International Journal of Computer Processing of Oriental Languages Vol. 19, No.

4 (2006) 249262 Chinese Language Computer Society & World Scientic Publishing Co.

Augmentative and Alternative Communication (AAC) Research and Development: The Challenge of Evidence-based Practice
KATYA HILL
Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA 15260, USA khill@pitt.edu

Augmentative and Alternative Communication (AAC) computer-based systems are used by individuals with severe disabilities who cannot speak. AAC technology is designed with the goal to optimize communication and improve quality of life. This paper presents principles of design based on evidence-based practice (EBP) and language activity monitoring (LAM). When applied to the research and development of AAC computer-based technology, these principles provide quantitative data for making decisions about product performance and achievable outcomes focusing on the benet to the end-user. The evaluation of a Mandarin language software application provides an example of how the steps of EBP and LAM data were applied during the initial research tasks. The EBP model offers a unique innovation to product development by challenging computer processing designers and programmers to design systematic and scientic data collection and analysis procedures specic to EBP. Keywords: Augmentative and alternative communication (AAC); Evidencebased practice; Language activity monitoring; Log le; Automated data logging; Outcomes.

1. Introduction
Augmentative and alternative communication (AAC) is a eld of endeavor with a goal to optimize the communication of individuals with signicant communication disorders [2]. The eld of AAC involves clinical rehabilitation and educational practice to improve the communication competence of individuals with little or no functional speech. Clinical and educational decisions about practice involve the identication, selection, and implementation of a variety of AAC technology solutions based on evidence. Consequently, a component of the eld of AAC
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involves the research and development of computer-based technology that leads to effective communication and an improved quality of life. Although the goal for the most effective communication has been accepted world-wide as a basic human right, not all AAC technology solutions will achieve this goal for every individual with a signicant communication disorder. Maximizing an individuals potential using AAC assistive technology requires selecting a solution that matches the individuals skills, needs, and expectations with specic language, input and output features of the system. Practitioners and consumers would not expect that if the same AAC solution were recommended for an individual with cerebral palsy, autism, or amyotrophic lateral sclerosis that the same performance or outcomes would be achieved. Practitioners and consumers depend on evidence to guide decisions in recommending AAC assistive technology. Yet many treatment approaches and technologies in common use have never been evaluated, and many others that have been evaluated remain of uncertain benet [3]. Research and development (R&D) for AAC computer-based systems has the purpose of creating new or improving existing materials, devices, products or processes. The process involves the systematic study and application of knowledge to design, develop, and improve prototypes or new methods, tools, and resources. Systematic and principled approaches to research provide evidence that can be disseminated for clinical, educational and consumer decision-making. With the increasing expectation that AAC decisions are driven by evidence, manufacturers or R&D teams are under closer scrutiny to offer the evidence that leads to product design, development and/or improvement.

2. Evidence-Based Practice (EBP)

This section reviews the principles and steps of EBP illustrated through a systems model for AAC clinical EBP. In addition, the section discusses software tools and resources to support EBP by the collection, analysis and reporting of performance and outcomes measurement. An example applying the EBP process is given using research on the feasibility testing for word prediction, a text input feature originally used to enhance rate. 2.1. Steps of EBP Evidence-based practice (EBP) is the conscientious and judicious use of current best evidence in making decisions about the care of individuals [19]. EBP is now part of every health care discipline and professional education program [14]. For AAC stakeholders, an important impetus for EBP has been the growing awareness

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of the limitations of expert opinion as the sole basis for decision making. AAC technology innovations are not accepted merely based on the recommendation of an expert or the newness of a feature, but with the expectation that data quanties the benet or improved performance of the innovation. Consequently, an expectation of EBP is that reliable and valid performance data are being collected and analyzed to monitor and compare results for reporting and dissemination [5]. A systems model for EBP represented in Figure 1 depicts the basic principles and steps expected of following an evidence-based approach to AAC clinical practice and research [9]. This approach applied to AAC computer-based product development, as in clinical practice, would promote the collection, interpretation, and integration of valid, important, and applicable subject-reported, clinicianobserved, and research-derived evidence [16]. R&D teams using an evidence-based approach to prototype development start by fully characterizing the potential client population(s) for whom the product may benet. Once the client populations have been identified research questions are formulated for the following: 1) searching for the current research that would answer the questions, 2) identifying current performance measures related to products and solutions presently used for the target clinical populations, 3) identifying performance measures for the stages of product testing and clinical trials, 4) supporting hypothesis testing for product development. These R&D processes correspond to the four steps of the clinical EBP process. However, R&D teams need to be aware that Institutional Review Boards (IRBs) will pay close attention to informed consent and the protection of human subjects in the approval of research projects. Therefore, although clinical practitioners are conscientious of informed consent and the application of scientic and principled approaches to AAC rehabilitation service delivery, R&D teams will be held to a higher standard of accountability. In addition, R&D teams are under closure scrutiny to report performance data that can be compared against other research or used to duplicate research. The development of automated resources and tools to support performance data collection makes reliable and valid reporting effective and efcient. 2.2. Language activity monitoring The best available external clinical evidence regarding language acquisition, development and use (performance) has been obtained through the collection and analysis of language samples. Traditional methods of collecting language samples generally have included personal observation or video and audio recording with subsequent transcription and analysis [8]. Therefore, language sampling is

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Start Here

Client Prole Development

Step 1 EBP Questions

Step 2: External Evidence (Performance of Other Individuals and Research)

Step 3: Personal Evidence (Performance Measurement)

Previous Performance

Evaluation of Evidence Other Factors (stakeholder input, environmental considerations, eld knowledge, clinical experience)

Step 4: Use of Evidence (AAC Therapy) Hill and Romich 2006

Figure 1. A model for AAC evidence-based practice (Hill and Romich, AAC Institute Press, 2006).

labor and time intensive. Nevertheless, language sampling is considered the best evidence of an augmented communicators performance [15]. Language Activity Monitoring (LAM) provides for the automatic recording of AAC system events along with a time stamp in a log le format allowing investigators to deduce a variety of parameters about communication performance [8]. LAM is a built-in feature of several modern high performance AAC computer-based products that when activated create a log le for analysis later. Along with U-LAM (universal language activity monitor) a software program that allows a PC to act as a LAM, developers can test almost any digitized or synthesized voice output AAC system during product development and/or clinical trials [11]. Consequently, replication of results of clinical trials should be at a high condence level. LAM data are recorded within the AAC system as the preferred method [1]. After the collection of the language sample, the data are sent or otherwise moved to a computer for analysis. The format for the internal recording is open.

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However, when the data are sent or moved to the computer, it must comply with a standard format in order to be recognized and processed by the analysis software. LAM data consist of two required elds and one optional eld. For each language event, a time stamp and the content are required. Analysis of a language sample containing this information yields much information of clinical signicance. However, these data also provide performance measures to evaluate R&D progress on product feasibility and development. The optional eld is a three letter mnemonic indicating how the language event was generated in the AAC system. It has been found that the method used to generate language can have a dramatic impact on communication performance. This optional eld provides information that addresses this issue. The LAM file can start with a header of unspecified structure. It is recommended that the header include two components. First is the name and version of the AAC system. Second is a privacy notice. A sample is presented here: ### CAUTION ### The following data represents personal communication. Please respect privacy accordingly. Language Activity Monitor device name Version 2.00 07/26/06 ACME AAC Company The following example reflects the required format for LAM data reporting. 09:27:17 09:27:19 09:27:22 09:27:24 09:27:26 09:27:29 09:27:34 09:27:36 09:27:38 09:27:43 09:27:49 09:27:51 09:27:58 OWS I OWS am SMP hungry OWS and OWS I SMP want SPE s SPE o SPE m WPR some DWP something OWS to PAG eat

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First required eld The rst eld in the language event reporting is the time stamp, reported with one second resolution. When the AAC system includes a real time clock, it is expected that the time stamp is derived from that clock and thus reports the actual time of day. If the AAC system does not have a real time clock, then the time stamp can be derived from an internally generated timer, starting at 00:00:00 when the system is powered up. If the clock does not reect real time, this may be noted in the header. The format is hh:mm:ss (hours, minutes, seconds) using a 24-hour number system. If the AAC system includes date information, that can be included when the LAM function starts to record and when the date changes. The format for recording the date is *[YY-MM-DD=04-06-20]*, including the asterisks. Second required eld The second eld is the content of the language event. This can be one or more letters or words that result from a single language generation action. The content is reported within quotation marks in order to make clear the presence of spaces. Optional source mnemonic When present, the optional three letter source mnemonic is used in the analysis of the language sample. This eld is placed between the two required elds. It facilitates the identication of language representation methods used for generating the language events, an important factor in AAC clinical service delivery and research. These are used in the analysis of utterances, or parts thereof, that are created using spontaneous novel utterance generation (SNUG). The three basic methods employed in all AAC systems are 1) single meaning pictures, 2) alphabet-based methods (spelling, word prediction, orthographic word selection, etc.), and 3) semantic compaction: SMP: Single Meaning Pictures SPE: SPElling WPR: Word PRediction OWS: Orthographic Word Selection SEM: SEMantic compaction

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Figure 2. Transfer process for LAM logles (Hill and Romich, AAC Institute Press, 2003).

LAM process Figure 2 depicts the transfer process of sending or moving the LAM le from the AAC system into a computer for analysis. This can be accomplished by: 1) a connection to the computer (serial, USB, IR, etc.) or 2) a means of saving the le and moving it intact (oppy disk, USB memory, ash card, etc.). When the transfer is implemented using a connection to the computer, a terminal program such as LAMterm software may be used in the computer to receive the le. LAMterm awaits serial port data and when the data string is interrupted it provides for storing the data that has been received. Therefore, if this method of transferring the data is used, be sure that the string is not interrupted. When the transfer is implemented using mass storage media, the data should be saved as a text (.txt) le. The Performance Report Tool (PeRT) software has been designed to analyse language transcripts based on LAM logles [10]. Upon completion of the utterance segmentation process and entering the information on the subject, the AAC system, and the language sample collection procedure, the AAC Performance Report can be automatically generated. PeRT provides seven utterance-based and ten word-based summary measures along with various attached appendices for reporting. R&D teams can use results from PeRT to monitor testing and clinical trials selecting specic summary measures that address the research questions. 2.3. Application of EBP: An AAC example An example of how the EBP process can be applied by AAC R&D teams may be found in the research on word prediction. Word prediction is a method in which the user starts to spell a word and the AAC system tries to guess what

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word is being spelled. The highest probability guesses are presented to the user in a list. The user reviews the list and either selects the desired word or continues to spell if the desired word is not present in the list [17]. Word prediction was proposed as an innovation to increase communication rate, since spelling is such a slow method for generating messages during conversations. Let us return to the EBP model (Figure 1) and start by characterizing the clinical population(s) that might benet from word prediction. Individuals with a variety of congenital and acquired disorders might make up the group of clients that could use word prediction. The primary characteristic of the potential clients is that literacy skills have been acquired; clients need to be competent spellers and familiar with text entry, or could be trained to perform text entry to create messages. An initial target group for product testing would most likely be adults with normal or above cognitive functioning expressing the values of being able to say what they want to say when they want to say it and saying it as fast as possible. Initial work on the feasibility of word prediction by R&D teams was based on the hypothesis that this innovation would increase communication rate. Today, a Step 2 search on word prediction research by evidence-based R&D teams would lead to results showing that although prediction features may reduce keystrokes, data do not support improved communication rates [13, 18, 20]. LAM data comparing rates among the AAC language representation methods has shown that word prediction offers no signicant rate differences with spelling [7]. Also, the word prediction process is said to be distracting and cannot become automatic. R&D teams attempting to create or improve prediction features have the responsibility to use the existing knowledge to compare and report results of present/future studies for prediction features available in AAC systems. A variety of prediction features are available on AAC computer-based systems to customize how the option functions for text entry. However, most options remain of uncertain benet if activated. R&D teams working on such rate enhancement strategies are expected to report clearly dened and operationalized performance measures used in the research. Standard denitions for performance measures and automated LAM tools provide reliability and validity to the evaluation process and support EBP expectations.

3. The Mandarin AAC Project

This section reviews the EBP process that was applied to the design and development of a Mandarin language system for an AAC computer-based system.

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The conceptualization of the specic aims and research design incorporated the four steps of EBP as the R&D team initiated the development plan. 3.1. Initial research planning The principles of EBP have been applied in the development of a Mandarin language application software program for an AAC computer-based system. With China entering the global technology community, and, therefore, potentially, the global assistive technology community, the need for AAC assistive technology to support individuals with disabilities who speak Mandarin was apparent. Preliminary work on the project was started as focus group discussions and surveying key AAC stakeholders to conrm the feasibility, acceptance, and perceived value of the potential AAC system. The outgrowth of focus group discussions led to the identication and selection of the primary R&D team members. In addition, results from focus group discussions and surveying supported the early discussion by R&D team members of characterizing the initial clinical population. Inclusion and exclusion criteria were listed that would support 1) formulation of EBP questions, 2) search for external evidence, 3) collection of personal evidence; 4) product testing or use of evidence to monitor results. 3.2. Characterizing the clinical population Inclusion criteria were identied for the initial clinical population in feasibility testing. The criteria were selected that would maximize input and feedback of the initial software product by the research participants. In addition, criteria that would support approval by the IRB for an expedited research application were taken into consideration. The targeted participants included the following: 1) adults at or above 18 years of age, 2) Mandarin as the native language, bilingual in English, but not required, 3) natural speech was not functional to meet daily communication needs due to disarthria or verbal apraxia, 4) normal to mildly impaired language abilities, 5) normal to mildly impaired cognitive abilities, 6) direct selection as a physical access method, 7) normal vision with correction, 8) normal hearing with correction, 9) able to participate in the study during the required testing period. 3.3. Step 1: EBP questions Step 1 required the formulation of several EBP questions based to structure the evaluation tasks for the project. EBP question formulation strategies were used to enhance the clinical application of the results and ensure that research

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results could be reported as evidence that mattered to clinical practitioners. The R&D team followed the COPES (client-oriented practical evidence search) strategy in formulating questions [4]. Therefore, questions required the following four parts: 1) client and/or disorder, 2) intervention, 3) alternative intervention, 4) performance outcomes. The two central questions selected by the R&D team included, but were not limited to: Question 1: For non-speaking clients with Mandarin as a native language would an AAC application based on frequency of vocabulary for individuals of native-speaking Mandarin backgrounds or vocabulary based on activities of daily-living result in optimized communication as measured by frequency of spontaneous novel utterance generation, mean length of utterance and frequency of core vocabulary. Question 2: For non-speaking clients with Mandarin as a native language would an AAC application based on text entry (i.e. spelling) or an application based on multiple methods (i.e. alphabet-based methods, single meaning pictures, and semantic compaction) result in optimized communication as measured by average and peak communication rates, frequency of language representation method, and communication rate by language representation method. 3.4. Step 2: External evidence Step 2 required a search for the current external evidence. EBP requires that the best evidence be located and appraised to answer the posed questions. The University of Pittsburgh library provided access to extensive Internet research tools to support evidence searches such as MEDLINE. Methodology-orienting locators for evidence based on the EBP questions and keywords were used [4]. In addition, R&D team members had access to various global resources and tools in multiple languages. Therefore, keywords could be searched in English, Mandarin, and German. Examples of a few of the studies used as the researchbase to answer the questions are identied below. Question 1 involved searching for frequency of word occurrence lists in Mandarin. This involved a general search of academic literature for corpusbased lexicons. Although both written and oral evidence are important to AAC, transcribed speech corpora were preferred because the resulting lexicons better reect natural language. The Linguistic Data Consortium (LDC) at the University of Pennsylvania provides several such spoken-word lexicons with frequency data extracted from telephone conversations. For this work, we selected a 45,000type lexicon from the LDC CALLHOME project, paired with part-of-speech information from the general literature.

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Question 2 involved searching for research on current AAC solutions for individuals speaking Mandarin. The search process resulted in no found research regarding AAC technology being used with clients who rely on AAC that were Mandarin speakers. Therefore, performance measures currently available for individuals who rely on AAC speaking English were used to establish performance indices as baseline data for feasibility testing. Present data indicate that adults with cerebral palsy using voice output communication aids (VOCAs) have an average communication rate around 12 words per minute and a peak communication rate around 20 words per minute in conversations with sentence lengths typical of adults using natural speech [6]. However, signicant differences have been found in comparing communication rates among AAC language representation methods. Semantic compaction has been found to be as much as six times faster than spelling and word prediction [7]. Once Steps 1 and 2 were completed, the R&D team initiated design and development of the initial version of the software application. A list of core vocabulary words was targeted for encoding. Approximately 80 of these core words were encoded in icon sequences. This includes certain closed classes, e.g., personal pronouns, common verbs, and words from a few other parts of speech. The icons were selected from a set of icons widely used in European augmentative communication systems. A format generally derived from Germany Words Strategy (Copyright Semantic Compaction Systems) was adopted as a template. A speech-generating device (SGD) with 128 location selection set was targeted. One potential user, a 71 year old man with a post stroke condition, was able to construct spontaneous novel utterances with brief training. 3.5. Next tasks Steps 3 and 4 are in progress. Step 3 has involved identication of the performance measures and outcomes to be collected during initial and beta testing. At present documents required for informed consent and procedures for the IRB process that provide for the protection of human subjects and the international collaboration among the R&D team members are being determined for necessary IRB applications. The research tasks being designed for beta-testing and clinical trials are taking into consideration the International Classication of Functioning, Disability, and Health (ICF) model adopted by the World Health Organization [21]. The ICF model provides the R&D team with a focus on globally validated strategies and intervention that touch on issues such as universal human rights and development, and our understanding of human cognition and functioning [12]. This model is being used to identify the activities (i.e. home, community,

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work, education, etc.) and levels of participation (i.e. conversation, discussion, requesting, informing, etc.) selected for the data collection protocols for language sampling. Specic research procedures to ensure the integrity of the project to avoid bias and collusion are being built into the design and methodology such as blinding and independent data analysis.

4. Summary
The challenge of EBP offers exciting opportunities for AAC assistive technology R&D teams to increase the value of the product development process for clinical practitioners and consumers. EBP provides a framework that allows R&D teams to interact with the individuals who will be using the product in the long-term. EBP provides a challenge in prototype development, because teams are expected to disclose and disseminate the results of product testing. The expectation is not simply the latest state-of-the-science technology, but computer-based technology that improves quality of life based on measured parameters of signicance. This principle is in direct contrast to practices of testimonial or commercial marketing. Simply pronouncing that technology offers a benet to an individual is not the same as providing measured performance and outcomes. The research procedures described regarding the Mandarin project document the collaboration between university research faculty, clinical practitioners, the manufacturer, and potential consumers that included steps to maintain the independent collection of data to ensure the integrity of the research. Many R&D teams working exclusively within the boundaries of the manufacturing facility may be challenged to design systematic and scientic data collection and analysis procedures required of EBP. The early work of the Mandarin R&D team provides a model for the EBP process that addresses this challenge. The research protocols involve the collection and reporting of results using automated LAM tools that will provide external and personal evidence for all AAC stakeholders. These principles can be applied to the research process for most assistive technology computed-based applications being developed for individuals with disabilities. Finally, basing the protocols on the ICF model provides a global framework for validating future AAC technology innovations that contribute to the universal human right of the most effective communication possible.

Acknowledgments
The research on the development and evaluation of language activity monitoring (LAM) was supported by the following National Institutes of Health (NIH)

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Small Business Innovation Research (SBIR) grants: 1) NIH Grant No. 1 R43 DC04246-01. Augmentative Communication Language Activity Monitor, Awarded September 1999, and 2) NIH Grant No. 1 R43 DC04472-01. Digitized Speech Language Activity Monitor (D-LAM). Awarded September 2000.

References
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