Conference PaperPDF Available

Facilitators and Barriers to Using Alternative and Augmentative Communication Systems by Aphasic:Therapists Perceptions



Previous research identifies facilitators and barriersrelated to the use of Alternative and Augmentative Communica-tion Systems, however, more evidence is needed to understandaspects related to introduction of such systems in an outpatientsetting. This paper aims to analyze theses aspects by identifyingthe facilitators and barriers that comprise systems use by aphasicpeople at a University Clinic in Brazil. Semi-structured interviewswere conducted and the collected data were analyzed based onqualitative techniques like open coding and constant comparison.In addition to the factors found in previous research, this studyidentified new factors such as: cost, infantilized systems andsentences quality produced, that can be considered as facilitatorsor barriers in using AAC systems. The results of this researchcan be used to improve the current and new AAC systems.
Facilitators and Barriers to Using Alternative and
Augmentative Communication Systems by Aphasic:
Therapists Perceptions
Jayr Pereira, Carolline Pena, Mariana de Melo, Robson Fidalgo, Sergio Soares
Center of Informatics
Federal University of Pernambuco
Recife, Brazil
Email: {jap2, cdp, mbm, rdnf, scbs}
Bruno Cartaxo
Dept.of Graphic Computing
Federal Institute of Pernambuco
Olinda, Brazil
Abstract—Previous research identifies facilitators and barriers
related to the use of Alternative and Augmentative Communica-
tion Systems, however, more evidence is needed to understand
aspects related to introduction of such systems in an outpatient
setting. This paper aims to analyze theses aspects by identifying
the facilitators and barriers that comprise systems use by aphasic
people at a University Clinic in Brazil. Semi-structured interviews
were conducted and the collected data were analyzed based on
qualitative techniques like open coding and constant comparison.
In addition to the factors found in previous research, this study
identified new factors such as: cost, infantilized systems and
sentences quality produced, that can be considered as facilitators
or barriers in using AAC systems. The results of this research
can be used to improve the current and new AAC systems.
Keywords-Aphasia; AAC; AAC systems; Assistive Technolo-
gies; Speech Therapy;
Aphasia is a language disorder provoked by brain lesions.
This condition may impose restrictions on the performance
of instrumental/daily activities, interfering in how subjects
interact with the world around them, as well as their quality
of life [1]. Aphasia can lead to cognitive impacts such as
difficulty in attention, perception, and memory, which in turn
affects oral language (comprehension and production) and
writing (reading and production) [1].
The neurolinguistic approach argues that language results
from social experiences with and on the language, stating
that language is related to cultural factors [2]. For many
individuals with aphasia, the language use becomes a major
challenge. The feeling of incompleteness towards the ability
to communicate can hamper the daily life of individuals, and
ultimately provoke exclusion from the social coexistence [2].
Alternative and Augmentative Communication Systems
(AAC systems) are tools aiming to support the communication
of individuals who have some type of difficulty in speech, such
as: children diagnosed with Autism Spectrum Disorder, people
with acquired cognitive disabilities, such as aphasia, or indi-
viduals with some physical impairment, such as quadriplegics,
among others. AAC systems might promote social inclusion
and the development or expansion of the social skills of these
people, giving them the possibility of communicating and
maintaining socio-affective relations.
In order to analyze the aspects involving the use of AAC
systems, this study aims at identifying facilitators and barriers
regarding the introduction of such systems in an outpatient set-
ting to adult aphasic patients at the University Clinic Professor
abio Lessa of Federal University of Pernambuco in Brazil.
We interviewed three therapists who works in the clinic, with
the purpose of exploring their perceptions regarding the use
of AAC systems by adult patients diagnosed with aphasia, in
order to identify the main facilitators and barriers of this group
in the use of these systems. We also compare the results of
this research with results obtained by previous studies on this
field [3], [4].
The evidence presented in this paper may be useful for
the development and improvement of AAC systems, and
thus facilitate their introduction by identifying the elements
that contribute to and prevent their use. It also allows these
elements to be recognized, mitigated, and improved, which in
turn enables AAC systems to be used in a larger scale, aiding
the treatment of people who have different degrees of speech
A. Core Concepts
The language limitations common in aphasic patients are
related to brain lesions, usually caused by Stroke or Traumatic
Brain Injury [1], which compromises the comprehension and
production of oral and written language. Patients with aphasia
can no longer convert (with the necessary precision) the
sequences and nonverbal mental representations to sentences
with grammatical organization that constitute language. In ad-
dition, the reverse process, which is the generation of internal
images of nonverbal representations from phrases heard or
read, can also be impaired [5].
Aphasics patients have their lifestyle modified, since com-
munication is essential for the construction of socioaffective
relations, as well as for the development of various activities,
such as study and work. In this context, Assistive Technologies
2019 IEEE 32nd International Symposium on Computer-Based Medical Systems (CBMS)
2372-9198/19/$31.00 ©2019 IEEE
DOI 10.1109/CBMS.2019.00077
(AT) expand the functional abilities of people with disabilities
through technological resources, aiming to promote greater
independence and inclusion of these individuals [6].
AAC systems is an AT to assist communication of people
with speech impairment or functional writing problems, such
as patients with aphasia. It compensates and facilitate, per-
manently or not, ones communication [7]. AAC systems may
be implemented with low-tech instruments like simple paper
boards, as in PECS [8], or with high-tech devices, ranging
from applications for smartphones and tablets to sophisticated
devices like the one used by British theoretical physicist
Stephen Hawking. Such systems are endowed with symbols
or figures representing words or expressions, or simply words
or letters that enable users to form sentences according to their
selection in order to communicate a message.
At first, high-tech AAC systems consisted of hardware
devices and software features, often coupled to wheelchairs
and furniture, or even simple software installed on personal
computers (PCs). The advent of mobile technologies enabled
the adaptation of AAC systems to applications that can be
installed on tablets and smartphones, such as aBoard [9],
LetMeTalk, and Livox, which according to Bradshaw [10],
increased patients mobility, and reduced costs.
B. Related Work
Baxter et al. [3] conducted a systematic literature review
aiming to identify the main potential facilitators and barriers
of using high technology AAC systems. The authors looked for
publications containing reports of users, therapists, and parents
of AAC systems users, in order to identify the main positive
and negative points using these systems, considering patients
from different conditions (e.g. aphasia, autism, dementia, and
paralysis). They identified 20 factors that may impact high
technology AAC systems adoption, among them are: ease
of use, reliability, technical support, voice and language,
family participation, training, message generation speed, and
acceptance of others.
Judge and Townend [4] conducted a research to explore
the perceptions of therapists, users, and caregivers of users
of high-technology AAC systems, or Voice Output Commu-
nication Aids (VOCAs). The research method was based on
interviews, and the results formed a set of requirements for
VOCAs, highlighting factors such as ease of use, systems
physical characteristics, speed of communication, environ-
ment, reliability, and technical support.
Baxter et al. [3] highlight that ease of use in AAC systems
is essential to the user experience, and that “mysterious and
complex” systems can be frustrating. They also affirm that
adults have difficulties in using these systems, often due to
their own limitations of knowledge and skills using technolog-
ical instruments. Franco et al. [11] state that one of the main
requirements to build robust AAC systems is the possibility of
software interface customization. While Baxter et al. [3] em-
phasize physical customization, for people who have physical
limitations and use AAC systems coupled with wheelchairs,
for example. For those cases, customization helps to improve
system usability. Judge and Townend [4] address this factor
based on four points: efficiency, reliability, user fitness, and the
ability of the system to adjust (i.e. adjustability). The authors
demonstrate that, for users and therapists, AAC systems ease
of use is an important factor, highlighting the difficulty that
the interviewees faced, both operating and configuring such
systems. According to the authors, this is caused by “poor
software design” and by the cognitive load required from the
System reliability is also another important factor identified
and highlighted by Baxter et al. [3]. They claim that failures
in AAC systems can become key barriers for users due
to the frustration they can cause. Failures during sentence
construction, battery unloading, and repair duration imply,
according to the authors, in reduced system efficiency, and can
also hamper users learning. According to Judge and Townend
[4] failures in systems can cause frustration, anger, and panic
in users, as well as affect their motivation. On the other hand,
some of the respondents in their survey say they are happy
and satisfied with systems reliability.
Technical support is also a factor identified by Baxter et
al. [3]. In many cases there is not a team or a company
contact that can help in troubleshooting. Judge and Townend
[4] emphasize that this factor is considered important by AAC
systems users and therapists, because finding people who can
support AAC systems is a complicated task since the level of
technical knowledge these people must have may vary between
the systems and devices used.
The quality of the voice and words generated by the systems
is also an important factor [3]. The volume of the voice
produced, the scope of the vocabulary, idioms, the possibility
of using users own voice on the synthesizer, and the gram-
matical quality are all points that can be facilitators or barriers
for AAC systems users [3]. Those interviewed by Judge and
Townend [4], in turn, point out that systems should be faster
in communicating phrases, to streamline the communicative
process. The authors further state that respondents (users and
therapists) would like the systems to have alternative ways
to share messages, and have voice options (male, female,
children, accents, etc.) for them to choose.
Another factor identified by Baxter et al. [3] is the time
the user takes to formulate and communicate sentences, which
can stimulate or discourage system usage. Judge and Townend
[4] also claims that this can be a source of frustration,
especially when the users have had experience with verbal
communication, as is the case of people who have limitations
due to injuries.
Both the studies of Baxter et al. [3] and Judge and Townend
[4], cite the participation of family members as an important
factor for AAC systems adoption, which can become a facilita-
tor or a barrier. Baxter et al. [3] highlight the influence family
can have in making decisions related to the system, as well
as their fundamental role in user’s learning. Family is also
involved in another factor addressed by both studies, which
is training. In addition to users, family members, therapists
and caregivers must also know AAC systems and learn how
to interact through it with the users. The two researches also
point out that the requirement of high levels of training may be
barriers to AAC systems adoption. However, on the other hand,
training parents, therapists, caregivers and users can help in
using the systems, and making communication more efficient.
The lack of training can generate demotivation which usu-
ally happens outside home and therapeutic environment [4].
In some cases, when possible, users prefer to communicate
verbally, even if little, according to the authors. Baxter et al.
[3] stress that it is necessary for users to have the means to
introduce their AAC systems to other people.
However, the aforementioned studies take into account
patients from different clinical settings. Thus, the factors
identified by them may not fully reflect the reality of a specific
group, such as aphasic adults. This research, on the other hand,
seeks to identify the main facilitators and barriers in the use
of AAC systems by adults diagnosed with aphasia.
Our research method is qualitative and based on Merriam
[12] and Easterbrook [13] guidelines. This research has an in-
terpretative exploratory nature and aims to understand the main
facilitators and barriers regarding the use of AAC systems by
adults with aphasia in the context of the University Clinic
Professor F´
abio Lessa of Federal University of Pernambuco
in Brazil.
A. Study Design
During the execution of this research, the ethical norms
foreseen in the Resolution 196/96 of the Brazilian National
Health Counsel were followed. All the interviewees signed
an Informed Consent Term that specifies the objectives of
this research and information regarding confidentiality and
anonymity. After conducting the interviews, we performed
Open Coding [14] techniques. Next, we performed a com-
parison of these codes for later analysis and definition of
categories, including those that are facilitators or barriers.
B. Sample and Sampling Technique
This study is an investigation, thus, our sample does not
constitute a probabilistic sample since there was a basis of
intentional criteria to choose the individuals who participated
in the interviews [15]. The following criteria were used to
choose participants: (i) the participant must work as a therapist
in the University Clinic Professor F´
abio Lessa of UFPE, being
supervisor or trainee; and (ii) the participant must currently be
assisting or have previously assisted one or more patients with
whom AAC systems were used during the therapy sessions.
Based on these criteria, three therapists were interviewed. Two
of them are internship supervisors at the clinic, and another is
a trainee student.
C. Interview Instrument
We constructed a semi-structured interview questionnaire1
with 23 questions. Our aim was to learn about the basic
concepts professionals have about aphasia and AAC systems,
their experiences using AAC systems applied to therapy of
adults with aphasia.
D. Data Analysis and Synthesis
The interviews were conducted, recorded and transcribed by
the researchers themselves. The MAXQDA I and RQDA were
software tools used to support the coding process.
The first step on the process of analyzing our data was
using the open coding method, which consists of assigning
codes to certain transcribed passages, so a section of an
interview is labeled by identifying some meaningful stretch
that can configure a concept, which is understood as an
abstract representation of events, actions, or interactions [14].
After the first round of open coding, we compared the
generated codes in each one of the interviews to determine
categories and their correlations aiming to specify the central
factors for our study. The open coding method allows compar-
ing relationships, similarities and divergences [14]. In the end,
it was possible to identify the facilitators and barriers through
the professionals perceptions and points of view.
E. Validity
According to Merriam [12], qualitative research must be
concerned with producing valid and ethical knowledge, so that
its results can be used by other professionals. In this section,
we consider some of the points specified by Maxwell [16]
and Merriam [12] that may interfere with qualitative research
credibility, and thus specify the actions we have been taken to
mitigate threats to validity of this study.
Related to description and interpretation validity, we rig-
orously recorded the interviewees perceptions following a
questionnaire that allowed us to capture and examine all
aspects related to participants meaning and understanding
about the theme under investigation. The interviews were
always conducted by two researchers, one in charge of asking
questions, and another in charge of making observations about
implicit aspects during the interviewees speech.
In order to mitigate threats to theoretical validity, we created
a theoretical framework based on concepts extracted from
previous studies [3], [4]. We also took care so that these
concepts did not interfere in the analysis of participants’
perceptions. Thus, we analyzed all the aspects emerged during
the interviews, not only those that corresponded in some
way to the concepts that were specified in our theoretical
As for the bias that can be produced by the researcher
himself or by the participants, it was not possible to mitigate
all the points related to this threat, since among the authors
of this study, two had contact with the subject and with the
interviewees of previous investigations. However, although the
researchers already have a concrete knowledge base and still
know the participants, we tried to conduct all the research in
an impartial way, free of personal beliefs, but it is necessary
to consider this threat. Also, it should be noted that two
interviewees had some kind of contact with the research group
that developed the aBoard AAC system [9].
In this section we present the results of this research, starting
with the description of the school clinic, then the interviewees
understanding about AAC systems, and finally the facilitators
and barriers identified, as well as a brief description of what
an ideal AAC systems would be, according to the interviewees
A. Context
The University Clinic Professor F´
abio Lessa of the Federal
University of Pernambuco was inaugurated in 2013. It assists
people with communication difficulties (e.g. apraxia, aphasia,
autism). The clinic assists an average of 15 people with
B. AAC systems Characterization
The questions are made to explore the understanding of
the interviewees about AAC, with the objective of aligning
participants’ concepts with those found in the literature. The
therapists defined AAC as something that is intended to help
people with verbal and written communication difficulties at
various levels, which are quite in line with the foundings in
literature [7], [6].
Interviewees also cite a serie of benefits of using AAC sys-
tems with aphasic patients, such as help in improving patient
communication, reducing patients’ stress during therapies,
the possibility of continuity in the extra-clinical therapeutic
process, and acting as a link between the patient and the
therapist. When asked what were the points they considered
positive in using AAC systems with aphasic adults, one of the
interviewees answered:
In the case of the aphasic it works sometimes as a facilitator
to be able to give a little more speed in this communication.
Its also mentioned that these tools give more independence
and autonomy to the patients, enabling their “empowerment”:
So in short, within rehabilitation it has the issue of self esteem,
patient empowerment, and also has the issue of acquiring
knowledge through the tool.
Another important point is the link created between the
patient and the therapist through a AAC systems, which allows
therapy to proceed:
(...) be a link between the therapist and the patient. Because
I can often understand how he’s thinking due to the board.
In addition, AAC systems enables the reconstruction of
bonds with people in the patient’s socio-affective circle as
described below by one of the interviewees.
With the application they can communicate better because
sometimes when people see that they cant communicate, they are
ignored, they dont socialize, they are excluded. And this I think
is a way for them to communicate, and to include themselves in
the conversations with people, in society. It helps a lot in their
The possibility of reintegration into daily conversation
reduces the process of exclusion that people with aphasia
experience. In this way, the use of AAC systems can improve
the quality of life of these users.
C. Facilitators and Barriers
A list of seven factors involving the use of AAC systems
by adults with aphasia were defined based on the interviews,
and through coding and analysis. These factors portray the
interviewees experience in the context of the indicated clinic
and their perception on the subject under investigation.
The cost of SCAAs is cited by participants as a decisive
factor for their use in therapies with aphasics. According to the
interviewees, the systems available in the market or are priced
high, or require devices such as tablets and smartphones,
which are also expensive and not always available. According
to the interviewees, the size of the patients’ smartphone
screens makes it difficult to use these applications, because,
in certain cases, patients with post-stroke aphasia also have
physical sequelae, which usually affect hand movements.
Some patients will require larger screens devices to use the
applications more easily, which entails costs. In the clinic
context, the cost also interferes in the use of the AAC systems
since several devices would be necessary due to the number
of therapeutic sessions performed.
The reliability its a factor mentioned by respondents. And
because the AAC systems are primarily mobile applications,
this factor is more related to failures such as crashes, errors,
and non-functionality of some features. The interviewees also
point out the lack of memory space in patients’ devices:
(...) it didn’t work, it got too heavy, it took up a lot of space,
it didnt work the sound part.
As argued by [3], this factor can become a key barrier. One
of the participants reports on the reaction of one of her/his
patients to the systems failures:
Look, this current patient of mine, I think he was the only one
that often uses [the system]. He stopped using it because he did
not run on his cell phone anymore.
Voice and language is identified as an important factor,
which can be both a barrier and a facilitator. The main
difficulties faced by patients related to this factor, according
to the interviewees, are: restricted vocabulary, lack of verbal
inflections, poor sentence formatting, and the fact that in some
systems it is not possible to use the patient’s own voice. Verb
inflections are important, according to the interviewees, be-
cause patients rely on the message produced as an instrument
of learning and training. Regarding restricted vocabularies,
respondents still report that not only vocabulary, but the whole
system, in some cases, are childish. And in fact, aBoard [9],
for example, which is the system most used by clinic patients,
is an application aimed mainly at children, especially children
diagnosed with autism.
In addition, infantile systems are a barrier because the
patients are adults with cognitive difficulty, and the fact that
they feel treated like children could generate frustrations and
demotivation. Therefore, as stated by one of the therapists
participating in this research, “The ideal would be with figures
aimed at adult audiences, no childish figures”.
Ease of use, for the participants, is an important factor
because most of the patients are adults with little familiarity
with mobile technologies. On the other hand, the possibility
of taking the mobile device to all places can facilitate both the
adoption of AAC systems and their use in day-to-day:
(...) I think in the mobile device its the facility of you to carry
from one place to another [...] because the computer sometimes
it’s stuck here...
In addition, the flexibility of some systems to customize
vocabulary, changing elements from one part of the application
to another, is a facilitator for therapists when they prepare
sessions, because they can customize according to each pa-
tients needs. As mentioned in Section II-B, the possibility of
customization helps to improve the usability of AAC systems
and decrease user frustration. Some of the interviewees point
out the systems inflexibility as a point that hinders their use.
The stiffness because sometimes you have to make the whole
way and then to, he does not have a fast path link, so he comes
back for other things, [...] do you understand?
Time taken to construct and communicate sentences is
also a point that must be taken into account because it is what
makes the communication fluid or not, and can frustrate both
the user and the interlocutor. One of the interviewees when
asked if there is a need for faster AAC systems, he said “yes,
because in a conversation between two people, speech tends
to be fast”.
Family participation is cited by the interviewees as an im-
portant factor, highlighting the importance of the acceptance of
the new technology by the relatives, as one of the participants
mentions that:
(...) the family has to buy the idea. Because its no use having
the best system in the world if he doesnt believe in it and the
family doesnt buy the idea, because [...] this process has to be
In addition, it was noticed that the use of a communication
tool can facilitate daily contact with family, because the patient
can make himself understood better. The following excerpt is
about one of the interviewees patients:
Because he is the father of three children, they are in adoles-
cence, then he said sometimes he was stood sideways. If he had
this, it might help his family relationship, the children would
talk to him.
Therefore, in addition to the crucial role of family in the
introduction and adaptation of AAC systems, patients are still
benefited because as the system establishes bonds between the
patient and the therapist, it also helps to strengthen family ties.
D. Ideal AAC Systems
Interviewees are asked about the ideal AAC for aphasic
adults in their opinion. The answers are mainly directed
towards customization. They believe a system in which it is
possible to customize vocabulary and voice, being able to use
the patient’s own voice, regulate the synthesizers voice tone,
is a system that tends to approach the ideal.
The participants pointed out that an ideal AAC system
should be fast in sentence construction, thus facilitating the
communication process, considering aBoard [9], as the closest
to the ideal.
This section discusses the main findings, their implications
in practice and their limitations.
A. Revisiting Findings
Cost is an important factor for the participants in this
research, but it is neither important in [3] or [4]. Two ex-
planations are plausible. One is that, none of these researches
are interested in researching about this factor, because it is
not directly related to AAC system usage. This suspicion
cant be ascertained since none of the researches cited the
reasons for not including the cost factor in their interviews,
analyzes, or results. Another possibility is that this factor is a
particularity of the context in which this research was carried
out, considering that the school clinic is a public agency that
depends on government funding, and the majority of patients
attended are low income.
On the other hand, factors such as technical support, and
training, addressed by [3] and [4], were not mentioned by
the participants of this research. The interviewees cite mainly
AAC systems as mobile applications, which do not always
have technical support service, and may cause them not to
mention this factor, since there is nothing to complain about
or compliment. In addition, in some cases, the therapists
themselves are the ones who give this kind of support to
AAC systems users, as shown by [4]. The training for using
AAC systems is also sometimes performed by the therapists
themselves, and the systems available and mentioned by the
interviewees do not have this type of service.
We avoided as much as possible inducing the participants to
comment on specific factors. The questions were open, seeking
the perception of the interviewees on using AAC systems in
the context of the clinical school, and not the validation of a
theoretical framework.
This justifies the absence of some factors, but also strength-
ens the hypothesis that in different contexts the factors appear
in different ways as well. An example of this is the voice and
language factor, which presents points related to the infantile
content of vocabularies, while in other researches it refers
to vocabulary poverty, voice quality and sound, etc. As with
infantile systems, which is an important factor because the
public is made up of adults, and is not cited by [3] or [4].
Still on voice and language, another point that makes the
results of this research contrast with the results cited in the
theoretical basis, is the quality of the sentences produced
by the systems. This is because people with aphasia need
both visual and auditory support during a conversation, to
understand and to make themselves understood better, and
also at the cognitive level, in the sense that they can use the
system as support for learning. Aphasics often have difficulty
converting sequences and non-verbal mental representations
into sentences [5], and they need these abstractions to be
synthesized in the right way.
About family participation, its possible to perceive that the
results obtained in this research are well aligned with those of
[3] and [4] except when referring to family training, which is
not mentioned by our interviewees. However, for the role of
the family in the insertion and continued use of the systems,
the results are similar.
B. Implication to Practice and Research
Because its an exploratory study, we hope to contribute
to the development of new researches that may deepen the
available knowledge about the subject.
The evidence presented in this paper may be used by
researchers and practitioners working on the development and
improvement of AAC systems and thus to foster the building
of systems that more adequate to the aspects and desires
described by the participants.
C. Limitations
This study is exploratory in order to identify and apprehend
initial perceptions regarding AAC systems, therefore, it has
a small sample with the objective of increasing the amount
of useful data produced during the interviews, and further
studies are needed to deepen our results. It is also necessary
to consider the methodological limitation that is produced by
the use of only one means of data collection, the interviews.
This work presents an exploratory research aiming to
identify the facilitators and barriers to use Alternative and
Augmentative Communication Systems by adults with apha-
sia. Our sample is composed by therapists of the University
Clinic Professor F´
abio Lessa of the Federal University of
Some facilitators and barriers identified has been reported
in some previous studies but some new, cost is one of them.
Cost is relative not only to the purchase of mobile devices for
using AAC systems during the sessions in the school clinic,
but mainly in the purchase of these devices by the patients,
which, as communicated by the professionals, would make it
possible to continue their use outside the clinic.
The main purpose of AAC systems is to be a mechanism
of support or assistance in the evolution of the group of
people who have some commitment related to speech and thus
somehow contribute to the insertion or reintegration of these
people in social circles. In this way, it is necessary to take into
account that not only technical aspects of production related
to voice and language should be at the center of attention in
the construction or improvement of AAC systems.
Thus, it is necessary for the AAC systems to pay more
attention to the age range of their target audience and to allow
a greater degree of personalization of the system in order to
bring meaning to the patient, considering that the clinician is
also linked to the social and thus prevent the system is rejected
or abandoned during treatment.
Jayr Pereira is supported by CAPES [88882.347547/2019-
01], Carolline Pena is supported by CNPq [131950/2018-
5] and Mariana de Melo is supported by FACEPE [IBPG-
0687-1.03/17], Sergio Soares is partially supported by CNPq
[304499/2016-1]. Also, this work is partially supported by
INES (CNPq [465614/2014-0], FACEPE [APQ-0399-1.03/17]
and PRONEX [APQ/0388-1.03/14]) and ASSISTIVE (CNPq
[458798/2013-4 and 461492/2014-8]).
[1] J. Pommerehn, M. C. C. Delboni, and E. Fedosse, “Classificac¸˜
internacional de funcionalidade, incapacidade e sa´
ude e afasia: um
estudo da participac¸˜
ao social,” in CoDAS, vol. 28, no. 2, 2016, pp. 132–
[2] M. I. H. Coudry et al., “Linguagem e afasia: uma abordagem discursiva
da neuroling¨
ıstica,” Cadernos de Estudos Ling¨
ısticos, 2011.
[3] S. Baxter, P. Enderby, P. Evans, and S. Judge, “Barriers and facilitators to
the use of high-technology augmentative and alternative communication
devices: a systematic review and qualitative synthesis,” International
Journal of Language & Communication Disorders, vol. 47, no. 2, pp.
115–129, 2012.
[4] S. Judge and G. Townend, “Perceptions of the design of voice output
communication aids,” International Journal of Language & Communi-
cation Disorders, vol. 48, no. 4, pp. 366–381, 2013.
[5] A. R. Damasio, “Aphasia,New England Journal of Medicine, vol. 326,
no. 8, pp. 531–539, 1992.
[6] R. Bersch, “Introduc¸˜
ao `
a tecnologia assistiva,Porto Alegre: CEDI,
p. 21, 2008.
[7] ASHA. American speech-language-hearing association. [Online].
[8] A. Bondy and L. Frost, A picture’s worth: PECS and other visual
communication strategies in autism. Woodbine House, 2011.
[9] N. Franco, T. Lima, A. Lima, E. Silva, R. Lima, T. Cavalcante, and
R. Fidalgo, “aboard: Uma plataforma para educac¸˜
ao inclusiva a partir
de comunicac¸˜
ao aumentativa e/ou alternativa,” in Brazilian Symposium
on Computers in Education (Simp´
osio Brasileiro de Inform´
atica na
Educac¸ ˜
ao-SBIE), vol. 28, no. 1, 2017, p. 977.
[10] J. Bradshaw, “The use of augmentative and alternative communication
apps for the ipad, ipod and iphone: an overview of recent developments,
Tizard Learning Disability Review, vol. 18, no. 1, pp. 31–37, 2013.
[11] N. Franco, E. Silva, R. Lima, and R. Fidalgo, “Towards a reference
architecture for augmentative and alternative communication systems,
in Brazilian Symposium on Computers in Education (Simp´
osio Brasileiro
de Inform´
atica na Educac¸ ˜
ao-SBIE), vol. 29, no. 1, 2018, p. 1073.
[12] S. B. Merriam and E. J. Tisdell, Qualitative research: A guide to design
and implementation. John Wiley & Sons, 2015.
[13] S. Easterbrook, J. Singer, M.-A. Storey, and D. Damian, “Selecting
empirical methods for software engineering research,” in Guide to
advanced empirical software engineering.Springer, 2008, pp. 285–
[14] S. H. Khandkar, “Open coding,University of Calgary, vol. 23, p. 2009,
[15] H. Carmo and M. Ferreira, “Metodologia da investigac¸˜
ao–guia para auto-
aprendizagem (2aedic¸˜
ao),” Lisboa: Universidade Aberta, pp. 001–89,
[16] J. Maxwell, “Understanding and validity in qualitative research,Har-
vard educational review, vol. 62, no. 3, pp. 279–301, 1992.
... Device reliability refers to if the device was able perform consistently its intended function. Poor reliability, such as devices giving false notifications or being inconsistent in performing a function, led to low confidence in the performance of the device and abandonment of the assistive technology [49,51,54,[58][59][60]64,65,[67][68][69][70][71][72][73]. The quality of the device was also a barrier that was identified by users. ...
... Aspects relating to the physical shape, size and weight of a device were also identified by users as a barrier to using their assistive technology. Examples identified included the assistive technology being too big for the user to carry or too heavy to use [51,54,56,57,64,65,67,69,73,77,[80][81][82]. The aesthetics of a device were also discussed by some users as a barrier to using their assistive technology. ...
... This included due to the Another barrier with the design of assistive technology related to the lack of customization to the end user needs. Both users and prescribers described how a universal design or one size fits all approach to assistive technology design was not appropriate to cover the individual needs and circumstances of each user [51,54,[57][58][59]62,[64][65][66][67][68][69][75][76][77]80,81]. Another sub-theme that restricts usage of assistive technology was if the device was inappropriate for the intended population. ...
Purpose Assistive technology can provide a key tool to enabling independence, greater inclusion and participation in society for individuals with chronic conditions. This potential is currently not always realized due to barriers to accessing and using assistive technology. This review aims to identify the common barriers to acquiring and using assistive technology for users with chronic conditions through a systematic meta-synthesis. This differs from other systematic reviews by applying a transdiagnostic approach to identify if barriers are common across chronic conditions. Materials and methods A systematic literature search of five scientific databases (PubMed, SCOPUS, PsycINFO, CINAHL and Medline) was conducted to identify relevant qualitative studies. The search was conducted in November 2019. For the identified articles, thematic content analysis was conducted and the methodological quality was evaluated using the Critical Appraisal Skills Programme (CASP) checklist for qualitative research. Results Forty papers met the inclusion criteria and were included in the analysis. Fifty-one descriptive themes grouped into six overarching analytical themes were identified from the studies. The analytical themes identified were: the design and function of the assistive technology, service provision, information and awareness, psychological barriers, support network and societal barriers. Conclusions The barriers are interconnected and common across different health conditions. More involvement in personalized care for developing strategies, adaptation of home technologies and provision of assistive technology could overcome the service provision and design barriers to assistive technology. Accessible information and providing greater awareness will be important to overcoming information, psychological and societal barriers to assistive technology. • Implications for rehabilitation • Individuals with chronic conditions face complex barriers to acquiring and using assistive technology as a result of the devices themselves, their individual context, the healthcare context where assistive technology is provided and wider societal barriers. • The provision of assistive technology needs to change away from the traditional medical model of the “expert” clinician and instead focus on more user involvement to deliver personalised care that utilises the users lived knowledge and experiences. • Assistive technology provision should be considered alongside how to adapt everyday mainstream technology to meet user needs; the provision of devices should encourage creative problem solving rather then relying on pre-defined prescription lists of assistive technology.
... Some research points out the barriers or difficulties faced by AAC users when using these tools for communication. [Pereira et al. 2019, Donato et al. 2018, Berenguer et al. 2022]. An example of difficulty is the time needed to construct and communicate sentences [Pereira et al. 2019, Berenguer et al. 2022, making communication less fluid and causing frustration in the user and his interlocutor. ...
... [Pereira et al. 2019, Donato et al. 2018, Berenguer et al. 2022]. An example of difficulty is the time needed to construct and communicate sentences [Pereira et al. 2019, Berenguer et al. 2022, making communication less fluid and causing frustration in the user and his interlocutor. To overcome this problem, a robust AAC system must support sentence construction by facilitating pictogram searching and selection [Franco et al. 2018]. ...
Conference Paper
Full-text available
Alternative Communication Boards are high-tech Augmentative and Alternative Communication (AAC) tools that try to compensate for the difficulties faced by people with complex communication needs. Generally, these tools consist of a mobile application in which the user can construct sentences by arranging pictograms (picture+label pair representing a concept) in sequence. This study systematically maps the literature on pictogram prediction in AAC systems. We analyzed eight studies to investigate how computational methods are used for pictogram prediction, how these proposals are evaluated, and what are the studies' outcomes regarding user communication improvement. The main findings indicate the usage of different methods for pictogram prediction and a mixture of automatic and expert evaluation, which lead to inconclusive outcomes regarding user communication improvement.
... Researchers used different colors to classify the different parts of speech (for example, yellow for subject words, orange for affirmative and negative words, green for verbs, and so on). They also used a structured layout design to guide participants in using lexical phrases in proper sequence [42][43][44]. 3. ...
Full-text available
Children with autism spectrum disorder (ASD) have marked difficulty with vocabulary, lack of language, or shortcomings with their ability to organize their oral expression; thus, they cannot effectively communicate with others. In particular, people with moderate or severe disabilities cannot systematically narrate an incident and cannot follow pragmatic rules provided by others. Their attempts at standard everyday conversation lead to cognitive problems. When children with ASD are faced with difficult circumstances, they are usually unable to seek help from others, which in turn can result in their being unable to communicate effectively. This research focused on three child participants with ASD and language disorders. The goal was to strengthen the effectiveness of their requesting help and to organize their oral expression, to use requesting help modules, to remove static key images, and to use augmented reality (AR) combined with the dynamic video clips in key partial video with action (KPV). This study developed request-assistance training in conjunction with an auto organizational menu (AOM), multiple case studies and withdrawal designs, training-response methods, and a comparison of outcomes. The proposed AR sentence intervention effectively increased the children’s desire to communicate with others and the accuracy rate of their help requests, and increased their level of communication. We conclude that the interface of our requesting help modules is efficacious enough to assist children with ASD at different levels. The proposed AR sentence intervention helps them build scenarios by themselves, helps them organize communication with their peers, and assists them to request help.
... This characteristic is essential due to the heterogeneity of the AAC population (Beukelman & Light, 2013;Elsahar et al., 2019;American Speech-Language-Hearing Association, 2021). Besides, different studies highlight the importance of customizing AAC solutions to address users' needs (Baxter et al., 2012;Cook & Polgar, 2014;Elsahar et al., 2019;Pereira et al., 2019;Shane et al., 2012). This way, PictoBERT usage may benefit individuals with CCN in diverse levels and with different conditions. ...
Augmentative and Alternative Communication (AAC) boards are essential tools for people with Complex Communication Needs (e.g., a person with down’s syndrome, autism, or cerebral palsy). These boards allow the construction of messages by arranging pictograms in sequence. In this context, a pictogram is a picture with a label that denotes an action, object, person, animal, or place. Predicting the next pictogram to be set in a sentence in construction is an essential feature for AAC boards to facilitate communication. Previous work in this task used n-gram statistical language models and knowledge bases. However, neural network literature suggests they can cope better with the task, and transformers-based models like BERT (Bidirectional Encoder Representations from Transformers) are revolutionizing this field. In this paper, we present PictoBERT, an adaptation of BERT for the next pictogram prediction task. We changed the BERT’s input embeddings to allow word-sense usage instead of words, considering that a word-sense represents a pictogram better than a simple word. The proposed model outperforms the n-gram models and knowledge bases. Besides, PictoBERT can be fine-tuned to adapt to different users’ needs, making transfer learning its main characteristic.
Conference Paper
Full-text available
Speech impaired people needs Inclusive Education (IE) and specific resources for developing their potencial and learning. In this context, this article presents the aBoard Plataform, a free and cloud-based set of softwares for Augmentative and Alternative Communication (AAC) that can be adapted for IE pedagogical activities (e.g., teaching letters, numbers and routines). This plataform is evaluated in comparison to other solutions according to specific functionalities for AAC aplications as well as their adherence to the Nielsen's Heuristics. aBoard stands out from other solutions and is configured as a suitable tool for public-inclusive education context. Resumo. Pessoas com deficiência na comunicaçcomunicaç˜comunicação precisam de uma EducaçEducaç˜Educação Inclusiva (EI) e de recursos específicos para desenvolver o seu potencial e me-lhorar a sua aprendizagem. Neste contexto, este artigo apresenta a Plataforma aBoard, um conjunto de softwares gratuitos e em nuvem para ComunicaçComunicaç˜Comunicação Aumentativa e/ou Alternativa (CAA) que pode ser adaptada para atividades pe-dagógicas da EI (e.g., ensino de letras, números e rotinas). Esta plataformá e avaliada em comparaçcomparaç˜comparação com soluçsoluç˜soluções similares no que tange a funcionalida-des específicas para aplicaçaplicaç˜aplicações de CAA e ` a aderêncià as heurísticas de Nielsen. O aBoard se destaca das demais soluçsoluç˜soluções configurando-se como uma ferra-menta adequada para o contexto do ensino público inclusivo. 1. IntroduçIntroduç˜Introdução No Brasil, segundo o Censo 2010 do IBGE [IBGE 2010], existem 2,6 milhões de pessoas com alguma deficiência intelectual (e.g., Transtorno do Espectro Autista e Síndrome de Down) ou desordens neurológicas (e.g., Paralisia Cerebral, Lesão Crânio Encefálica e Mi-crocefalia) que podem ter sua capacidade de comunicaçcomunicaç˜comunicação limitada de forma temporária ou permanente. De maneira geral, a privaçprivaç˜privação na comunicaçcomunicaç˜comunicação restringe as possibilidades de acesso igualitáriò a educaçeducaç˜educação e ` as oportunidades de crescimento intelectual. Quando esta privaçprivaç˜privação ocorre durante os primeiros anos de vida, esta pode provocar déficit no de-senvolvimento cognitivo e atraso na aquisiçaquisiç˜aquisição da língua escrita [Mousinho et al. 2008]. Para estes casos, faz-se necessária a inserçinserç˜inserção de Tecnologias Assistivas (TA) que visam complementar a capacidade de comunicaçcomunicaç˜comunicação destes indivíduos. Neste contexto, estas TA são denominadas recursos de ComunicaçComunicaç˜Comunicação Aumentativa e/ou Alternativa (CAA).
Full-text available
Purpose To identify and analyze the impact of aphasia on social participation and daily activities of people affected by this disease, as well as to understand implications of environmental factors on limitations and restrictions of participation according to the criteria established by the International Classification of Functioning, Disability and Health. Method Data presented and discussed were collected from 12 people of both sexes with aphasia participating in an Interdisciplinary Group for Coexistence. Data were collected between October 2011 and March 2013 and analyzed based on the International Classification of Functioning, Disability and Health checklist. Results All subjects had restrictions on performing and participating in their daily activities, either by biological, environmental or socio-cultural factors. Conclusions The restriction in participation was the most evident, mostly due to environmental factors than sequels resulting from the brain injury.
Full-text available
Para responder ao convite da Profa. Eni Orlandi - e fazer parte do número temático dos Cadernos destinado à história das idéias lingüísticas, em domínios de estudo da linguagem que compõem uma área de investigação - apresento alguns caminhos tomados por uma Neurolingüística que têm sua origem traçada por condições históricas, início dos anos oitenta, em nosso Departamento, tempo caracterizado por debates fundantes, nele, de idéias e ideais da Lingüística, em várias de suas dimensões, que abriam novas possibilidades de interfaces - envolvendo uso, funcionamento e conhecimento da linguagem e de sistemas de línguas naturais.
Full-text available
Voice output communication aids (VOCAs) are a key form of aided communication within the field of augmentative and alternative communication (AAC). In recent years, rapid developments in technology have resulted in an explosion of devices available commercially, yet little research has been conducted into what people who use VOCAs think about them. The aim of this research was to explore the perceptions of communication aid design from the perspective of end users and AAC professionals, with the objective being to inform and influence the design of future devices. A two-part study was conducted: interviews were undertaken with people who use VOCAs, and questionnaires were distributed to those who use aided communication and to AAC professionals. Analysis of the interview data was carried out using a qualitative method based on framework analysis, whilst descriptive statistics were generated from the questionnaire data. Interview participants were an opportunity sample of VOCA users within a defined region of the UK. Those recruited were over the age of 12 years and able to engage in the interview process; they were identified through the caseloads of local Speech and Language Therapists specializing in AAC. The questionnaire was marketed to the AAC community throughout the UK. Respondents were self-selecting as those using aided communication, their carers and AAC professionals. Eighteen people participated in the interviews. Questionnaires were completed by 43 people who use aided communication and 68 AAC professionals. The data suggest that current devices are considered to be neither reliable nor durable by users and professionals. Although features given a higher importance ranking are more likely to be perceived as available, a number of important design deficits are identified by users and/or professionals. Simplicity of design (and use) and the desire for devices which support communication that is as fast and spontaneous as possible also emerge as key requirements. Synthesis of the data produced a framework with three main themes covering the range of issues which influence the successful use of a VOCA: specific aspects of the design of a device; the consideration of the wider picture around the person; and the personal context in which someone uses their device. Although the original aim of the project was to establish the user requirements of VOCA design, the data indicate that the characteristics of the device cannot be considered in isolation. Those factors uncovered highlight questions about whether the design of communication aids is truly effective in meeting the needs of the people who use them. Based on these data, an initial specification for future device design is proposed.
Full-text available
Selecting a research method for empirical software engineering research is problematic because the benefits and challenges to using each method are not yet well catalogued. Therefore, this chapter describes a number of empirical methods available. It examines the goals of each and analyzes the types of questions each best addresses. Theoretical stances behind the methods, practical considerations in the application of the methods and data collection are also briefly reviewed. Taken together, this information provides a suitable basis for both understanding and selecting from the variety of methods applicable to empirical software engineering.
Purpose – The purpose of this paper is to provide an overview of the communication applications (apps) that can be used with devices such as the iPad, iPod and iPhone to support augmentative and alternative communication (AAC). Design/methodology/approach – A brief discussion of the research into the use of high‐technology communication aids is followed by an introduction to the iPad, iPod and iPhone AAC apps. Findings – These devices and apps clearly have a role within the spectrum of AAC devices currently available. They may have some distinct advantages in cost, ease of use and acceptability but more research into their use is needed. Originality/value – This article starts with a model of communicative competence and presents some recent research into barriers in the use of high‐technology AAC. It suggests some ways in which AAC apps may address some of the barriers to implementation and functional use. Finally, the need for individual assessment to determine specific communication needs is stressed. These devices and apps may not always be the best solution for people with complex communication needs.
Qualitative researchers rely — implicitly or explicitly — on a variety of understandings and corresponding types of validity in the process of describing, interpreting, and explaining phenomena of interest. In this article, Joseph Maxwell makes explicit this process by defining five types of understanding and validity commonly used in qualitative research. After discussing the nature of validity in qualitative research, the author details the philosophical and practical dimensions of: descriptive validity, interpretive validity, theoretical validity, generalizability, and evaluative validity. In each case, he addresses corresponding issues of understanding. In conclusion, Maxwell discusses the implications of the proposed typology as a useful checklist of the kinds of threats to validity that one needs to consider and as a framework for thinking about the nature of these threats and the possible ways that specific threats might be addressed.