Everybody deserves a voice.

As a Master’s student in the world of Speech-Language Pathology, that is a statement I hear frequently and also, one that I believe. So, how can clinicians provide clients with this voice? While there are a variety of answers to this question, the most important answer for the purpose of this blog is: Augmentative and Alternative Communication (AAC). 

AAC devices provide a voice to individuals with a range of disabilities (Kulkarni & Parmar, 2017). AAC can be as simple as picture exchange communication system (PECS) or as complex as an iPad. When thinking of clients who might benefit from AAC, this includes bilingual clients, also known as culturally and linguistically diverse clients. 

Defining What It Means To Be Bilingual

When I hear “bilingual” my mind automatically jumps to the idea of someone that can speak two languages. For this blog, let’s think deeper into the definition and consider two different types of bilingualism: simultaneous bilingualism and successive bilingualism. Simultaneous bilinguals are children who learn two languages at the same time from birth (Patterson, 2002). Successive bilinguals are children who learn one language initially and then learn a second language relatively early, but later in childhood (Itani-Adams, Iwasaki, & Kawaguchi, 2017). As a Speech-Language Pathologist, you may work with bilingual clients who need AAC recommendations.  

AAC is a form of language made up of rules that have to be taught and practiced just like any other language (Kempka Wagner, 2018). Keeping that in mind, if an AAC user speaks one language (L1) and a second language (L2), then AAC becomes the third language (L3) and the client is considered multilingual (Kempka Wagner, 2018). 

View of Disability in Other Cultures  

As a clinician who works with clients with a range of disabilities, it is important to consider how disability might be perceived in other cultures. These views can play a role in how families choose to accept and incorporate AAC devices (Kulkarni & Parmar, 2017). A brief overview is presented below based on what exists within the literature regarding European Americans, Asian Americans, Native Americans, and Hispanic Americans. 

  • European American (Parette & Huer, 2002)
    • Disability stems from medical or social factors including genes, environment, or health problems 
    • Full trust and support given to the recommendations of related professionals 
  • Asian Americans  (Parette & Huer, 2002)
    • Disability is related to previous sins, fate, or shame 
    • Hesitation when interacting with related professionals 
    • Limited attention given to a disability 
  • Native Americans (Stuart & Parette, 2002) 
    • Disability is related to previous sins, choices made before birth – spiritual connections 
    • May be reluctant to accept the idea of intervention 
  • Hispanic Americans (Rodriguez & Allen, 2018)
    • Authoritarian view
      • Full trust and support given to the recommendations of related professionals 

Everybody you meet from each cultural group may not feel this way, but as a clinician, it is important to at least consider these viewpoints in order to be culturally sensitive. By doing so, one can make culturally and linguistically appropriate/sensitive recommendations! As a student clinician, I have personally taken the time to consider these viewpoints when working with clients from other cultures. I believe this has led to better therapeutic relationships and better treatment outcomes. 

A Glimpse into the Bilingual AAC Experience 

For a bilingual client who may already struggle with communication, the idea of adding a third language (i.e., AAC) can appear overwhelming. Furthermore,a central theme in the literature:families feel restricted by the lack of support available for non-English speaking clients. Specifically, Mexican-American families and Malaysian families have reported difficulty with obtaining AAC resources for non-English speaking clients (Huer, Parette, & Saenz, 2001; Joginder Singh, Hussein, Mustaffa Kamal, & Hassan, 2017). According to Joginder Singh et al. (2017), Malaysian families found AAC terminology challenging to understand and half of the families desired AAC application options in other languages. 

Understanding the rationale behind using AAC devices has also played a role in child and parent interest, as some Mexican-American and Malaysian families have preferred natural speech instead of AAC devices (Huer, Parette, & Saenz, 2001; Joginder Singh et al., 2017). Family focus group participants have highlighted the importance of being mindful of terminology use and being culturally sensitive when working with families (Rosa-Lugo & Kent-Walsh, 2008). As explained previously, some cultures may have difficulty accepting the idea of disability and thus, certain feedback may be perceived negatively. How do you think we can help these families and provide a better AAC experiences? Read below for helpful tips! 

Making the AAC Experience More Accessible for Bilingual Clients and their Families

This is not an exhaustive list, but simply a few ways to improve the bilingual AAC experience

1. Incorporate the family – The client’s family is one of the most important pieces of the AAC process. The family should be involved with every step including assessment, developing goals, and treatment (ASHA, 2019). The assessment process is the perfect opportunity for clinicians to inquire about the client’s language proficiency with each language and a good opportunity to learn more about their culture. This will help ensure          that the client has access to all of the languages they need when using the device and it helps promote generalization of AAC skills in as many settings as possible (personal communication, April 5, 2019).

2. Educate the family –AAC is potentially a form of therapy that will be new for the family that you are working with. In order to help families understand the importance of AAC, clinicians should take the necessary steps to educate them (ASHA, 2019). For example, if a clinician was working with one of the families mentioned above that preferred natural speech over the AAC device, that clinician could provide evidence to show that AAC is not a replacement for verbal communication and there is actually          evidence that shows that it does not negatively affect speech development (Adamson & Dunbar, 1991; Cress, 2003). This may help the family remain committed with the device! Providing handouts and website links is a great way to share detailed information. 

3. Recommend communication partner training – This type of training can include family members, friends, teachers, coworkers, and more.It gives communication partners an opportunity to learn how to utilize the AAC device themselves, incorporate active listening strategies, incorporate an appropriate amount of wait time for conversational turn-taking, and use visual and environmental cues (ASHA, 2019). 

4. Provide opportunities for communication in all languages – When working with a   bilingual client, clinicians can provide multiple ways for the client to communicate. If the client speaks Spanish and English, one blog suggests that, if using a communication board, the clinician can create one board in Spanish and one board in English (Lopez, 2015). In addition, the clinician can create picture cards that include both the English term and the Spanish term on the same card (Lopez, 2015). For instance, if requesting      “more” in Spanish, a clinician might write “more” (English word) and write “más” (Spanish word) underneath, followed by the picture reflecting “more.” If using a high-tech device with voice output, a clinician may set up the device so that both languages are recorded and stored in the device (Lopez, 2015). Depending on the device, language options may be limited. The clinician can provide additional low or mid tech choices to    supplement the client’s high tech device (personal communication, April 5, 2019).

5. Include a professional interpreter (as needed) – An interpreter can help translate information during all stages of the AAC process including assessment, goal writing, treatment, and training sessions. They can also help bridge the gap between the clinician and the client/family to make for a better therapeutic relationship (personal communication, April 5, 2019).

AAC support for bilingual users– Below are resources for clinicians and bilingual clients using AAC devices. The first website is an ASHA website in Spanish that provides an overview of AAC. The second website lists bilingual AAC applications that can be used when recommending applications/devices to clients for different needs including medical, functional communication, and social communication.

1) https://www.asha.org/public/speech/disorders/Los-Sistemas-Aumentativos-y-Alternativos-de-Comunicacion/

2) https://www.pdx.edu/multicultural-topics-communication-sciences-disorders/bilingual-aac-apps

As a graduate student clinician, I completed one of my outside placements at Children’s National Medical Center (CNMC). During my time at CNMC, I was able to work on the AAC team, conducting evaluations and leading treatment sessions. When working with bilingual clients and their families, I was able to see first-hand the importance of incorporating the family, educating the family, and using an interpreter. For example, for many families, AAC was a new concept. Because of this, many families were unsure which AAC device would be best for their child or they questioned why we did not recommend a device. Taking the time to explain the purpose of the different devices and the rationale behind our decisions helped families understand our recommendations. Overall, incorporating the tips listed above made a difference in our therapeutic relationship and AAC experience. Every experience will be different, but taking the steps to be culturally sensitive most certainly goes a long way! 


Adamson, L., & Dunbar, B. (1991). Communication development of young children with tracheostomies. Augmentative and Alternative Communication7(4), 275-283.

American Speech-Language-Hearing Association [ASHA] (n.d.). Augmentative and Alternative Communication(Practice Portal). Retrieved March 10, 2019 from https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942773&section=Key_ Issues

Cress, C. J. (2003). Responding to a common early AAC question: “Will my child talk?”. Perspectives on Augmentative and Alternative Communication12(5), 10-11.           

Huer, M. B., Parette Jr, H. P., & Saenz, T. I. (2001). Conversations with Mexican Americans regarding children with disabilities and augmentative and alternative communication. Communication Disorders Quarterly22(4), 197-206.

Itani-Adams, Y., Iwasaki, J., & Kawaguchi, S. (2017). Similarities and differences between simultaneous and successive bilingual children: Acquisition of Japanese morphology. International Journal of Applied Linguistics and English Literature, 6(7), 268-276.

Joginder Singh, S., Hussein, N. H., Mustaffa Kamal, R., & Hassan, F. H. (2017). Reflections of Malaysian parents of children with developmental disabilities on their experiences with AAC. Augmentative and Alternative Communication33(2), 110-120.

Kempka Wagner, D. (2018). Building Augmentative Communication Skills in Homes Where English and Spanish Are Spoken: Perspectives of an        Evaluator/Interventionist. Perspectives of the ASHA Special Interest Groups3(12), 172-  185.

Kulkarni, S. S., & Parmar, J. (2017). Culturally and linguistically diverse student and family perspectives of AAC. Augmentative and Alternative Communication33(3), 170-180.

Lopez, L. (2015, May 31). AAC Tips for Multilingual Clients [Blog post]. Retrieved from https://www.bilingualspeechtherapist.com/?p=447

Parette, P., & Huer, M. B. (2002). Working with Asian American families whose children have augmentative and alternative communication needs. Journal of Special Education Technology17(4), 5-13.

Patterson, J. L. (2002). Relationships of expressive vocabulary to frequency of reading and television experience among bilingual toddlers. Applied Psycholinguistics23(4), 493-508.

Rodriguez, Y. S., & Allen, T. E. (2018). Exploring Hispanic parents’ beliefs and attitudes about deaf education. Journal of Latinos and Education, 1-11.

Rosa-Lugo, L. I., & Kent-Walsh, J. (2008). Effects of parent instruction on communicative turns of Latino children using augmentative and alternative communication during storybook reading. Communication Disorders Quarterly30(1), 49-61.

Stuart, S., & Parette, Jr, H. (2002). Native Americans and augmentative and alternative communication issues. Multiple Voices for Ethnically Diverse Exceptional  Learners5(1), 38-53.

(C. Weeden Shannon, personal communication, April 5, 2019). 

Tiara Booth Head Shot

Tiara Booth is part of the the Cultural and Linguistic Diversity program for Speech-Language Pathology students at the University of Maryland. The program aims to broaden students’ understanding of culture and language in order to minimize disparities in service delivery to culturally and linguistically diverse populations.