client communication-initiat-
ing behaviors. Eye contact is most desirable but not an
absolute necessity, especially for the visually impaired.
Silverman (1980) has stressed the importance of social
behaviors for augmentative communication. He is partic-
ularly interested in the current communication system of
the client. These skills can be assessed through observa-
tion, although a few assessment tools are available (Horst-
meier & MacDonald, 1978; Owens, 1982; Russo & Ow-
ens, 1982). If the client exhibits some affective noncom-
municative disorder or does not meet criterion, it would
be advisable to target social/communicative skills in or-
der to establish a need to communicate. Such training
might include receptive augmentative training and the
expressive use of gestures for the purpose of establishing
communication. This goal is very different from the
augmentative terminal goal of expressive symbolic com-
munication. If social/communicative skills are exhibited,
the clinician should proceed to receptive/language corre-
lates.
Receptive language correlates. Developmental studies
have indicated that in the early language stages, receptive
vocabulary use seems to precede expressive (Bloom &
Lahey, 1978). Several early language programs have tar-
geted these skills (Bricker & Bricker, 1974; Horstmeier &
MacDonald, 1978; Kent, 1974; Miller & Yoder, 1974;
Owens, 1982). Of particular interest are discrimination of
object and action labels and the following of simple one-
step commands. Although no specific content criterion for
assessing receptive language behavior exists, the pres-
ence of general receptive skills is vital. If the client does
not have a small initial receptive vocabulary, receptive
use of simple signs or gestures may facilitate the needed
symbol-referent learning. Simple signs or gestures can
also facilitate comprehension of simple commands.
Again, this tSacilitation is not the long-term goal of aug-
mentative communication. The terminal behavior is
spontaneous expressive communication. If the client has
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49 18-25 February 1984
these limited initial receptive language skills, the clini-
cian should proceed to the next level.
Motor speech skills. The Level I matrix contains three
categories related to motor speech, from the most ad-
vanced, s p o n t a n e o u s o n e - t o - t w o - w o r d utterances,
through imitation of single words, to imitation of sounds
or oral movements (Bricker & Brieker, 1974; Guess,
Sailor, & Baer, 1978; Horstmeier & MacDonald, 1978;
Owens, 1982). A fourth category probes oral motor diffi-
culties. Clients who exhibit behaviors in the first three
categories should continue with speech training unless
they exhibit a therapy history of little improvement or of
continued unintelligibility. Such clients should be recon-
sidered in light of the criteria of the therapy history/at-risk
category below. Several assessment tools and published
programs suggest methods of evoking and training motor
speech skills (Horstmeier & MacDonald, 1978; Kent,
1974; Miller & Yoder, 1974; Owens, 1982). All three
speech categories were included in the matrix because of
clinical experience with early language clients who occa-
sionally plateau after acquiring only limited oral language
use.
The fourth motor speech category, the presence of
motor speech difficulties, is extremely important. Such
difficulties often frustrate clients and delay needlessly
the onset of expressive language. A thorough oral periph-
eral examination is needed. Dworkin and Culatta (1980)
have provided guidelines for such an evaluation. Severe
structural anomalies, the persistence of primitive or atypi-
cal oral reflexes, and weaknesses or paralysis should be
noted. If there are no indications of oral motor difficulties,
the clinician should continue speech training. The pres-
ence of oral motor difficulties is a signal to proceed to the
therapy history/at-risk category.
Therapy history or at-risk. The therapy history or at-
risk category consists of two questions. The clinician
should answer the question that seems most appropriate
to the client's present state. The questions are as follows:
1. Has the individual had at least 1 year of appropriate,
intense speech-language therapy?
2. Is the individual at risk of being severely language
impaired because of severe physical, affeetive, or cog-
nitive limitations?
The first question requires the most explanation. The
term of 1 year is a compromise. Many speech-language
pathologists prefer a longer "oral-only" approach, while
others would abandon such procedures much earlier. As
stated previously, this matrix is merely a guide. Those
who feel that 1 year is not long enough should remind
themselves that we are not advocating abandonment of a
speech approach. To the contrary, augmentative commu-
nication can enhance and complement speech training. It
is our purpose with augmentative communication to pro-
vide a communication avenue. There is always the possi-
bility, however, that the augmentative mode will become
the primary means of communicating.
Two additional words, appropriate and intense must
also be explained. Appropriate speech and language
therapy for nonspeaking clients includes all the prerequi-
sites previously mentioned, plus oral musculature train-
 OWENS & HOUSE: Decision-Making Processes 21

ing. The intensity of such programming varies with the Augmentative Communication Decision Matrix
clinical setting but should involve daily speech and Level II: Which augmentative mode is appropriate? (2)
language training within the natural environment. For Manual Nonelectronic indicating Electronic
severely involved clients, a year of speech and language
training with little success may seem inappropriate. Lou- Manual dexterity-
ise Kent (1979) recommended that an "atmosphere" of and expression
augmentative communication be established at birth for \
children who are determined to be at risk. Thus, parents Good Poor
and/or caregivers would begin receptive augmentative / 4/
training as soon as the child is identified as being at risk. Use of gestures Physical indicating
Such clients are served more appropriately by Question abilities
2.
! \
Environment
• If the answer to either question is negative, the clini- No pointing but
cian should continue verbal training before considering compression!
expressive augmentative training. This continuation does
not preclude early receptive augmentative training or
experimentation with various augmentative modes. With
a positive response, the clinician should proceed to the
next category.
Sign or I
finger-
spellingl
No sign
;ye Pointing with
head, limb, or

Yes/no
"~ I
I

a
I *Electronic
Environmental concern. At this point, the clinician is indicating I
concerned with the willingness of other persons within Type of d i s p l a y , , I
the client's environment to utilize an augmentative mode. \ I
Little generalization can be expected i f those within the Group, I
client's natural environment do not also communicate, at Individual, permanent
least in part, via an augmentative mode. If the environ- temporary (if can justify I
ment will not accept augmentative communication, the (communication the cost) ~ '
board) 2~
clinician must become a strong advocate for such an ~" Electronic
approach. Several studies can be cited to demonstrate the Ambulation
beneficial effects of augmentative communication (Ful-
, / \
wiler & Fours, 1976; Griffith & Robinson, 1980; Grinnel,
Ambulatory Nonambulatory or
Detamore, & Lippke, 1976; Hobson & Duncan, 1979; ig. in wheelchair
Kohl, 1981; Song, 1979; VanBiervliet, 1977; Webster,
I**Notebook,
1973). The clinician can also demonstrate the ease with Ibankbook, or **Mounted board
which augmentative means can be used. A few iconic isoft board
signs or visual symbols, such as Blissymbols, can be
taught to parents or caregivers in a few short minutes. Manual I Nonelectronic indicating Electronic
While training can proceed without outside involvement,
*Type dependent upon individual abilities and needs.
such training can be expected to be little more than **Placement of material and size of symbols depends on the
therapist-client communication. Often a sympathetic physical abilities of the client.
teacher will offer to use an augmentative means. If the
environment is supportive, or at least not hostile, and
caregivers are convinced of the benefit to be derived by movements and the level of exertion. For this assessment,
the client, then the clinician should proceed to Level II. the speech-language pathologist might seek counsel from
an occupational therapist. Several batteries, such as the
Parsons Language Sample (Spradiin, 1963), Illinois Test
Level II of Psycholinguistic Abilities (Kirk, McCarthy, & Kirk,
1968), and the Porch Index of Communicative Abilities
Level II, shown in (2), concerns selection of the appro- (Porch, 1967) have subtests which also address manual
priate augmentative mode. Here motor skills are impor- dexterity. Zweiban (1977) found the Manual Expression
tant. While this matrix appears more complex than Level subtest of the ITPA to be the best indicator of success in
I, the decisions are still essentially binary. Three modes acquiring use of signs. A simple assessment procedure is
of augmentative communication are presented: manual, for the clinician to request that the client imitate a few
nonelectronic, and electronic. Since the goal is to maxi- simple signs, physically prompting, if necessary. Mean-
mize communication, selection of one mode should not ing should not be attached at this time, since the clinician
preclude use of another. One mode can augment another is interested only in manual dexterity or motor imitation
just as augmentative communication enhances speech. (Piaget, 1959). Medical history is important, especially
Manual dexterity and expression. Silverman (1980) has regarding the stability of fine motor abilities.
proposed a very detailed assessment of manual dexterity. If the client has good manual dexterity and is likely to
Of interest are the accuracy, speech, and force of move- remain at this level of functioning, a manual model of
ment, as well as the presence of abnormal or involuntary communication is suggested. Spontaneous use of gestures

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 22 Journal of Speech and Hearing Disorders
further reinforces this choice (Brookner & Murphy, 1975;
Reich, 1978; Silverman, 1980). Gestures can be standard-
ized then modified into signs. The clinician should pro-
ceed to the next category, environmental support. If
manual skills are poor, then manual communication
seems inappropriate, so physical indicating abilities
should be explored.
Environmental supporL As with environmental ques-
tions in Level I, the critical question is the willingness of
the environment to support augmentative communica-
tion, specifically a manual mode. Of interest is general-
ization to the natural environment (Silverman, 1980).
Occasionally, parents are unwilling to use such visible
means of communication. In addition, institutional staff
may be reluctant to learn sign or finger spelling. Some
professionals question the use of sign because of its poor
generalization to the nonsigning world. Such an objection
may be moot if the client's prognosis is continued institu-
tional care. If the natural environment or professional
staff will not support manual communication, then other
means must be sought. The clinician should consider a
communication device and explore the type of display
desired.
Physical indicating abilities. Those with poor manual
dexterity and expression should be considered for some
primary augmentative mode other than signing or finger
spelling. This decision does not exclude the use of some
motorically easy signs as a complement to the primary
augmentative mode. Included under physical indicating
abilities are all manner of pointing, such as head, limb, or
eye. Most clients can at least establish eye contact with
desired items, but this type of indicating may be too
limiting. This is especially true when it is anticipated that
the client will be able to use a large number of symbols
expressively. If eye pointing seems too nonspecific for
the number of anticipated symbols or if pointing is
inconsistent or nonexistent, then the clinician should
consider an electric or yes/no indicating type of commu-
nication. The choice between these two types of augmen-
tative communication is based on the purpose such com-
munication will serve and on the client's ability to estab-
lish pressure.
Purpose and/or compression. Those clients who do not
have a consistent pointing response are poor candidates
for a communication board. If the client has good recep-
tive skills and the therapy goal is immediate communica-
tion, a yes/no indicating system may be appropriate, The
client will need to be trained for consistent yes/no signal-
ing. The first author has seen one closed head trauma
client who had the additional requirement of having to
learn the expressive concepts of "yes" and "no." In
general, yes/no indicating has the advantage of being easy
to teach and provides communication with very few
expressive symbols. Electronic communication has more
generalization and offers a broader range of expressive
abilities, albeit an expensive mode of communication
initially. If the client can apply pressure with any part of
the body consistently, a specifically adapted switch for an
electronic display can be operated. Coleman, Cook, and
Meyers (1980) have presented an assessment procedure
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49 18-25 February 1984
for determining the appropriate communication device.
Training via an electronic mode might take place while
the client is communicating with yes/no indicating.
Type of display. For the client with good pointing
abilities or the client with no environmental support for
signing, an electronic or communication board mode
seems appropriate. Such a decision is based on the
desired type of display. If the client and clinician desire
an output that can be shared by more than those in the
immediate environment or that provides a semiperma-
nent or permanent print-out, then they should choose an
electronic mode of communication. Such devices are
capable of prerecorded speech, typewritten print-outs,
video images, and lighted signals. The desire for such a
mode of communication must be weighed against the
initial cost and the cognitive and physical abilities of the
client. If individual communication with a nonpermanent
type of display is desired, a communication board may be
more appropriate. Such a device can become a training
tool for later electronic modes while serving as the
current means of communication.
Ambulation. Noneleetronie communication boards can
be designed for variations of size, organization, and lay-
out and can be constructed from many different materials.
Many decisions related to range and accuracy of move-
ment should be made in conference with the occupation-
al therapist. The basic construction of the board seems
best related to client ambulation. Clients who are nonam-
bulatory or in wheelchairs might best be served by a
mounted board near the bed or on the wheelchair tray. If
the upper extremities are not severely affected, a soft
board might be appropriate. In general, ambulatory cli-
ents can use soft communication boards also. Such boards
can include wallets, bankbooks, notebooks, or heavy
paper or cardboard upon which the symbols are mounted.
Soft communication boards allow those with good fine
motor skills to utilize a convenient, less obvious mode of
communication such as a wallet. In addition, those with
poorer motor skills need not carry heavy materials. The
danger from falls is also minimized by use of a soft
communication board.
Upon completing the decision process of Level II, the
clinician should know the mode or modes which seem
most appropriate for the client. This is not a static situa-
tion. As client abilities change, the mode or modes of
communication may change also.
Level III
Once the clinician has determined the appropriate
mode or modes, a symbol system or code must be
chosen. A hierarchy of systems for visual and manual
communication appears in (3). For the purpose of the
table, visual codes include communication boards or
electronic means. The symbol systems are arranged from
least representational to most symbolic. The codes listed
are those that the client employs. Thus, the HandiVoice
(Phonic Mirror, HC120) would employ a numerical code,
even though the output is synthesized speech. Although
 OWENS & HOUSE: Decision-Making Processes 23

Augmentative Communication Decision Matrix prognosis is limited, kinetic and tactile symbols may
Level III: Which augmentative code is appropriate? (3) provide a means of training clients in use of symbols. This
Hierarchy of codes: Visual Manual early training may facilitate subsequent learning of a
higher form of the manual mode. Several authors have
Symbolic Alphabetical/Numerical Fingerspelling presented guidelines for selection of a first sign lexicon
Printed words based on iconicity, symmetry, taction, and developmental
Blissymbolics Sign language information (Fristoe & Lloyd, 1980; Grifflth & Robinson,
Pietographs
1980; Kohl, 1981; Kohl, Karlan, & Heal, 1979).
Representational Line drawings A few iconic signs Visual decision process. A general guide for the visual
Pictures Amerind eode decision-making process is contained in (4). Specific
Pictographs Gestures questions related to code appropriateness should be de-
Models or miniatures
Non-SLIP (Carrier, cided on the basis of cognitive skills, visual discrimina-
1974) tion, and match-to-sample tasks.
1. Cognitive functions: The ability to use symbolic
thought is related to the cognitive functioning level of the
Augmentative Communication Decision Matrix individual (Piaget, 1954). Several infant development
Visual code decision process (4)
scales agree that children must attain a cognitive age of
Cognitive functioning - - No---~ Wait. Attempt cognitive about 18 months before they are capable of associating
(at least 18 months) training. referents with two-dimensional pictorial representations
f
(Bayley, 1969; Frankenburg & Dodd, i967; Grift3th &
Yes
Sanford, 1975; Schafer & Moersch, 1977). The 18-month
Cognitive functioning - - No---~ Attempt representation- age restriction is not at variance with previous guidelines
(24-36 months) al system. of 11 to 14 months of verbal representational use in
I speech. If the client is not functioning at an 18-month
Yes level, then cognltive rather than representational training
Visual discrimination --Poor--* Representational sys- seems in order. Such training might include object identi-
L tem or visual discrimi- fication and matching of pictures to objects. If the client
Good nation training. If very has a cognitive age of 18 to 24 months, then a visual
poor attempt Braille or representational code seems appropriate. In order to use
Symbolic system manual system in palm.
a visual symbolic code functionally, the client should
have a cognitive level of 24 to 36 months or higher
the manual and visual codes are printed next to each (Bayley, 1969; Vanderheiden & Harris-Vanderheiden,
other, they are not meant as exact comparisons. A general 1974). These age guidelines are from the available devel-
rule of thumb is that each client should utilize the highest opmental literature and will only be verified via empiri-
possible code on the hierarchy of which he or she is cal evidence. Song (1979) found that a receptive vocabu-
capable. As with the mode of communication, the code lary age of at least 26 months on the Peabody Picture
may change over time and is not viewed as static. In Vocabulary Test was needed in order to use Blissymbo-
addition, a client may use more than one code at a time, lies spontaneously. She recommended Blissymbolics for
such as line drawings and pictographs, or may learn clients at this low functioning level only as a last resort
symbols in one code and later use another code in when the client fails to learn other modes of nonspeeeh
functional communication. For example, new symbols communication. While a few visual symbols may be
might be introduced as line drawings, and the drawing learned by clients at a lower cognitive level, the authors'
faded to a pictograph in representation prior to inclusion clinical experience has been that such symbols do not
on the communication board. serve a truly linguistic function until the client attains
If a manual mode of communication has been chosen, certain levels of cognitive functioning.
the clinician must decide upon the sign system to employ 2. Visual discrimination: A final issue relates to visual
and the specific signs to train. Questions of the appropri- diseimination. The speech-language pathologist can em-
ateness of finger spelling or a particular sign system, such ploy a match-to-sample procedure using the intended
as American Sign Language, Signed English (Bornstein, symbols (Wulz & Hollis, 1980). Poor discrimination may
Hamilton, Saulneir, & Roy, 1975), Seeing Essential En- mean that a more representational system is needed.
glish (Anthony, 1974), Signing Exact English (Gustason, Clients with extremely poor visual acuity or visual field
Pfetzing, & Zawolkow, 1972), or American Indian Sign limitations may need additional tactile input, such as
Language (Tompkins, 1969), are related to generalization Braille or symbols made from different materials or cut
to the environment, iconicity of signs, ease of use of from sandpaper.
reference material, and prognosis for speech. Finger
spelling provides flexibility but seems inappropriate as
an initial code for severely impaired clients. If the prog- CONCLUSION
nosis for speech is excellent or if the client demonstrates
a potential for later extensive use of signs, then a system The augmentative communication decision matrix is
that mirrors English may be more appropriate. When the presented as an aid for clinicians who are evaluating

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 24 Journal of Speech and Hearing Disorders
nonspeaking individuals. As such, the matrix combines
the authors' clinical experience with developmental and
experimental literature in an attempt to describe and
order clinical considerations. The matrix also addresses
the professional concerns of the ASHA Ad Hoc Commit-
tee on Communication Processes and Nonspeaking Per-
sons. It must be stressed again that the matrix is not a
rigid formula and that several considerations still await
empirical verification, nor is the matrix meant as a substi-
tute for clinical expertise and insight. The client-clinician
team are central to all clinical decisions.
Received February 9, 1982
Accepted June 14, 1983
Requests for reprints should be addressed to Robert E. Owens,
Jr., Ph,D., Department of Speech Pathology and Audiology,
SUNY Geneseo, Geneseo, NY 14454.
REFERENCES
ANTHONY, D. (1974). The Seeing Essential English manual.
Greely, CO: University of Northern Colorado Bookstore.
BATES,E.; BEX~CNI,L., BRETHERTON,I., CAMAIONI,L., & VOLTER-
RA, V. (1977). From gesture to the first word: On cognitive and
social prerequisites. In M. Lewis & L. Rosenblum (Eds.),
Interaction, conversation, and the development of language.
New York: Wiley.
BATES,E., CAMa~ONr,L., & VOLTERRA,V. (1975). The acquisition
of performatives prior to speech. Merrill Palmer Quarterly, 21,
205-226.
BAYLEY, N, (1969). The Bayley Scales of Infant Development.
New York: Psychological Corporation.
BLOOM, L., & LAnCY, M. (1978). Language development and
language disorders. New York.
BORNSTEIN,H., HAUmTON, L., SAULNIER,K., & RoY, H. (1975).
Signed English dictionary for pre-school and elementary
levels. Washington, DC: Gallaudet College Press.
BOWERMAN,M. (1974). Discussion summary--Development of
concepts underlying language. In R. Schiefelbusch & L. Lloyd
(Eds.), Language perspectiVes--Acquisition, retardation, and
intervention. Baltimore: University Park Press.
BRICKER, W., & BRICKER;D. (1974). An early langtaage training
strategy, in R. Schiefelbuseh & L. Lloyd (Eds.), Language
perspectives--Acquisition, retardation, and intervention. Bal-
timore: University Park Press.
BROOKNER,S., & MURPHY,N. (1975). The use of a total communi-
cation approach with a nondeaf child: A case study. Language,
Speech, and Hearing Services in Schools, 6, 131-139.
BRowN, R. (1973). A first language: The early stages. Cambridge,
MA: Harvard University Press.
BRUNER,J. (1974/75). From communication to language~A psy-
chological perspective. Cognition, 3, 255-287.
CARRIER, J. (1974). Application of functional analysis and non-
speech response mode to teaching language. In L. McReyn-
olds (Ed.), Developing systematic procedures for training
children's language (ASHA Monographs No. 18). Danville, IL:
Interstate.
CHAPMAN, R., & MmLER, J. (i980). Analyzing language and
communication in the child. In R. Schiefelbusch (Ed.), Non-
speech language and communication. Baltimore: University
Park Press.
COLEMAN,C. L., COOK,A. M., & MEYERS,L. S. (1980). Assessing
non-oral clients for assistive communication devices. Journal
of Speech and Hearing Disorders, 45, 515-526.
DIHOFF, R., & CHAPMAN,R. (1977). First words: Their origin in
action. Papers and Reports in Child Language Development,
13, 1-7.
Downloaded From: http://jshd.pubs.asha.org/ by a Western Michigan University User on 02/16/2016
Terms of Use: http://pubs.asha.org/ss/rights_and_permissions.aspx
49 18-25 February 1984
DWORKrN, J., & CULATTA,R. (1980). Dworkin-Culatta Mecha-
nism Examination. Nicholasville, KY: Edgewood Press.
DUNST, C. (1981). Infant learning: A cognitive-linguistic inter-
vention strategy. Hingham, MA: Teaching Resources.
FRANKENBuRc,W., & DODD,J. (1967). The Denver Developmen-
tal Screening Test. Journal of Pediatrics, 71,181-191.
FREEDLE, R., & LEWIS,M. (1977). Prelinguistic conversation. In
M. Lewis & L. Rosenblmn (Eds.), Interaction, conversation,
and the development of language. New York: Wiley.
FmSTOE, M., & LLOYD, L. (1976). A survey of the use of non-
speech systems with the severely communication impaired.
Mental Retardation, 16, 99-103.
FRISTOE, M., & LLOYD,L. (1980). Planning an initial expressive
sign lexicon for persons with severe communication impair-
ment. Journal of Speech and Hearing Disorders, 45, 170-180.
FULWmER,R., & FOUTS,R. (1976). Acquisition of American Sign
Language by a non-communicating autistic child. Journal of
Autism and Childhood Schizophrenia, 6, 43-51.
GREENWALD, C., & LZOYARt~, L. (1979). Communicative and
sensorimotor development in Down's syndrome children.
American Journal of Mental Deficiency, 84, 296-303.
GRIFFIN, P., & SAr,-FORD,A. (1975). Learning Accomplishment
Profile for Infants. Winston-Salem: Kaplan School Supply.
GmFFITr~, P., & ROBINSON,J. (1980). Influence of ieonicity and
phonological similarity on sign learning by mentally retarded
children. American Journal of Mental Deficiency, 85, 291-298.
GR~NNEL,M., DETAMORE,K., & L~PPKE,B. (1976). Sign it success-
ful--Manual English encourages expressive communication.
Teaching Exceptional Children, 8, 123-124.
GrJEss, D., SAILOR,W., & BAER,D. (1978)~ Children with limited
language. In R. Schiefelbusch fEd.), Language intervention
strategies. Baltimore: University Park Press.
GUSTASON; G., PFETzING, D., & ZAWOLKOW,E. (1972). Signing
Exact English. Rossmoor, CA: IVlodern Signs Press.
HARDINC,C., & GOHNKOFF,R. (1978). The origins of intentional
vocalization in prelinguistic infants. Child Development, 49,
33-40.
HOBSON,P., & DUNCAN,P. (1979). Sign learning and profoundly
retarded people. Mental Retardation, 17, 33-37.
HORSTMEIER,D., & MACDONALD,J, (1978). Ready, set, go--Talk
to me. Columbus, OH: Charles E. Merrill.
I~HN, J. (1975). Relationship of Piaget's sensori-motor period to
language acquisition of profoundly retarded children. Ameri-
can Journal of Mental Deficiency, 79, 640-643.
I~HN, J. (1978). Acceleration of object permanence with severely
and profoundly retarded children. American Association for
the Education of the Severely~Profoundly Handicapped Re-
view, 14, 15-22.
KENT, L. (1974). Language acquisition program for the retarded
or multiply impaired. Champaign, IL: Research Press.
KENT, L. (1979). Programming a first language: Content and
strategies. Capitol Area Speech and Hearing Association
Spring Workshop, Albany, NY.
I~iRK, S., McCAR:{HY,J . , & KU~K, W. (1968). llIinois Test of
Psyeholinguistic Abilities. Urbana, IL: University of Illinois
Press.
KOHL, F. (1981). Effects ofmotoric requirements on the acquisi-
tion of manual sign responses by severely handicapped stu-
dents. American Journal of Mental Deficiency, 85, 396-403.
KOHL, F., KARLAN,G., & HEAL, L. (1979). Effects of pairing
manual signs with verbal cues upon the acquisition of instruc-
tion-following behaviors and the generalization to expressive
language,with severely handicapped students. American Asso-
ciation for the Education of the Severely~Profoundly Handi-
capped Review, 4, 291-300,
LEWIS, M.,& CHEERY, L. (1977). Social behavior and language
acquisitio n. In M. Lewis & L. Rosenblum (Eds:), Interaction,
conVersation, and the development of language. New York:
Wiley.
MCLEAN, J., & Sr~YDER-McLE_~N, L. (1978). A transactional
approach to early language training. Columbus, OH: Charles
E. Merrill.

MILLER, J., CHAPMAN,R., BRANSTON, M., & REICHLE, J. (1980).
Language comprehension in sensorimotor stages V and VI.
Journal of Speech and Hearing Research, 1980, 23, 284-311.
MILLER, J., & YODER, D. (1974). An ontogenetic language teach-
ing strategy for retarded children. In R. Schiefelbusch & L.
Lloyd (Eds.), Language perspectives--Acquisition, retarda-
tion, and intervention. Baltimore: University Park Press.
MOREHEAD, D., & MOREHEAD, A. (1974). A Piagetian view of
thooght and language during the first 2 years. In R. Schiefel-
busch & L. Lloyd (Eds.), Language perspectives Acquisition,
retardation, and intervention. Baltimore: University Park
Press.
ASHA AD n o c COMMITTEE ON COMMUNICATIONPROCESSES AND
NONSPEAKINGPERSONS.(1980). Non-speech Communication: A
position paper. ASHA, 22, 267-272.
OWENS, R. (1982). Program for the acquisition of language with
the severely-impaired. Columbus, OH: Charles E. Merrill.
PIAGET, J. (1952). The origins of intelligence in children. New
York: International Universities Press.
PIAGET, J. (1954). The construction of reality in the child. New
York: Basic Books.
PIAGET, J. (1959). Language and thought in the child. London:
Routledge & Kegan.
PORCH, B. (1967). Porch Index of Communicative Ability. Palo
Alto, CA: Consulting Psychology Press.
POULTON, K., & ALGOZZINE,B. (1980). Manual communication
and mental retardation: A review of research and implications.
American Journal of Mental Deficiency, 85, 145-152.
REICH, R. (1978). Gestural facilitation of expressive language in
moderately/severely retarded preschoolers. Mental Retarda-
tion, 16, 113-117.
REICHLE, J., & YODER, D. (1979). Communication behavior of the
severely and profoundly mentally retarded: Assessment and
early stimulation strategies. In R. York & E. Edgar (Eds.),
Teaching the severely handicapped (Vol. 4). Columbus, OH:
Special Press,
RUSSO, ]., & OWENS, R. (1982). Development of an objective
observational tool for parent-child interaction. Journal of
Speech and Hearing Disorders, 47, 165-173.
Downloaded From: http://jshd.pubs.asha.org/ by a Western Michigan University User on 02/16/2016
Terms of Use: http://pubs.asha.org/ss/rights_and_permissions.aspx
OWENS • HOUSE: Decision-Making Processes 25
SCHAFER, D., & MOERSCH, M. (Eds.). (1977). Developmental
programming for infants and young children. Ann Arbor:
University of Michigan Press.
SCHAEFER,R, (1977). Mothering. Cambridge, MA: Harvard Uni-
versity Press.
SHANE,H., & BASHIR,A. (1980). Election criteria for the adoption
of an augmenfative communication system: Preliminary con-
siderations. Journal of Speech and Hearing Disorders, 45,
408-414.
SILVERMAN,F. (1980). Communication for the speechless. Engie-
wood Cliffs, NJ: Prentice-Hall.
SONG,A. (1979). Acquisition and use of Blissymbolics by severe-
ly mentally retarded adolescents. Mental Retardation, 17,
253-255.
SPRADLIN,J. (1963). The Parsons Language Sample. In Language
Studies of Mentally Retarded Children, ASHA Monographs
No. 10. Danvill% IL: Interstate.
TOMPKINS,W. (1969). Indian sign language. New York: Dover
Publications.
UZGImS, I., & HUNT, J. (1975). Assessment in infancy: Ordinal
scales of psychological development. Urbana, IL: University
of Illinois Press.
VANBIERVLIET, A. (1977). Establishing words and objects as
functionally equivalent through manual sign training. Ameri-
can Journal of Mental Deficiency, 82, 178-186.
VANDERHEIDEN, G., & HARRIS-VANDERHEIDEN,D. (1974). Com-
munication techniques and aids for the nonvocal severely
handicapped. In L. Lloyd (Ed.), Communication assessment
and intervention strategies. Baltimore: University Park Press,
WEBSTER, C. (1973). Gestural training breaks communication
barrier in child autism. Special Education in Canada. 48, 6.
WULZ, S., & HOLL1S,J. (1980). Word identification and compre-
hension training for exceptional children. In R. Schiefelbusch
(Ed.), Nonspeech language communication. Baltimore: Uni-
versity Park Press.
ZACHAaV,W. (1978). Ordinality and interdependence of repre-
sentation and language development in infancy. Child Devel-
opment, 49, 681--687.
ZWEIBAN, S. (1977). Indicators of success in learning a manual
communication mode. Mental Retardation, 15,47-49.