Eye Tracking Measures Reveal How Changes in the Design of Displays for Augmentative and Alternative Communication Influence Visual Search in Individuals With Down Syndrome or Autism Spectrum Disorder

Introduction to the forum on the role of basic science in AAC access

This introduction to the special forum on basic/foundational research in AAC offers a brief rationale for the importance of the three pillars of evidence-based practice, including scientific evidence, clinical expertise, and client/family insights, and underscores that each pillar can and should offer something and also benefit from the other pillars. It briefly overviews several areas in which basic science has been instrumental in promoting clinical advances and then introduces the articles in the current forum, which each in its own way relates to access. The hope is to promote constructive dialog between scientists, clinicians, and individuals who use AAC to move these ideas forward.

Process evaluation of a complex intervention in augmentative and alternative communication care in Germany: a mixed methods study

BACKGROUND

In Germany, clear care pathways for people without natural speech who require augmentative and alternative communication (AAC) are currently lacking. Therefore, AAC is often not sustainably implemented in everyday life. For this reason, a complex intervention was developed that supplements existing AAC consultation with additional AAC training, AAC therapy, and case management. This article presents the results of the process evaluation of the complex intervention. It examines (1) how caregivers and AAC consultants rate the intervention (2), which contextual factors influence its implementation, and (3) the acceptance, use competence, and use of the new AAC system.

METHODS

The process evaluation used a mixed methods design. Quantitative data were collected with a longitudinal survey of caregivers of AAC users in the intervention and comparison groups at three time points (T0: after AAC consultation; T1: 4 weeks after AAC system receipt; T2: 4 months after AAC system receipt). Semi-structured focus group interviews were conducted with caregivers of AAC users and with AAC consultants. The quantitative data were analysed descriptively and with nonparametric mean value comparisons. The qualitative results were analysed using structured qualitative content analysis.

RESULTS

The evaluation and presentation of results were based on the Medical Research Council process evaluation guidance by Moore et al. The intervention elements were rated positively. AAC training and therapy enabled the participants to use the AAC system effectively in different contexts. Case management provided support, particularly in the event of problems in the care process. However, the results also show the heterogeneity of the intervention, as it depended on various contextual factors. Overall, acceptance, use competence, and use of the AAC system were rated higher in the intervention group than in the comparison group.

CONCLUSIONS

The process evaluation illustrates various contextual factors that can influence the implementation of the AAC intervention. The results highlight the potential of the intervention to improve AAC care and establish a sustainable use of AAC systems in everyday life. In addition, the process evaluation provides indications of how AAC interventions can be adapted for successful implementation.

TRIAL REGISTRATION

Grant number 01NVF17019.

A novel multi-modal model to assist the diagnosis of autism spectrum disorder using eye-tracking data

Background and objective

Timely and accurate detection of Autism Spectrum Disorder (ASD) is essential for early intervention and improved patient outcomes. This study aims to harness the power of machine learning (ML) techniques to improve ASD detection by incorporating temporal eye-tracking data. We developed a novel ML model to leverage eye scan paths, sequences of distances of eye movement, and a sequence of fixation durations, enhancing the temporal aspect of the analysis for more effective ASD identification.

Methods

We utilized a dataset of eye-tracking data without augmentation to train our ML model, which consists of a CNN-GRU-ANN architecture. The model was trained using gaze maps, the sequences of distances between eye fixations, and durations of fixations and saccades. Additionally, we employed a validation dataset to assess the model's performance and compare it with other works.

Results

Our ML model demonstrated superior performance in ASD detection compared to the VGG-16 model. By incorporating temporal information from eye-tracking data, our model achieved higher accuracy, precision, and recall. The novel addition of sequence-based features allowed our model to effectively distinguish between ASD and typically developing individuals, achieving an impressive precision value of 93.10% on the validation dataset.

Conclusion

This study presents an ML-based approach to ASD detection by utilizing machine learning techniques and incorporating temporal eye-tracking data. Our findings highlight the potential of temporal analysis for improved ASD detection and provide a promising direction for further advancements in the field of eye-tracking-based diagnosis and intervention for neurodevelopmental disorders.

Visual fixation patterns to AAC displays are significantly correlated with motor selection for individuals with Down syndrome or individuals on the autism spectrum

Eye tracking research technologies are often used to study how individuals attend visually to different types of AAC displays (e.g. visual scene displays, grid displays). The assumption is that efficiency of visual search may relate to efficiency of motor selection necessary for communication via aided AAC; however, this assumption has not received direct empirical study. We examined the relation between speed of visual search and speed of motor selection of symbols. Ten individuals on the autism spectrum (AS; Study 1) and nine with Down syndrome (DS; Study 2) participated in a search task using simulated AAC displays with a main visual scene display (VSD) and a navigation bar of thumbnail VSDs. Participants were given an auditory prompt to find one of four thumbnail VSDs in the navigation bar. Eye tracking technologies measured how long it took participants to fixate visually on the thumbnail VSD, and recorded how long it took participants to select the thumbnail VSD with a finger. A statistically significant relationship emerged between visual fixation and selection latencies, confirming the positive relationship between visual processing and motor selection for both groups of participants. Eye tracking data may serve as a useful proxy measure for evaluating how display design influences selection of AAC symbols, especially when individuals are unwilling or unable to comply with traditional behaviorally-based assessment tasks.

The effect of background elements of pictures on the visual attention among ASD children with intellectual disabilities, children with intellectual disabilities and typical development: Evidence from eye-tracking and fMRI

Traditional picture books for children come with colourful images and a multitude of elements to attract attention and increase the reading interest of typical-developing (TD) children. However, children with Autism Spectrum Disorder (ASD) are less capable of filtering out unimportant elements in pictures and focusing on social items (e.g., human faces). This study proposed that the removal of background and less important elements in the pictures of children's storybooks could facilitate better attention and enhance children with ASD's focus on the main object and thus the intended meaning of the storybook. We adopted pictures from a well-known children's book and modified them by removing the inessential background elements. Then, ASD children with intellectual disabilities (ASD+ID) (n = 40), children with ID (n = 38) and TD (n = 40) were asked to view the original and modified pictures in an eye-tracking experiment, respectively. Additionally, brain activation of ASD+ID participants (n = 10) was recorded as they were viewing those pictures in an fMRI scan. Eye-tracking found that ASD+ID children viewed the modified pictures with significantly longer average fixations, fewer fixations, fewer saccades, and higher fixation/saccade duration ratio. Contrary to the original pictures, no significant differences were found among ASD+ID, ID only and TD. Especially, ASD+ID group showed highly similar visual patterns to the TD participants when viewing the modified pictures and particularly focusing on the main character in the pictures. Additional fMRI evidence on ASD+ID group also revealed that modified pictures were associated with enhanced activation in bilateral fusiform gyri as compared to those from original pictures, which might suggest increased visual attention. Theoretical and practical implications were discussed in light of our findings.

An Evidence-Based Approach to Augmentative and Alternative Communication Design for Individuals With Cortical Visual Impairment

PURPOSE

This article highlights the contributions of three pillars of an evidence-based practice approach (service providers, researchers, and families/clients) in the development of a framework to offer a way forward for professionals, families, and technology companies to support optimal visual and communication outcomes of individuals with cortical visual impairment (CVI) who use augmentative and alternative communication (AAC). By providing available research findings as well as practical information and lived experiences, the article offers clinical considerations and design features that can lead to addressing the unique needs of these individuals.

METHOD

This article reviews literature concerning what is known about CVI and describes in detail and from multiple viewpoints important features required in AAC systems to support individuals with CVI and enable them to communicate effectively.

RESULTS

Components necessary for teams, communication partners, and AAC designers to optimize AAC system design in CVI are presented using external research evidence as internal evidence from lived experience to support their importance.

CONCLUSIONS

An AAC system design that is tailored to the unique visual processing characteristics in CVI is likely to promote positive communication outcomes. The presentation of the lived experience of an individual who has CVI themselves illustrates the need for individualized assessments and interventions that incorporate and reflect the research presented here.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23902239.

Demands Associated With an Augmentative and Alternative Communication System in Relation to Alternative Forms of Access for Individuals With Motor Impairments

PURPOSE

Successful adoption and use of aided augmentative and alternative communication (AAC) must address how to promote fluid, efficient, and organized execution of the motor behavior needed to access the AAC system. A substantial number of people who use AAC have significant motor impairments and require "alternative" access options, such as eye gaze or switch use. Such individuals may be particularly vulnerable to interference from a poorly designed system. However, the inherent demands of alternative access methods have received little direct study. The goal of this tutorial is to offer a clinically and theoretically guided framework for considerations concerning AAC access, with the hope of spurring further discussion and empirical research.

METHOD

A framework that draws upon dynamic systems theory was used to illustrate the interactions between the various elements of importance to AAC access. Information and research from the fields of motor learning, developmental dynamic systems theory, AAC, and assistive technology was integrated into this tutorial to examine their applications for alternative AAC access methods.

RESULTS

The framework illustrated that AAC access involves a complex coordination between individual skills, the demands of the communication environment, the activity being undertaken, and the supports and demands inherent in the AAC system itself.

CONCLUSIONS

Awareness of the many demands that alternative forms of access place on the person who uses them can guide clinicians during assessment and intervention decision making regarding access options for individuals with significant motor impairments. Specific directions for future research are considered.

"Finding Common Ground" - Impact of a Complex Intervention on Collaboration in Augmentative and Alternative Communication Care of People without Natural Speech

Purpose

Many care settings are characterized by collaboration between a variety of stakeholders. People without natural speech who rely on augmentative and alternative communication (AAC) are often strongly dependent on the involved stakeholders and collaboration among them. Since collaboration can be challenged by many barriers, this study examines the impact of a complex intervention on collaboration in AAC care.

Methods

In a quasi-experimental mixed methods intervention study which include AAC training, AAC therapy and case management, caregivers of AAC users were surveyed at 3 time points to assess collaboration and case management in the intervention versus comparison group. In addition, semi-structured focus group interviews were conducted with caregivers in the intervention group. Quantitative data were analyzed descriptively and by comparison of means. Qualitative data were analyzed using qualitative content analysis.

Results

The Mann-Whitney U-test showed significantly better collaboration in the intervention group with stakeholders that are more actively involved in AAC care, such as schools (p=0.026) and residential or social facilities (p=0.010), but not with passive stakeholders such as health insurance companies. Most aspects of case management were rated significantly better in the intervention group (p<0.001). The focus group results show mainly positive changes in collaboration with the active stakeholders, such as more commitment and openness toward AAC.

Conclusion

The results show a positive impact of the intervention on the collaboration between stakeholders involved in AAC care - especially with active stakeholders. In particular, the organization of care and the accompanying case management by the AAC consultation centers seem to positively affect collaboration.

Judicious Arrangement of Symbols on a Simulated Augmentative and Alternative Communication Display Optimizes Visual Attention by Individuals With Down Syndrome

PURPOSE

Aided augmentative and alternative communication (AAC) displays are often designed as symmetrical row-column grids, with each square in the grid containing a symbol. To maximize vocabulary on displays, symbols are often placed close to one another, and background color cuing is used to signal/differentiate symbols across different grammatical categories. However, from a visual and developmental standpoint, these display features (close-set symbols and use of background color cues) may not be optimal. In particular, placing symbols quite close together may result in visual crowding, in which individual symbols cannot be distinguished due to the presence of many neighbors, or flankers. This research sought to examine the role of display arrangement and background color cuing on the efficiency of visual attention during search.

METHOD

Ten adolescents and adults with Down syndrome underwent a visual search task while a research-based eye tracking system recorded their patterns of visual attention. Participants searched for symbol targets on displays with varying levels of visual crowding and background color cuing.

RESULTS

Spatial arrangements that reduced visual crowding and that used the spatial organization to cue the grammatical category of symbols resulted in significantly fewer fixations to nonrelevant distracters during search and reduced the likelihood of fixations away from the target once it was located. Background color was helpful in reducing the latency to find the target.

DISCUSSION

Spatial cues may offer a powerful means to maximize the efficiency of search within AAC displays. Background color cuing may facilitate speed to locate targets in these older individuals. Implications for AAC design, as well as future avenues for maximizing (growing) vocabulary, are discussed.

Cognitive Assessment in GNAO1 Neurodevelopmental Disorder Using an Eye Tracking System

GNAO1 gene mutations are associated with a neurodevelopmental disorder characterized by developmental delay, epilepsy, and movement disorder. Eye tracking and eye movement analysis are an intriguing method to assess cognitive and language function and, to the best of our knowledge, it has never been tested in a standardized way in GNAO1. GNAO1 children are usually wheelchair-bound and with numerous motor constrains, including dystonic movements and postures, heterotropia, and hypotonia, making the cognitive assessment arduous. These contribute to the burden and disability, with a high level of frustration of caregivers and patients. We have herein demonstrated that, through an eye tracking system, six GNAO1 patients evaluated showed variable degrees of communicative intent through intentionally directed gaze. Moreover, three of these were able to complete a cognitive evaluation, and showed normal fluid intelligence and lexical comprehension. In conclusion, in GNAO1-related disorders, the degree of cognitive development is underestimated; eye tracking technologies may help in overcome these boundaries.

Clinical and Research Perspectives on Visual Scene Displays

Purpose The purposes of this study were to measure the perceptions of speech-language pathologists (SLPs) and researchers regarding the design of visual scene displays (VSDs) and to investigate the perceived difficulties of SLPs in regard to the acquisition and programming of VSDs. Method We recruited 270 SLPs and nine researchers who focus on VSDs to complete an online survey. The SLP survey addressed both perception of VSD design and difficulties associated with implementing these images as communication supports in the clinical realm. The researcher group was surveyed solely regarding their opinions associated with VSD design. Results SLPs and researchers both ranked high-context VSDs as more effective at supporting communication than low-context VSDs. In addition, both groups ranked VSDs with task-engaged people as more effective at supporting communication than VSDs with camera-engaged people or no people. SLPs reported difficulties with acquiring high-quality VSDs from online sources as well as difficulties with maintenance and upkeep of VSDs. In addition, a large portion of SLPs reported challenges with representing complex concepts through VSDs. Conclusions Results from this study provide evidence of general agreement between SLPs and researchers regarding perception of VSD design. SLPs continue to report challenges with the acquisition and programming of VSDs. Further research is needed to develop evidence-based guidelines to support clinical endeavors in these areas.

Visual Attention to Cued Targets in Simulated Aided Augmentative and Alternative Communication Displays for Individuals With Intellectual and Developmental Disabilities

Purpose Many aided augmentative and alternative communication (AAC) systems require the use of an external display that is represented via a visual modality. It is critical to evaluate and understand visual-perceptual processing in individuals with disabilities who could benefit from AAC. One way to evaluate how individuals process visual materials is through research-based automated eye-tracking technologies that obtain a fine-grained stream of data concerning gaze paths of visual attention. Method The current study examined how individuals with autism spectrum disorder (n = 13), Down syndrome (n = 13), intellectual and developmental disabilities (n = 9), or typical development (n = 20) responded to a spoken prompt to find a thumbnail-sized navigation key within a complex AAC display, including a main visual scene display (VSD) and a navigation bar of four thumbnail-sized VSDs. Stimuli were presented on a monitor containing automated eye-tracking research technology that recorded patterns of visual attention. Results Participants across groups spent more time fixating on a target thumbnail VSD navigation image after the presentation of the spoken cue to look at the target, compared to before the presentation of the spoken cue; they also spent more time looking at the target thumbnail VSD than the other thumbnail-sized VSDs in the navigation bar after the cue. Discussion Participants were able to locate the target thumbnail VSDs, even within the context of a visually complex AAC display. Implications for the design of AAC displays and for assessment of comprehension are discussed.

Eye-trackers, digital-libraries, and print-referencing: A single case study in CDKL5

BACKGROUND

Providing emergent literacy intervention and assessing outcomes for children with low-incidence, complex disabilities with concomitant physical, cognitive, sensory, and communication impairments presents a significant challenge to researchers, educators, clinicians, and families alike.

AIMS

This study aimed to leverage advancements in commercially available eyetracking technologies to measure visual attention to print before and after a parentmediated print referencing intervention with a child with a severe, low incidence, congenital disability. Print referencing means drawing attention to the print on the page while reading.

METHODS AND PROCEDURES

The single case study investigated a mother-daughter dyad who completed the protocol using eye-gaze technology, digital children's books, and a computer configured with software for observing and recording interactions that were shipped to the family's home and set up by the mother with remote support from a researcher.

OUTCOMES AND RESULTS

Results demonstrate that the eye-tracker successfully captured the participant's eye-gaze. Furthermore, mean-level shifts in frequency of fixations demonstrates changes in visual attention to print after the parent introduced the print referencing strategy during reading.

CONCLUSIONS AND IMPLICATIONS

Commercially available eye-trackers and digital libraries were successfully used by the parent-child dyad to record visual attention. Furthermore, remote support from a trained researcher was sufficient to support the parent through set-up, calibration, intervention, and implementation.

Stakeholder Perspectives to Support Graphical User Interface Design for Children with Autism Spectrum Disorder: A Qualitative Study

The development of digital supports for people with autism has increased considerably in recent years. Technology designers and developers have interpreted the needs and learning styles of people with autism in different ways. As a result, there are generic, non-specific or heterogeneous guidelines for the design and development of technology for people with autism. This study aims to identify and describe the recommended elements to support graphical user interface design for children with Autism Spectrum Disorder (ASD), considering the stakeholders' perspective, engaged in a computer application development. A qualitative, longitudinal, multicentre study was carried out. A sample of 39 participants belonging to four groups of stakeholders participated: children with autism, family members, professionals with experience in the intervention with children with autism, and professionals with expertise in the design and development of assistive technology. The techniques used to formalise the collection of information from participants were semi-structured interviews and observation. MAXQDA 2020 software (Verbi Software, Berlin, Germany) was used to analyse the data. The result is a guide with suggestions to support an interface design that emerges from the stakeholder perspectives. This study provides useful information to offer alternatives for children with ASD and facilitate the understanding of daily life.

Assessing working memory capacity through picture span and feature binding with visual-graphic symbols during a visual search task with typical children and adults

This study investigated developmental memory capacity through picture span and feature binding. Participants included third grade students and college age adults with typical development. Picture span was used to assess working memory capacity when participants were asked to identify, locate, and sequence common visual-graphic symbols from experimental grid displays. Feature binding was assessed to evaluate how symbols, locations and sequences are bound together in working memory. The features assessed included symbol recall, location recall, symbol location binding, symbol sequence binding, and location sequence binding. All participants were shown a sequence of visual-graphic symbols on 4 by 4 stimulus grid displays. Participants were then asked to remember symbols amidst distractor symbols and place them in the correct location on a response grid, using the correct sequence. Results revealed expected developmental differences between third graders and adults on picture span. Significant differences between third graders and adults were also obtained for symbol sequence and location sequence binding. Performance for both groups on the sequence binding features were marginal (i.e., 30% of third graders and 60% of adults binding symbol sequence; 27% of third graders and 52% of adults binding location sequence). These results convey the influence of picture span and feature binding on working memory capacity. Implications are discussed in relation to theoretical models on working memory and compensatory strategies to increase feature binding with target and contextual memory.

Collaboration between stakeholders involved in augmentative and alternative communication (AAC) care of people without natural speech

Collaboration among health care providers is intended to dissolve boundaries between the sectors of health care systems. The implementation of adequate augmentative and alternative communication (AAC) care of people without natural speech depends highly on collaboration among multiple stakeholders such as speech and language pathologists, teachers, or physicians. This paper examines existing barriers to and facilitators of collaboration from a stakeholder perspective. Five heterogeneous focus group interviews were conducted with N= 32 stakeholders including speech and language pathologists, AAC consultants, teachers, employees of sheltered workshops, parents, and relatives of AAC users, and other educational professionals (e.g., employees of homes for persons with disabilities) at three AAC counseling centers in Germany. Interview data were analyzed by structured qualitative content analysis. The results show very different experiences of collaboration in AAC care. Factors were identified that can have both positive and negative effects on the collaboration between all stakeholders (e.g., openness toward AAC, knowledge about AAC, communication between stakeholders). In addition, stakeholder-specific influencing factors, such as working conditions or commitment to AAC implementation, were identified. The results also reveal that these factors may have an impact on the quality of AAC care. Overall, the results indicate that good collaboration can contribute to better AAC care and that adequate conditions such as personnel, and time-related resources, or financial conditions need to be established to facilitate collaboration.

Speech-Language pathologists' decisions when designing an aided AAC display for a compilation case study of a beginning communicator

PURPOSE

The current study sought to identify decisions speech-language pathologists (SLPs) make and their rationale for those decisions when designing an AAC display for a hypothetical school-aged child who was a beginning communicator. Augmentative and alternative communication (AAC) displays support communicative interactions for children who are unable to use spoken language to meet their communication needs. Children who are at the early stages of learning language, often termed beginning or emerging communicators, may rely heavily on the AAC display to support comprehension and expression. Thus, it is important for speech-language pathologists (SLPs) to design a display that facilitates beginning communicators' communication development.

METHODS

This paper reports on the answers related to a specific case study presented in an online survey completed by 77 SLPs with experience in AAC.

RESULTS

Data illustrated design decisions driven by child-specific characteristics and informed by research regarding type of layout, representation, and the importance of various design features.

CONCLUSIONS

Suggestions for future research are provided, including identifying goals and communicative functions best supported by different types of displays, clinicians' challenges/successes growing a system with the child, and determining the importance of symbol arrangement and organisation in communicative tasks by AAC users.Implications for RehabilitationIdentification of current practices reported by speech-language pathologists given a case study to develop and implement future research.A gap between research and practice suggests the need for better dissemination and application of research supporting the inclusion of people engaged in the event depicted in a visual scene display.Foundations for future research to provide guidance regarding best design of and communication goals supported by visual scene displays and grid-based displays.