Evidence-B ased Lit eracv Instruction forIndividuals Who Require Augmentative andAlternative Communication: A Case Studyof a Student with Multiple Disabilities

Janice Light, Ph.D.,t David McNaughton, Ph.D.,z Marissa Weyer, M.S.,tand Lauren Kargl

ABSTRACT

Literacy skills provide numerous benefits to individuals whorequire augmentative and alternative communication (AAC), indudingnew oppoftunities for education, work, and social interaction. Literaryskills also have a powerful impact on communication and languagedevelopment. This paper describes the components of effective evi-dence-based literacy instmction, induding skills to taqget for instruction,effective instructional procedures to teach these skills, and adaptations toaccommodate the needs of individuals with significant speech, motor,and other disabilities. The paper also presents a case study that describesongoing intervention with an 8-year-old gid with multiple disabiiitieswho required AAC. Evidence-based instruction was provided in phono-logic awareness, letter-sound correspondences, decoding, sight-wordrecognition, ieading connected text, reading comprehension skills, andearly writing and keyboarding skills. During the 16 months of inter-vention, a total of 55 hours of instmction, the student acquired 20 letter-sound correspondences, leamed to use decoding and sight-word skills toread 60 words, and began to read simple tocts both in shared readingactivities and independendy. She also began to type simple shortmessages and stories using spelling approximations. The acquisition ofthese new literary skills resulted in increased educational opportunitiesfor the learner and also enhanced her language and communication skills.

KEYWORDS: Augmentative and alternative communication,l iteracy, reading, writ ing

lDepartment of Communication Sciences and Disorders;

'Department of Educational and School Psychology andSpecial Education, Penn State University, University PrlqPennsylvania-

Address for correspondence and reprint requests:JaniceLight, Ph.D., Department of Communication Sciencesand Disorders, Penn State University, 308 Ford Buitding,University Park, PA 16802 (e-matl: JCL4@psu.edu).

Augmentative and Aiternative Communication from Pre-school to High School Building Success with Evidence-Based Interventiom; Guest Editor, Karen A. Fallon, Ph.D.

Semin Speech Lang 2008)9:L20-732. Copyright @2008 by Thieme Medical Publishers, Inc., 333 SeventhAvenue, New York, NY 10001, USA. Tel +1(212) 584-4662.DOI 10.1055/s-2D8-t07 9126. ISSN 0734-0478.

120

EVIDENCE.BASED UTERACY INSTRUCTION/LIGHT ET AL 121

Learning Outcomes: As a result of this activity, the reader will be able to {1) describe essential components ofliteracy instruction for individuals who require augmentative and alternative communication (AAC), (2) describethe importance and f unction of the three steps included in direct explicit instruction of basic skills, and (3) describeappropriate adaptations to support participation for individuals who require MC in literacy instruction activities.

It is diffcult to overestimate the impor-

tance of literacy skills for individuals with

compiex communication needs who requireaugmentative and alternative communication(AAC). Learning to read and write (a) enhan-ces cognitive development and advanceslearning; (b) facilitates participation in theeducational curriculum; (c) provides access toa greater range of employment opporn:nities;(d) facilitates the use of mainstream technolo-gies; (e) supports the deveiopment of friend-ships and social relationships (e.g., throughe-mail, instant messaging, social networkingWeb sites); (0 fosters personal expression(e.g., through journals, autobiographical writ-ing, personal Web sites); (g) enhances personalorganization (e.g., through schedules, lists);and (h) provides access to meaningful andenjoyable leisure pursuits (e.g., reading books

for pleasure) .7'' In fact, literacy skills haveassumed even greater importance in recent yearswith society's increased reliance on text-basedtechnologies such as the Internet, comPuters,and cell phones.'

The importance of literacy skills for indi-viduals who require AAC extends weil beyondthe benefits described above. The acquisitionof literacy skills also offers the potential tosignificandy improve communication and en-hance language development. Without ltteracyskills, individuals who require AAC mustrely on others to provide them with access toappropriate vocabulary/symbols to communi-cate. With the acquisition of literary skills,individuals who require AAC can. communi-cate any message to any individual." They have

complete access to the generative capaciry oflanguage. Thus, the acquisition of iiteraryskills offers individuals who require AAC tre-

mendous advantages for communication andlanguage development in addirion to substan-tial educational, vocational, social, and personalbenefits.

Unfornrnateln many individuals who re-

quire AAC do not acquire functional reading

and writing skills.s-7 One of the major barriersto the acquisition of literacy skills with this

population has been the lack of effective evi-

dence-based instnrction adapted to meet theneeds of individuals who require AAC.8'eThere is an urgent need to develop, implement,and evaluate literacy instruction designed tomeet the complex needs of individuals whorequire AAC to ensure their successful acquis-ition of literary ski1ls.

The goals ofthis paper are as foilows: (a) toreview the research and describe the essentialcomponents of literary instruction for thispopulation and (b) to provide a case ercample

to illustrate implementation of evidence-basedliteracy instruction with a student with multi-ple disabilities who required AAC. This paperfocuses only on the early stages ofinstruction in

conventional literacy skills (i"e., learning to read

and write). Discussion of the developmentof advanced literacy skills (i.e., reading andwriting to learn) is beyond the scope of this

paper; readers are referred to Light andMcNaughton for further discussion of inter-vention to build advanced literary skills withindividuals who require AAC.10 It is alsobeyond the scope of this paper to discuss the

development of emergent literary skills prior to

instruction in conventional literacy.

LITERACY INSTRUCTION FORINDIVIDUALS YUHO REOUIRE AACThis section describes the components ofeffective evidence-based literary instructionbased on the results of a S-year research grant

funded by the National lnstitute on Disability

and Rehabilitation Research as part of theRehabfitation Engineering Center on Com-

munication Enhancement (the AAC-RERC

II).2 The instructional program is based onthe recommendations of the National ReadingPanel11 and provides adaptations to support the

participation of individuals who require AAC'

The progra-m builds on earlier literary research

122 sEMINARs rN spEEcH AND IANGUAGE/voLUME 29, NuMBER z 2ooa

with individuals who require AAC.12'13 Thissection describes the following components ofliteracy instruction: (a) the skills targeted forinstruction; (b) the techniques used to teachthese skills; and (c) the adaptations to allow frillparticipation by individuals who require AAC.

Skills Targeted for InstructionThe acquisition of conventional literacy ski1lsis a complex process that rests on the integra-tion of knowledge and skills in a variety ofinterrelated domains, induding languageskills, phonologic awareness skills, knowledgeof letter-sound correspondences, decodingskills, sight-word recognition skills, applicationof decoding and sight-word recognition skillsduring meaningf:l reading activities, readingcomprehension skills, early writing skills, andtext production/keyboarding skills. 1a

TANGUAGE SKILLSTo read and understand texts and to composemeaningfirl written texts, individuals who useAAC require semantic, syntactic, and morpho-logic skills, as well as knowledge of differentwritten genres (e.g., narrative, persuasive).4Individuals who require AAC frequentlyrequire concerted language intervention topromote pragmatic, semantic, syntactic, andmolphoiogic development and

-to lay the

foundation for literary learning." Althoughlanguage skills greatly facilitate literacy learn-ing, they should not be viewed as a prerequisiteto literary instruction. In fact, our researchsuggests that literacy inscuction can serye tobootstrap language development for individualswho require AAC, espec_ialiy syntactic andmorphologic development.z

PHONOTOGIC AWARENESS SKILLSIndividuals who require AAC also need todevelop phonologic awareness skills to supportthe acquisition of conventional literaryski.1ls.1a'16 Phonologic awareness is defined asan individuafs undentanding or ar/vzlreness ofthe sound structure of language; it involves theability to notice, think about, and manipulatethe phonemes of words." Research suggeststhat individuals who require AAC can developphonologic awareness skills despite severe

speech impairments; however, many demon-strate deficits in phonologic awareness com-pared with that of their nondisabled peers.18-24Focused instn-rction is typically required tobuild phonologic awareness skills with individ-uals who require AAC. In our instructionalprogr"*,2 *" focus primarilyon teaching soundblending and phoneme segmentation skillsbecause these phonologic awareness skills arestrongly correlated with later positive literacyoutcomes."

Sound blending skilk involve the ability tobuild words from individual phonemes; theseskills are essential to the process of decodingnovel words.2t Typi.rfly, sound blending tasksrequire students to listen to a word said slowly(with the individual phonemes h the wordeach extended 1, to 2 seconds) and then blendthe sounds and say the word ora17y at a typicalrate.11 This task can be adapted to allowindividuals who require AAC to respond byselecting the AAC qymbol representing thetarget word from an array of symbols providedby indicating the AAC symbol from their ownaided AAC system (e.g., communication boardor spee*-generating device [SGD]) or bysigring.t"r'tto

Phoneme segmentation sh.ills refer to theability to break words down into individualsounds; these skills are essential to the writinEpro."rr.29 Usually, instruction focuses on ,.glmentation of the initial sounds of one-syllablewords because these tend to be stressed and areeasier to learn to segment.l3'2a Instructionaltasl,is typically require students to listen to aword and then say the beginning sound. Thetask can be adapted as follows for individualswho require AAC: The learner is presentedwith a sound orally and then indicates the wordthat starts with this sound by selecting thecorrect AAC qpmbol from an array of symbols,b.y

irhq$"ir own aided AAC system, or by

slgmng.--'--

KNOWLEDGE OF LETTER.SOUNDCORBESPONDENCESTo leam to read and write, students mustunderstand the correspondence between thephonemes, or sounds of speech, and the gra-phemes, or letters of the wri*en language, thatencode speech.14 Instmction in letter-sound

EVTDENCE.BASED LITERACY INSTRUCTTONILIGHT ET AL 123

correspondences can be easily adapted for in-dividuals who require AAC to bypass the needfor oral responses: Learners are presented witha sound orally and asked to indicate the letterthat represents the sound from an aray ofletters provided or from a keyboard adaptedto meet their needs.2'72'r328'37 Camine et alsuggest letter-sound correspondences shouldbe introduced incrementally, with the follow-ing considerations: (a) the most frequendy usedletter-sounds should be taught fust; (b) shortvowels should be taught before long vowels;(c) letter-sound correspondences that are similarvisually or aurally should be separated withinthe instructional sequence to minimize confu-sion; and (d) lowercase letters should be taughtprior to uppercase letters because the formeroccur more frequently in written t *t .32

DECODING SKILLSDecoding skills involve the integration ofknowledge of letter-sound correspondencesand sound blending skills as weli as langrageskilIs.33 Students must be able to (a) look at awritten word; (b) recognize each of the lettersin the word and retrieve its sound in sequencel(c) blend the sounds together to form the word;and then (d) retrieve the meaning of the word.Typically, decoding tasks require students tosound a word out and then say the word orally.Fallon and colleagues proposed the followingadaptation to bypass the need for oral re-sponses: The student who requires AACis presented with a written word and mustindicate the AAC symbol that represents thewritten word from at a$ay of AAC symbols,representing four different words, induding(a) the target word, (b) a word that differsonly in the initial lefter-sound, (c) one thatdifFers in the medial letter-sound, and (d) onethat differs in the final letter-sound.12 Analysisof the AAC symbols selected by the student inerror allows the instnrctor to determine pat-tems that may indicate areas of difficulty thatrequire fi.rrther instruction (e.g., most errorsrefiect difficulty with medial vowels).

SIGHT-WORD RECOGNITION SKILLSUnfornrnately, not all words in the Englishlanguage are regular and easily decoded;therefore, individuals who require AAC must

also develop sight-word recognition skills toread irregularwords that are di-ffi.cult to decode.In addition, individuals who require AAC mayalso be taught to recognize by sight morecomplex, high-interest words (e.g., dinosaurnames, names ofpopular characters) to enhancetheir motivation for readin g.2 Typir i|ry, sight-word instruction involves some tFpe of pairedassociate task where the written word is oairedwith the spoken word, sign, or AAC symbol.sAlthough it is essential for individuals whorequire AAC to learn to recognize irregularwords by sight, literacy instruction should notbe limited to teaching isolated sight-wordvocabulary because students with AAC needswill be severely resfficted in their ability to reada wide .*g. of *ords and texts succeisfully.8

APPUCATION OF DECODING AND SIGHT.WORDRECOGNITION SKILLS IN READING ACTIVITIESAs soon as individuals who require AAC learnsome basic decoding skills and./or recogni:ze afew sight words, they should have numerousopporrunities to applythese skills in the contoftof meaningfirl shared reading activities. In theseactivities, the literate partner (e.g., teacher,educational assistant, parent, peer readingpartner) reads the text of the book and pausesfor the individual who requires AAC to readspecific words. The individual who requiresAAC reads the target word and then indicatesthe word by selecting the AAC s).rnbol on acommunication board or SGD or by signing.

A wide range of reading materials can beeasily adapted for shared reading activitiesinduding I Spy books, children's booLc, booksrelated to curriculum content, or personalizedstories of t-he learner's experiences.2'l2 Sh"t dreading activities provide important opportu-nities for learners to apply their basic skills inthe contsct of meaningfirl and enjoyable read-ing experiences. As individuals who requireAAC acquire greater competence and fluencydecoding and recognizing words by sight, theycan assume responsibility for reading an in-creased number of words per page until theymake the transition to reading simple stories.'

BUILDING READING COMPREHENSION SKILLSThe ultimate goal of literacy instruction is forindividuals who require AAC to learn to read

124 sEMTNARS rN spEEcH AND LANGUAGE/voLUME 29, NUMBER 2 2008

and understand a wide range of texts.2'6Although the acquisition of decoding skillsand sight-word recognition skills is necessaryto meet this goal, acquisition of these basic

ski1ls alone is not sufficient. Individuals who

require AAC must leam to read and under-

stand written texts. Copeland and Keefe de-

scribed four factors that are critical to readingcomprehension: (a) the ability to decode and

recognize sight words fluendy; (b) the ability tocomprehend the vocabulary and language

structures of the tex! (c) the ability to activateprior experiences and wodd knowledge andrelate these to the text; and (d) the ability touse metacognitive processes to monitor com-prehension and make adustments as requiredto build understanding.'4 Indi.ridrr*1, *ho ,"-quire AAC may be at risk for experiencingdifficulties with reading comprehension be-cause of difficulties in one or more of theseareas. The National Reading Panel identi-fiedseven evidence-based strategies that enhancereading comprehension, induding comPre-hension monitoring, summarization, graphicorganizers, question answering, question gen-.t"tior,, and cooperative learning.l1 Individualswho require AAC may benefit from instructionin one or more of these strategies with appro-priate adaptations to suPPort the. use ofAAC; ftture research is required to determinethe relative effectiveness ofthese strategies forindividuals who require fu\C.2'10

EARLY WRITING SKILLSTo access the firll benefts of literacy, individ-uals who require AAC must not only developreading skills but also writing skills. To write,individuals who require AAC must integrateknowledge and skilis across several domains:(a) knowledge of basic narrative structure orother genres to orgarttz,e stories or other writtentexts; (b) language skills to structure sentencesin the stories appropriately (c) phoneme seg-mentation skills to break down the words in

sentences into component sounds; (d) knowl-edge of letter-sound correspondences to codethe sounds of language into written form; and(e) handwriting, keyboarding, or other accessskills to produce or locate/selecf the requiredletters/words .2 Clearly, learning to write isa complex process. To reduce the learning

demands initially, Light and colleagues pro-

posed using familiar motivating story books to

help structure writing experiences: (a) Initially'

individuals who require AAC read simple storyboola with repeated lines (e.g., Brozon Bear,

Broasn Bear; f ^!ry books) and fiIl in selected

slots in the story with their own tefi (e.g.,

Red pig, rcd BiS. I spy a bu$. (b) Later,individuals who require AAC filI in shortnarrative sequences in longer story books withrepeated plot lines. (c) Finally, students buildtheir own simple narratives with a beginning,middle, and end based on their experiences,familiar books, or picture prompts." As a firststep in writing simple narratives, the studentcommunicates a word/story using a picturedisplay, a SGD, or by signing. The instnrctortien provides oral scaffolding support to helpthe learner encode the text by saying each wordslowly and segmenting the phonemes while theleamer listens and selects the appropriate letters

from an accessible keyboard. At this early stageof writing, sound spellings are accepted; theinstructor models conventional spellings for thelearner as required. Gradually, the supportsare faded as the learner develops greater com-petence. The texts generated by individualswho require AAC are published as boolc andscanned into their AAC systems for independ-ent reading or use in shared reading with adultsor peers, thus illustrating the power of readingand writing."

OPERATIONAL SKILLS AND KEYBOARDINGSKILLSTo encode written text, individuals who require

AAC must be able to produce the requiredletters. Although some individuals who requireAAC may have suffcient motor dexterity tolearn to use handwriting, most will use some

form of computer technology with a conven-

tional keyboard or adapted keyboard. In either

case, individuals who require AAC must iearn

the operational skills to hold a pencil and form

the letters legrbly or to locate and select the

target letters from a keyboard as accurately andefficiendy as possible. To build operationalskills, the instructor may introduce the key-board incrementally as soon as the learner hasacquired a few letter-sound correspondencesand may use the keyboard during instruction

EVIDENCE.BASED UTERACYINSTBUCTTON/LIGHT ETAL 125

in ietter-sound corresoondences to build sreaterfluency.2

In summary, the development of readingand writing skills is a complex process tirat restson the integration of knowledge and skillsacross a variety of domains. Instruction typi-cally targets several skills at a time, startingwith instruction in phonologic awareness skillsand letter-sound corespondences; graduallyadding instruction in decoding and sight-word recognition; and providing numerousopporrunities to apply these basic skills duringmeaningful reading and writing

^activitiestfuoughout the instructional process.'

INSTRUCTIONAL TECHNIOUESIndividuals with complex communicationneeds require organizsd and consistent instruc-tion to maximize the acquisition of Jiteracyskills and to ensure the successfi.rl integrationof these skills in the context of meaningfirlreading and writing activities.ll Literary in-struction is most effective if it is rwo-pronged,induding (a) direct instruction in basic skillsand (b) numerous opportunities to apply theseskills in the context of meaningfi:l reading andwriting activities.ll

Direct Instruction in Basic Skil lsDirect explicit instruction in basic skills uses amost-to-least prompting hierarchy to supporterrodess learning and provides numerousopporrunities for learners to practice skills:(a) First, the instructor models the skill forthe student. (b) Then, the instructor providesguided practice with scaffolding support toassist the learner in completing the skill suc-cessfully. (c) Finalln the learner has opportu-nities for independent practice. This "model,guided practice, independent practice" instruc-tional sequence has been used effectivelyto teach a wide range of skills to learnerswith and without disabilities.35'37 These in-structional procedures have been applied suc-cessfirlly to teach conventional reading andwriting skills to students who require AAC aswell.2'12'L3

Opportunities n oPPIy skilk in the context ofmeaningful literacy activities. To illustrate the

power of reading andwdting, build motivation,and ensure generalization of skills, individualswith complex communication needs requirenumerous opportunities to apply their basisski1ls ia the context of meaningfirl readingand writing activities. For example, as studentsacquire letter-sound correspondences, soundblending skills, and some basic decoding skills,they are provided with opporrunities to partic-ipate in shared reading activities where theinstructor reads part of the text, pausingto allow the student to apply newly acquiredskills by reading words from the text. Theseopportunities build motivation and also en-hance generaTtzatron of skills to a range ofreading and writing contexts.

ADAPTATIONS FOR INDIVIDUALSWHO REOUIRE AACUnfornrnately, most of the literacy curriculaused in the schools require oral responses fromstudents. However, it is possible to adapt liter-acy instruction to meet the needs of individualswho require AAC, induding those who havesignificant speech and motor impairments.Task adaptations to bypass the need for oralresponses, to allow alternative access/selectiontechniques, and to support systematic erroranalyses to determine areas of difficulty havealready been described in the earlier section"Skills Targeted for Instmction."

In addition to these adaptations, individ-uals who use AAC may also require adaptationsto compensate for their lack of speech soundproduction.'When young children are learningto read and write, they typically sound outwords aloud to help them link the writtenlanguage to the spoken language. Individualswho require AAC may be unable to producesome or all of the speech sounds in the targetword, they may be unable to sound out wordsaloud, and they may have difficulty with sub-vocal rehearsal as well, resulting in increaseddemands on working memory and increasedchallenges in learning to decode and encodewords.13'21 They may benefit from externalscaffolding support in the initial stages ofinstruction to compensate for their lack ofaccess to oral rehearsal and to help thembuild subvocal rehearsal. Specifically, it may

126 SEMTNARs rN spEEcH AND LANGUAGE/voIuME 29, NUMBER 2 2oog

be helpful if the instructor models saying thesounds aloud for the student.while encouragingthe student to say the sounds in his or her headsubvocally. Research suggests the effectivenessof this type of oral scaffolding support duringliterary instruction.2'12'13

SummaryDesigning appropriate literary instruction forindividuals with complex communicationneeds requires (a) systematic targeting of ap-propriate skiIls, known to contribute to positiveliterary outcomes; (b) implementation of effec-tive evidence-based instructional procedures,known to result in successful skill acquisition;and (c) development of appropriate adaptationsto accommodate the unique needs of indi-viduals with complex communication needs.Recent research suggests that with thesethree components in place, we can successfirllysupport individuals who require AAC in theacquisition of conventional literacy skills.'

IMPLEMENTATION OF LITERACYINSTRUCTION: A CASE EXAMPLEOften, individuals who require AAC presenta complax array of disabilities that make itchallenging to implement effective literacy in-stmction. This single case study illustrates thespecific implementation of literary instructionwith a student with multiple disabilities todemonstrate the positive outcomes that canbe achieved with appropriate instruction. Katiewas 8 years old when she was referred forliterary intervention by her p,uents. She had arare genetic disorder that resulted in significantspeech, motor, visual, and hearing impair-ments. Specifically, she had delayed skeletalmaturation and used a Dower wheelchair formobility. The joints of her hands and fingerswere fused; Katie was able to produce broadgestures and point with her hand, but she wasnot able to isolate her index finger. Katie had acleft palate that had been surgically repairedwhen she was an infant. She had undergonesurgery for a tracheostomy as an infant and wasventilator-dependent for the fust years of herli{e. By the time we started literary instruction,Katie had been weaned off the ventilator. but

she had a permanent ffacheostomy to supportrespiration and the handling of secretions.Katie was fed via a gastrostomy tube. She hada bilateral moderate to severe sensorineuralhearing loss and used hearing aids and an FMsystem to enhance her performance at school.She was diagnosed with cortical visual impair-ment (CVI), a neurologic condition that causessignificant visual impairment despite normalocular functioning. Katie wore glasses andperformed best when tasls were familiar andshe was motivated and engaged.

Katie communicated via muitiple modesinduding gestures and a small number ofsign approximations, facial expressions,vocalizations to attract attention, and aSGD, specifically a Mercury (Tobii; Dedham,MA) with Speaking Dynamically Pro software(Mayer-Johnson; Solana Beach, CA). TheMercury was programmed with a few hundredwords and phrases represented by photographsand Mayer Johnson Picture CommunicationSymbols (PCS; Mayer-Johnson, Solana Beach,CA) and organized in a grid layout of rowsand columns. Katie typically communicatedtelegraphically, expressing a single concept viasign approximations, gestlrres, or her SGD.She understood basic instructions and simplev.sho, ubat, uhere (WH) questions presentedin context. She performed best when herpartner used augmented input to support hercomprehension, that is, when her partner usedspeech to provide input in conjunction withAAC (e,g., signs or PCS).

Katie attended a life-skills ciassroom; shehad a nurse to care for her medical needs and aclassroom aide to suppoft her educationalneeds. She was not receiving literacy instruc-tion when we started intervention. Katie's pa-rents were very committed to her and wantedher to have the opportunity to develop literacyskills and attain her firll ootential.

BaselinePrior to initiating literary intervention withKatie, we assessed her skills over a series ofsessions to determine appropriate startingpoints and instructional procedures. Katie'sphonologic awarenes$ skills, her knowledgeof letter-sound correspondences, her decoding

EVIDENCE-BASED LITEMCY INSTRUCTION/LIGHT ET AL 127

skills, and her sight-word recognition skillswere assessed using the task adaptationsdescribed earlier. Her performance did notexceed chance levels of accuracy (i.e., 25%accuracy) for any ofthese skills. These resultsare not surprising as Katie had not receivedliteracy instruction within her classroomprogram. Clearly, she required systematicinstruction to build her literacy skills.

Literacy InstructionAfter the assessment was completed, we beganto provide literary instruction to Katie in one-to-one sessions for 30 minutes twice a week ather school. Ideally, Katie would have beenreceiving more intensive literacy instructionon a daily basis; however, there were numerousscheduling constraints given the wide range ofsupport services that she required. This casestudy illustrates t}le gains that can be madeunder less than ideal instructional conditions.Designing appropriate litetac'l instruction forKatie posed signifcant challenges because ofthe complexity of her speech, motor, hearing,and visual impairments. Instruction focused ondirect instruction in the basic skills describedearlier along with numerous opportunities forKatie to apply these skills in meaningfirl read-ing and writing activities. The instructionalprocedures for each skill followed the sequencedescribed earlier (i.e., model, guided practice,independent practice). All tasks were adaptedso that Katie could participate actively in in-stmction by signing, pointing to PCS/letters/words, and/or using her SGD. All text waspresented in large black font (i.e., 80- to90-point font) on yellow badcground to reduceglare, increase contrast, and maximize Katie'svisual attention. The instructor used Katie's FMsystem and used augmented input to supportKatie's comprehension; explanatiohs were pre-sented in sign or traditional orthography as wellas orally. A written visual schedule was used tostructure the instructional session.

The Initial Phase of Literacy Instruc'tionAs summarized in Table 1, the 6rst phase ofliteracy instruction with Katie focused on directinstruction in the following skills: knowledge

of letter-sound correspondences, sight-wordrecognition of high-interest vocabulary, andsingle-word decoding skills using the letter-sound correspondences that she had acquired.Given Katie's hearing loss, phonologic aware-ness skills wele not targeted in isolation; rathervisual supports (e.g., written letters) wereprovided to reduce the auditory processingdemands and assist with learning, With thevisual supports provided, this task resembledthe guided practice stage ofsingle-word decod-irg instruction: The instructor presenteda wriften word to Katie, pointed to each ofthe letters in the word in sequence, and said theletter sounds orally slowly extending eachsound 1 to 2 seconds. Katie needed to lookat the letters, listen to the sounds, blend them inher head to determine the target word, and thensign the word or select it from an array of AACsymbols. In addition, to direct instruction inbasic skills, Katie had numerous oppoftunitiesto applythese skills in the conter<t ofmeaningftlshared reading activities.

LETTER-SOUND CORRESPONDENCESIt was anticipated that it would be challengingfor Katie to leam letter-sound correspondencesgiven her heariag impairment. Instruction wasconducted in a quiet serting using her FMsystem to maximize her auditory performance.Letter-sound correspondences were introducedincrementally following the general principlesproposed by Carnine et a1."" The instructionalsequence was modified (i.e-, m, b, 4 c, r, i, t, o, e,g, d, I, u s, n, /t, p,f j, u, v, !, z, q) to reflect thefollowing additional considerations: (a) thosesounds that would be more difficult for Katie tohear were spaced in the instructional sequenceand were introduced later in the sequence onceshe had acquired some of the letter soundsthat were easier for her to discriminate; and(b) bilabials (e.g., n, b) were taught fust be-cause these sounds provided Katie with dearvisual speech reading cues in conjunction withthe auditory cue. The letter-sound correspond-ences wefe inuoduced slowly over time toensure maste{y.

SIGHT-WORD RECOGNITION SKILLSIt was anticipated that Katie would requiresome time to learn the firll range ofletter-sound

128 sEMTNARs rN spEEcH AND I-ANGUAGE/voLUME 29, NUMBER 2 2acll

Table 1 lntervention Sequence to Teach Literacy Skills to a Student with Multiple DisabilitiesWho Required AAC

Instruction Targeted Skills Outcomes

Phase 1. lntroducing conventional

literacy skills, months 1-7;

20-25 hours of instruction

Phase 2. Reading and writing

simple texts, months B-16;

total of -55 hours since

the start of instruction

Knowledge of letter-sound

correspondences

Sight-word recognition of

high-interest words

Single.word decoding skillswith known letter-sounds

Opportunities to apply skills

in shared reading activitieswith personalized books

Knowledge of letter-sound

corresponoences

Sight-word recognition of

high-interest words

Single-word decoding skills

with known letter-sounds

Opportunities to apply skills

in shared reading activities

with a wide range of books

Skills to read and understand

simple sentences

Keyboarding skills

Skills to type simple personalized

stories using assistive technology

Acquired nine letter-sound

correspon0ences

Read 30 words with > 907o

accuracy

Applied single-word reading

skills in shared reading

activities with > 90% accuracy

Acquired 11 new letter-sound

correspondences (total of

20 letter-soundcorrespondences)

Learned -30 new words (total

of 60 words)

Applied reading skills in shared

reading activities with > 907o

accuracyParticipated in peer reading

buddy program

Read simple sentences with

)907o accurac!

Located letter-sounds on the

keyboard with >80% accuracy

Typed short sentences with some

oral scaffolding support

correspondences and to develop competencewith single-word decoding given the complexityof her multiple disabilities. Therefore, weintroduced her to instruction in sight-wordrecognition of high-interest words (e.g., horse,szoim, bahy) to allow her to participate in sharedreading activities at an early stage. Instruction insight-word recognition skills followed a pairedassociate paradigm with Katie leaming to pairthe written word with the appropriate sign,PCS, or other AAC symbol.

SINGLE.WORD DECODING SKILLSAs Katie acquired letter-sound correspond-ences, she was introduced to instruction insingle-word decoding using the letter-soundsthat she had acquired. Instruction followed the

model, guided practice, and independent Prac-tice sequence described earlier. Katie indicatedher responses using signs, PCS, or other AACsymbols.

SHARED READING ACTIVITIESEarly in t}le instructional process, we intro-duced Katie to oppoftunities to participate inshared reading activities where the instructorread the text and then paused for Katie toread a target word and sign it. These activities

were designed to deady illustrate for Katiethat reading was meaningfirl and fun. Initially,we used personalized books that refectedKatie's experiences and interests. Katie'sknowledge of vocabulary and sentence struc-tures was limited when we started literacy

EVIDENCE.BASED LITERACY INSTRUCTION/LIGHT ET AL 129

instruction. Using personalized books ensuredthat Katie had the background knowledgeand experience to understand the text. Thesehigh-interest books were very simple initiallywith just a simple sentence on a page with asingle target word highlighted in yellow forKatie to read. New vocabulary and languageconcepts were taught to Katie as requiredwithin the context of these reading activities.

OUTCOMES OF LITERACY INSTRUCTIONA-fter the fust 7 months, -2A to 25 hours ofinstruction, Katie was well on her way tobecoming a reader (see Table 1): (a) She hadacquired nine letter-sound correspondences(i.e., m, b, a, c, r, i, t o, e) and identified theseletters with ) 90o/o accurary from a field of 8 to10 letters when the sounds were presentedto her orally. (b) She was able to reai (decodeor recognize by ttght) -30 words (e.g., ntom,dad, dog, cat, baby, eat, play, szoim, borse, etc.)with > 90o/o accuracy. (c) She loved to partic-ipate in a wide range of shared reading activitiesand demonstrated ) 900/o accu:raq readingtargeted words (-JQ different words). (d) Shedemonstrated competence reading target wordsin shared reading activities even when the bookwas a new one that she had not read previouslyand the pictures/photos were covered so thatshe could not rely on them for contexrualcues. Katie had dearly established the basicfoundations for further literacy developmenqand she was highly motivated with respect toliterary learning. Her literary gains resultedin increased expectations within her schoolprogram; her class placement was modified sothat she was induded in a regular educationdass with learning suppoft provided on anindividual basis.

Next Phase of Literacy InstructionOver the next 9 months (months 8 to 16 sincethe start of instruction), we continued totarget instruction in letter-sound correspond-ences, sight-word recognition skills, anddecoding skills as described earlier. In addi-tion, we placed increased emphasis on Katie'sapplication of her skills in the context ofmeaningful reading and writing activities(Table 1).

BOOK READING ACTIVITIESKatie was highty motivated by book readingactivities. During this next phase of literacyinstnrction, we increased tl-re number of wordstargeted for Katie to read in each sentence sothat she was regularly reading at least three tofour words per sentence; over time, she beganto read simple sentences independendy (e.g,,Katie loves morn and dad Mom and dad eat.).When we had started literacy instruction withKatie, her communication was telegraphic.She reiied on single words to express herselfand omitted the functors (e.g., prepositions,articles, conjunctions). As Katie developed herreading skills, we used the written te)cts tointroduce her to new vocabulary and sentencestructures induding basic functors. Thus, Iiter-acy learning served to scaffold her languagelearning. At this stage, we also introducedKatie to a much wider array of written texts,including books that focused on the classroomcurriculum (e.g., socid studies, science) as welias commercial storybools of interest to Katie.As Katie's hteraq skills and language skillsprogressed, she began to demonstrate interestin more complex, age-appropriate topics (e.g.,the TV show Hannab Montana).We also intro-duced a range of books with age-appropriatetopics to facilitate interaction with her peers.

EARLY WRITING ACTIVITIESAt this stage of instruction, we expandedinstruction to target not only reading skillsbut also writing skills. We introduced Katieto assistive technolog'y for writing, specificallythe Dpuwrite (DynaVox Technologies,Pittsburgh, PA). She was able to access thestandard keyboard using the side ofher finger/hand, angled toward the keyboard. Keycapswere used to label the keys with lowercaseletters using bold black font on yellow back-ground to maximize hervisual performance. Weused the keyboard during letter-sound corre-spondence activities to enhance Katie's fluenry.

During writing instruction, Katie had theopportunity to produce her own stories usingphotos or pictures ofinterest to her to providea context. Initially, the instructor modeledfyping a short story for Katie. Then Katie hadthe opportunity to produce her own storywith guided practice: First she signed her

130 SEMTNARs tN spEEcH AND LANcUAGE/voLUME 2e, NUMBER 2 2008

story/message; then, the instructor providedscaffolding support to help her encode herstory/message into text; specificaliy, theinstructor said each word slowly, elongatingthe sounds to help Katie segment the wordsinto their component sounds; Katie selected the

letters that represented each ofthe comPonent

soundsl as she completed each word, she spokethe message out on the Dynawrite and pointedto each word in sequence. Initially, Katie'swritten texts were very short telegraphic mes-sages; the instructor modeled how to expandthese telegraphic messages into slightly longer,more complete texts. As Katie developed greaterliteracy and language skills, she began to pro-duce longer sentences (..g., 1 love dad. Katieand dad and mon.); she was less dependent onthe instructor's oral scaffolding supPort to seg-ment the phonemes in words. Katie's writtentexs were made into short bool,rs that she couldshare with adults and peers. The emphasis wason using writing to communicate with othersin ways that were meaningful and fun.

OUTCOMESAfter a total of 16 months of instnrction, a totalof -55 hours since the start of instruction,Katie demonstrated substantial progressin her literacy and language skills (Table 1):(a) She had acquired atotal of20 letter-soundcorrespondences (all *cept g, ,(.), w, x, y, and z)and located these on a standard keyboard (an

arcay of 26 letters plus punctuation and func-tion keys) with greater than 80% accuracy.(b) She read (decoded or recognized by sight)more than 60 words with > 90o/o acanracy.(c) She participated actively in reading activ-ities with a wide range of texts, reading knownwords with >90% accuracy with adults orpeers. (d) She used assistive technology totype simple one-sentence."stories" or messages(e.g., I lo'ue mom- Dad eat.). With appropriateinstruction, Katie had developed into a readerand a writer. Her acquisition of Iiteracy skillsresulted in increased expectations and learningopportunities at school. She had opportunitiesto participate in a general education dassroom,and her reading and writing activities incorpo-rated current classroom themes (e.g., Life onthe prairies). With ongoing instruction, it isexpected that Katie will continue to develop her

reading and writing skills. With improvedliteracy skills, she will accrue significant bene-fits in all aspects of her life-increased languageskills, enhanced communication skills, im-proved educational access, o<panded access toinformation and digital technologies, increasedemployment opportunities, enhanced self-esteem, improved social networking, and in-

creased societal perceptions of her competence.

FUTURE CHALLENGESKatie is just one of several individuals whorequire AAC with a wide range of disabilities(e.g., cerebral palsn autism, developmentalapraxia, Down syndrome) who have benefitedfrom the literacy instruction described in thisp^p.r.2It is difficult to overestimate the powerof literary skills for individuals who requireAAC like Katie. As a 6eld, we have madesignificant advances in the development ofeffective evidence-based instruction to teachreadins and rwiting skills to individuals who..q.rirJ fu{C.2'8'3i33 We now know whatski]ls to target, what instructional proceduresto implement, and what adaptations are re-quired to successfirlly teach individuals whorequire AAC to read and write. The results forKatie and others demonstate that we canteach literacy skills successfi:.Ily to individualswho require AAC.12'13'3s Niow, it is ourchallenge to do so. We need to successfullytranslate these research results into daily prac-tices in schools, homes, and community pro-granrs so that individuals who require AAChave the opportunities and effective instruc-tion needed to ensure that they develop theliterary skills that they require to attain theirfull potential.

ACKNOWLEDGMENTSThe authors are gratefirl to the children andfamilies who participated in this research proj-ect, especially "Katie" and her family. Theauthors dso wish to thank the entire hteraqresearch team at Penn State for their contribu-tions: Megan Amrein, Elizabeth Benedek-Wood, Julia Birmingham, Maggie Case,Samantha Horochak, Jennifer Jansen, LineKristiansen, Josh Mason, Jennifer May, Leora

EVIDENCE.BASED LITERACY INSTRUCTION/LIGHT ET AL 131

Miller, Micheile Penna, Emily Qrinn, ChayaStark, Christina Weaver, and April Yorke.

The literary instruction described in thisarticle was developed and evaluated as part ofa federally funded research grant under theCommunication Enhancement RehabfitationEngineering Research Center (the AAC-RERC II). The AAC-RERC is a virtual re-search center that is funded by the NationalInstitute on Disability and Rehabilitation Re-search (MDRR) of the U.S. Department ofEducation under grant number H133E030018.The opinions contained in this publication arethose of the grantees and do not necessarilyreflect those of the Deoartment of Education.For additional information on the AAC-RERC, see http://www.aac-rerc.com.

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