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School Staff Perspectives on Using Augmentative and Alternative Communication with Students with Severe or Profound Intellectual and Multiple Disabilities

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Title: School Staff Perspectives on Using Augmentative and Alternative Communication with Students with Severe or Profound Intellectual and Multiple Disabilities
Language: English
Authors: Anna Rensfeldt Flink (ORCID 0000-0002-2006-8569), Sofia Wallin, Johanna Larsson, Ellen Westling, Jakob Åsberg Johnels
Source: Journal of Research in Special Educational Needs. 2025 25(3):500-513.
Availability: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
Peer Reviewed: Y
Page Count: 14
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Descriptors: Foreign Countries, School Personnel, Attitudes, Augmentative and Alternative Communication, Severe Disabilities, Students with Disabilities, Severe Intellectual Disability, Multiple Disabilities, Incidence, Educational Attainment, Cooperation, Stakeholders
Geographic Terms: Sweden
DOI: 10.1111/1471-3802.12742
ISSN: 1471-3802
Abstract: This mixed methods survey study aims to investigate school staff's perspectives on using augmentative and alternative communication (AAC) with students with the most severe disabilities in Swedish school settings. The study employed a convergent mixed methods design, where both quantitative and qualitative data were collected and analysed in parallel and then integrated and compared in the discussion and conclusion section of the paper. The study's respondents consisted of school staff who worked with students with severe or profound intellectual and multiple disabilities (S/PIMD) in Swedish schools. Results showed that almost all staff reported using AAC with students at least half of the time. The frequency of AAC use did not seem to differ between staff with different educational backgrounds, apart from teachers/special educators appearing slightly more inclined to use AAC in planned classroom activities when compared to staff with other educational backgrounds. The results also corroborate previous research stating that collaboration between stakeholders (such as school, family and the habilitation services) is fundamental to successful AAC implementation but that there are challenges when establishing efficient collaborations between stakeholders.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1476578
Database: ERIC
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  Value: <anid>AN0186527083;0lc01jul.25;2025Jul12.02:53;v2.2.500</anid> <title id="AN0186527083-1">School staff perspectives on using augmentative and alternative communication with students with severe or profound intellectual and multiple disabilities </title> <p>This mixed methods survey study aims to investigate school staff's perspectives on using augmentative and alternative communication (AAC) with students with the most severe disabilities in Swedish school settings. The study employed a convergent mixed methods design, where both quantitative and qualitative data were collected and analysed in parallel and then integrated and compared in the discussion and conclusion section of the paper. The study's respondents consisted of school staff who worked with students with severe or profound intellectual and multiple disabilities (S/PIMD) in Swedish schools. Results showed that almost all staff reported using AAC with students at least half of the time. The frequency of AAC use did not seem to differ between staff with different educational backgrounds, apart from teachers/special educators appearing slightly more inclined to use AAC in planned classroom activities when compared to staff with other educational backgrounds. The results also corroborate previous research stating that collaboration between stakeholders (such as school, family and the habilitation services) is fundamental to successful AAC implementation but that there are challenges when establishing efficient collaborations between stakeholders.</p> <p>Keywords: augmentative and alternative communication; collaboration; mixed methods; schools; severe or profound intellectual and multiple disabilities; survey</p> <p></p> <ulist> <item> Staff in Swedish schools frequently use augmentative and alternative communication with children with severe/profound intellectual and multiple disabilities, according to self‐reports.</item> <p></p> <item> Staff reportedly use various tools and methods for augmentative and alternative communication, and value multi‐modality.</item> <p></p> <item> Only minor differences were found between staff of different educational backgrounds regarding the self‐reported use of augmentative and alternative communication.</item> <p></p> <item> Staff use of augmentative and alternative communication is influenced by factors such as their own competence, the individual student's abilities, access to sufficient time to adapt and apply the methods/tools properly, and collaboration with other stakeholders.</item> </ulist> <p>Key Points</p> <hd id="AN0186527083-2">INTRODUCTION</hd> <p>The rights of students with severe disabilities to participate actively in society and access education are protected by the Convention on the Rights of Persons with Disabilities United Nations ([<reflink idref="bib47" id="ref1">47</reflink>]), where the acceptance and facilitation of accessible means, modes and formats of communication are specifically mentioned as a communicative right. This study aims to investigate school staff perspectives when it comes to applying augmentative and alternative communication (AAC) with students with the most severe disabilities in Swedish school settings.</p> <p>AAC is an umbrella term comprising various methods and tools that have the purpose of enabling effective engagement and participation in interactions and activities and/or to enhance further communicative development in individuals with communication difficulties (Beukelman & Light, [<reflink idref="bib2" id="ref2">2</reflink>]). AAC has been suggested to enhance communication skills in various populations, including individuals with severe or profound intellectual and multiple disabilities (S/PIMD)[<reflink idref="bib1" id="ref3">1</reflink>] (Light & McNaughton, [<reflink idref="bib24" id="ref4">24</reflink>]; Sigafoos et al., [<reflink idref="bib41" id="ref5">41</reflink>]; Simacek et al., [<reflink idref="bib42" id="ref6">42</reflink>]; Wilder et al., [<reflink idref="bib54" id="ref7">54</reflink>]). An AAC system may be unaided, hence building on bodily modes (e.g., manual or tactile signs), or aided, meaning that it includes some sort of low‐tech or high‐tech equipment (e.g., paper‐based AAC symbols or photos, tangible objects, speech‐generating devices (SGDs) or computer/tablet‐based AAC systems) (Beukelman & Light, [<reflink idref="bib2" id="ref8">2</reflink>]). Multimodal approaches are encouraged, for example, to combine two or several AAC modes to meet an individual's uneven and often complex communication needs (Beukelman & Light, [<reflink idref="bib2" id="ref9">2</reflink>]; Smidt & Pebdani, [<reflink idref="bib44" id="ref10">44</reflink>]). The individual's development within the domains of communication, intellectual functioning, and motor and sensory perception should guide decision‐making on what a child's AAC system should look like (O'Neill & Wilkinson, [<reflink idref="bib34" id="ref11">34</reflink>]). Ideally, the AAC system should build on current strengths (Sigafoos, [<reflink idref="bib40" id="ref12">40</reflink>]) and enhance the integration of skills (Light & McNaughton, [<reflink idref="bib24" id="ref13">24</reflink>]). Moreover, it should meet the child's current communicative needs as well as enhance further development (O'Neill & Wilkinson, [<reflink idref="bib34" id="ref14">34</reflink>]). To be successful, an AAC system should not only concern the person with a communication disability but also engage their entire social context (Biggs & Hacker, [<reflink idref="bib3" id="ref15">3</reflink>]; Light & McNaughton, [<reflink idref="bib24" id="ref16">24</reflink>]; Mandak et al., [<reflink idref="bib25" id="ref17">25</reflink>]; von Tetzchner, [<reflink idref="bib49" id="ref18">49</reflink>]). Collaborative partnerships within and across school staff, the family and other AAC‐related service providers are important for successful AAC interventions (Biggs & Hacker, [<reflink idref="bib3" id="ref19">3</reflink>]; Moorcroft et al., [<reflink idref="bib28" id="ref20">28</reflink>]; Rensfeld Flink et al., [<reflink idref="bib36" id="ref21">36</reflink>]).</p> <p>In students with the most hindering combinations of intellectual and motor disabilities, the combined complexity makes exact assessments of level of ID challenging and causes substantial care needs as well as a very high dependence on others in all activities, including communication (Nakken & Vlaskamp, [<reflink idref="bib29" id="ref22">29</reflink>]). The combination of severe/profound ID and significant gross motor disabilities has been applied to characterise this population in several publications (e.g., Arthur‐Kelly et al., [<reflink idref="bib1" id="ref23">1</reflink>]; Flink et al., [<reflink idref="bib16" id="ref24">16</reflink>]; Johnels et al., [<reflink idref="bib21" id="ref25">21</reflink>]), and the term severe/profound intellectual and multiple disabilities (S/PIMD) has been used to acknowledge the indistinctiveness between severe and profound ID, when combined with other severe disabilities (Flink et al., [<reflink idref="bib16" id="ref26">16</reflink>]; Griffiths & Smith, [<reflink idref="bib18" id="ref27">18</reflink>]; Johnels et al., [<reflink idref="bib21" id="ref28">21</reflink>]).</p> <p>It is very common for the communication of students with S/PIMD to be further impacted by visual or hearing impairments, autism, and medical difficulties such as epilepsy (Flink et al., [<reflink idref="bib16" id="ref29">16</reflink>]; Nakken & Vlaskamp, [<reflink idref="bib29" id="ref30">29</reflink>]). Students with S/PIMD generally communicate pre‐linguistically (Dhondt et al., [<reflink idref="bib14" id="ref31">14</reflink>]; Grove et al., [<reflink idref="bib19" id="ref32">19</reflink>]) and may exhibit fluctuating levels of alertness (Sigafoos et al., [<reflink idref="bib41" id="ref33">41</reflink>]), even though some linguistic abilities would be expected to be present in students with severe ID. Social–emotional and communicative development happens in minimal increments at an extremely slow pace in this group (Van keer et al., [<reflink idref="bib48" id="ref34">48</reflink>]), and precise and reliable assessments of intellectual functioning, as well as communication, are difficult (Chadwick et al., [<reflink idref="bib7" id="ref35">7</reflink>]; Nakken & Vlaskamp, [<reflink idref="bib29" id="ref36">29</reflink>]). All of these factors have been found to complicate the professional decision‐making process when it comes to AAC intervention for children with S/PIMD (Rensfeld Flink et al., [<reflink idref="bib36" id="ref37">36</reflink>]).</p> <p>There is indeed limited available knowledge on AAC with regard to students with S/PIMD. Regarding the potential benefits of using AAC with the S/PIMD population, quicker responses, reduced memory load and increased comprehensibility have been suggested (Simacek et al., [<reflink idref="bib42" id="ref38">42</reflink>]), as well as promoted communicative intentionality (Sigafoos et al., [<reflink idref="bib41" id="ref39">41</reflink>]) and enhanced receptive skills (Siegel‐Causey & Bashinski, [<reflink idref="bib39" id="ref40">39</reflink>]). In broader populations of children with disabilities in the early stages of communication development, AAC has also been found to potentially increase interaction (Cress & Marvin, [<reflink idref="bib10" id="ref41">10</reflink>]), for example, turn‐taking (Wandin et al., [<reflink idref="bib51" id="ref42">51</reflink>]). Intervention research on specific AAC systems within the S/PIMD population has primarily focused on switches/one‐message SGDs in school contexts, revealing some promising results (Simacek et al., [<reflink idref="bib42" id="ref43">42</reflink>]). However, the utilisation of other AAC systems in this population, especially unaided AAC, remains relatively unknown due to a scarce research base (Sigafoos et al., [<reflink idref="bib41" id="ref44">41</reflink>]). In general, a number of factors seemingly influence the AAC use of communication partners of individuals with S/PIMD. Emphasis has been placed on the importance of the communication partner's openness to the individual's communicative behaviour and the potential benefits of AAC, as well as having a supportive social environment (Hanley et al., [<reflink idref="bib20" id="ref45">20</reflink>]).</p> <p>As for school staff's perceptions of communication and AAC use with students with S/PIMD, an Australian study described that teachers' functional use of AAC was associated with access to adequate tools and knowledge on how to implement high‐tech AAC, as well as functional cooperation with speech‐language therapists (SLT) (De Bortoli et al., [<reflink idref="bib13" id="ref46">13</reflink>]). A British study addressing a special school's various professions' perceptions of their AAC use with broader populations of students with disabilities (approximately half of them belonging to the S/PIMD group) identified key barriers to efficient AAC implementation in school settings. These barriers included staff's limited understanding of the rationales for using AAC and their lack of confidence in using it (Norburn et al., [<reflink idref="bib31" id="ref47">31</reflink>]). The most commonly applied AAC modes were gestures, manual signs and photographs (Norburn et al., [<reflink idref="bib31" id="ref48">31</reflink>]). From a broader special education practice perspective, it has been reported in a meta‐synthesis of team members' perceptions of requirements and necessary conditions for supporting students in need of AAC (in the US) that characteristics of the student, their family, the staff as well as the AAC device impacted student outcomes (e.g., increased frequency of appropriate communicative behaviours, acquisition of particular communicative skills or increases in communication opportunities) (Chung & Stoner, [<reflink idref="bib8" id="ref49">8</reflink>]). Moreover, available support in terms of time, training and funding was perceived as crucial, as well as various aspects of team collaboration (Chung & Stoner, [<reflink idref="bib8" id="ref50">8</reflink>]).</p> <p>In Sweden, the context of this study, little is known about AAC experience, training and practice of school staff working with students with S/PIMD. In a nationwide survey study covering the vast majority of teachers working with students with all levels of intellectual disability (ID) in Sweden, more than half of the teachers reported feeling confident or very confident about implementing AAC with their students and to always or almost always use AAC in their teaching (Frostlund & Nordgren, [<reflink idref="bib17" id="ref51">17</reflink>]). Around 42% of the respondents reported to have received AAC training within their formal teacher training, and 35% had participated in some kind of additional AAC training since they started working as teachers with children with ID (Frostlund & Nordgren, [<reflink idref="bib17" id="ref52">17</reflink>]). In a study involving 11 teachers and 17 support staff from seven schools working in non‐inclusive classrooms for students with ID in Sweden (Wallin et al., [<reflink idref="bib50" id="ref53">50</reflink>]), 82% of the teachers and 59% of the support staff had some kind of AAC education, most commonly focussing on manual signs. Self‐reported AAC education was reflected in the behaviour of the entire staff group. Out of the targeted AAC modes, manual signs were used most frequently (40% of all utterances during circle time, 9.8% during leisure time activities), followed by low‐tech symbol‐based AAC (circle time: 5.1%, leisure time: 0%). SGDs were the least used AAC mode and were not used at all during leisure time. It is not known whether these results are representative of the specific teaching context for students with S/PIMD.</p> <p>In Sweden, students with ID are eligible to follow an adapted curriculum. For students with milder ID, the syllabus focusses on adapted academic subjects, while the syllabus for students with severe or profound ID, including those with S/PIMD, focusses on five subject areas related to daily life, whereof one is communication (Wilder & Klang, [<reflink idref="bib53" id="ref54">53</reflink>]). The communication syllabus states that students should be supported to develop their communicative skills in different contexts through various means of communication, such as speech, body language, manual signs and other communicative tools (Skolverket, [<reflink idref="bib43" id="ref55">43</reflink>]). The adapted curriculum can be taught in both inclusive and non‐inclusive school settings, that is, in classrooms with or without peers who do not have ID. Due to the complex needs of students with S/PIMD, most of them are likely to receive their education in self‐contained classrooms or at special schools. Such units have more resources in terms of smaller groups of students, higher staff‐student ratios and more teachers who have had training in special needs education than teachers in inclusive settings (Klang et al., [<reflink idref="bib23" id="ref56">23</reflink>]).</p> <p>Similar to what is the case in many other countries (e.g., Jones & Bender, [<reflink idref="bib22" id="ref57">22</reflink>]), Swedish schools for students with S/PIMD do not only recruit teachers and special educators but rely heavily on paraeducators and other staff categories to support the educational and overall needs of the students. This is likely a very heterogeneous category of staff since some of them have no post‐secondary education, others have education related to disability care or paraeducational tasks, and yet others have advanced university degrees unrelated to the school context.</p> <p>The professions in Sweden that are specialised in the field of AAC are SLTs and occupational therapists (OT). The communication and language domains of AAC are the SLT's field of expertise, while the OTs are experts on assistive technology and physical accessibility. However, SLTs and OTs only rarely work within the Swedish educational system (National Board of Health and Welfare, [<reflink idref="bib30" id="ref58">30</reflink>]; Swedish National Agency for Education, [<reflink idref="bib46" id="ref59">46</reflink>]). On the contrary, students with S/PIMD have free‐of‐charge access to the habilitation services, which are a part of the Swedish healthcare system (Wettergren et al., [<reflink idref="bib52" id="ref60">52</reflink>]). This generally means access to an SLT and OT within the habilitation services, who may conduct communication interventions oriented toward the home context, sometimes in collaboration with the educational context, and who may potentially prescribe free‐of‐charge communication aids. Swedish SLTs within the habilitation services have found that cooperation with school staff is very important when implementing AAC with children with S/PIMD and their parents. Motivated and skilled school staff are considered a potentially contributing factor to positive AAC outcomes, especially when it comes to high‐tech AAC systems (Rensfeld Flink et al., [<reflink idref="bib36" id="ref61">36</reflink>]).</p> <p>Against a background of very little prior research on AAC practices in the education of students with S/PIMD, it is important to learn more about current practices, as well as the perspectives and attitudes of school staff. Here, we are interested in the use of AAC both as an input system (aiming to aid comprehension) and as an output system (aiding expression) in the communication with students. Three research questions form the basis of this study:</p> <p>(<reflink idref="bib1" id="ref62">1</reflink>) With what frequency do school staff report using various AAC with students with S/PIMD and are there any differences in AAC use depending on the educational background of the staff? (<reflink idref="bib2" id="ref63">2</reflink>) What stakeholders are involved in the collaborative partnership concerning AAC? (<reflink idref="bib3" id="ref64">3</reflink>) What contributing and hindering factors are perceived by the school staff as influential in their AAC use with students with S/PIMD?</p> <hd id="AN0186527083-3">METHODS</hd> <p></p> <hd id="AN0186527083-4">Research design</hd> <p>A survey study was conducted using a convergent mixed methods design where both quantitative data (i.e., closed‐ended survey responses) and qualitative data (i.e., open‐ended survey comments) were collected and analysed in parallel and then integrated and compared in the discussion and conclusion section of the paper (Creswell, [<reflink idref="bib11" id="ref65">11</reflink>]).</p> <hd id="AN0186527083-5">Participants</hd> <p>The study respondents consisted of staff who worked with students with S/PIMD (defined as severe/profound ID combined with significant gross motor impairment, or 'flerfunktionsnedsättning' in Swedish) in Swedish school settings. Inclusion criteria were that respondents had worked with at least one student in the last 2 years who (a) followed the curriculum for compulsory school for students with severe ID (i.e., had a formal diagnosis of severe or profound ID) and (b) had extensive motor disabilities (i.e, their mobility required physical assistance or assistive devices).</p> <p>The administrative offices of four municipalities in southwest Sweden were contacted to obtain contact information for principals overseeing students enrolled in the curriculum for students with severe ID. Contact information was provided on a total of 21 principals, all of whom were contacted through email and informed about the study. Seven principles (33%) from three municipalities replied and offered to help recruit survey respondents within their staff. The principals were instructed to forward an email to all staff who worked with students following the curriculum for severe ID, and then report the number of forwards. This email contained: (<reflink idref="bib1" id="ref66">1</reflink>) study information and (<reflink idref="bib2" id="ref67">2</reflink>) a web link to the anonymous survey. The data collection period lasted for 10 weeks. All principals received a minimum of one reminder email to forward to their staff.</p> <p>A total of 130 school staff were offered the survey, of whom 54 responded, resulting in a response rate of 41.5%. Of these responses, 13 were excluded because the respondents did not meet the inclusion criteria. The responses of the remaining 41 respondents were included in the study. An overview of respondent characteristics is presented in Table 1.</p> <p>1 TABLE Respondent characteristics.</p> <p> <ephtml> <table><thead valign="bottom"><tr><th align="left">Characteristic</th><th align="left">Teacher/special educators</th><th align="left">Other educational backgrounds</th><th align="left">All respondents</th></tr><tr><th align="left"><italic>n</italic> (%)</th><th align="left"><italic>M</italic> (<italic>SD</italic>)</th><th align="left">Min‐max</th><th align="left"><italic>n</italic> (%)</th><th align="left"><italic>M</italic> (<italic>SD</italic>)</th><th align="left">Min‐max</th><th align="left"><italic>N</italic> (%)</th><th align="left"><italic>M</italic> (<italic>SD</italic>)</th><th align="left">Min‐max</th></tr></thead><tbody valign="top"><tr><td align="left">Total</td><td align="char" char="(">21 (51)</td><td align="left" /><td align="left" /><td align="char" char="(">20 (49)</td><td align="left" /><td align="left" /><td align="char" char="(">41 (100)</td><td align="left" /><td align="left" /></tr><tr><td align="left">Sex</td></tr><tr><td align="left">Female</td><td align="char" char="(">18 (85.7)</td><td align="left" /><td align="left" /><td align="char" char="(">18 (90)</td><td align="left" /><td align="left" /><td align="char" char="(">36 (87.8)</td><td align="left" /><td align="left" /></tr><tr><td align="left">Male</td><td align="char" char="(">2 (9.5)</td><td align="left" /><td align="left" /><td align="char" char="(">2 (10)</td><td align="left" /><td align="left" /><td align="char" char="(">4 (9.8)</td><td align="left" /><td align="left" /></tr><tr><td align="left">Other/non‐disclosed</td><td align="char" char="(">1 (4.8)</td><td align="left" /><td align="left" /><td align="char" char="(">0 (0)</td><td align="left" /><td align="left" /><td align="char" char="(">1 (2.4)</td><td align="left" /><td align="left" /></tr><tr><td align="left">Age</td><td align="left" /><td align="char" char="(">45 (11.2)</td><td align="char" char="–">26–63</td><td align="left" /><td align="left">40.9</td><td align="char" char="–">25–53</td><td align="left" /><td align="char" char="(">42.9 (9.7)</td><td align="char" char="–">25–63</td></tr><tr><td align="left">Years working with students with ID</td><td align="left" /><td align="char" char="(">11.2 (9.0)</td><td align="char" char="–">2–34</td><td align="left" /><td align="left">5.4 (4.2)</td><td align="char" char="–">1–20</td><td align="left" /><td align="char" char="(">8.4 (7.6)</td><td align="char" char="–">1–34</td></tr><tr><td align="left">Number of students with S/PIMD</td><td align="left" /><td align="char" char="(">10.8 (13.5)</td><td align="char" char="–">1–50</td><td align="left" /><td align="left">10.7 (8.9)</td><td align="char" char="–">1–38</td><td align="left" /><td align="char" char="(">10.7 (11.3)</td><td align="char" char="–">1–50</td></tr></tbody></table> </ephtml> </p> <p>The respondents had various educational backgrounds, where 21 stated that they held a minimum of one academic degree within education (i.e., they were qualified teachers and/or special educators). These 21 respondents will hereafter be referred to as 'teachers/special educators'. The other 20 respondents stated no academic degree within educational sciences. Of these, eight had non‐academic training in disability care or paraeducation (teaching assistant, child carer, nurse assistant and disability support worker). Yet another two had academic degrees related to the field of AAC but not to education (SLT, OT). The (in total) 20 respondents without an academic degree within education will henceforth be referred to as respondents with 'other educational backgrounds'.</p> <p>The work experience of the teachers/special educators, as well as the respondents with other educational backgrounds, is shown in Table 1. To allow for transparency regarding potential differences in work experience between those two respondent groups, group differences were explored using the Mann–Whitney U test. The teacher/special educator group had significantly more worked years in school settings with students with ID than the group with other educational backgrounds (<emph>p</emph> = 0.047, <emph>U</emph> = 135). No significant differences were found in the number of students with S/PIMD with whom they had worked in the last 2 years (<emph>p</emph> = 0.32, <emph>U</emph> = 210).</p> <hd id="AN0186527083-6">Survey</hd> <p>The anonymous digital survey was designed by the authors. The survey content was guided by the authors' professional experiences in the fields of special education and speech‐language therapy, as well as their previous related studies, in particular Rensfeld Flink et al. ([<reflink idref="bib36" id="ref68">36</reflink>]).</p> <p>The survey comprised both closed‐ended and open‐ended items. Following an introductory section describing AAC and S/PIMD, survey items 1–9 concerned consent to participate and demographic information about the respondents. Survey items 10–17 consisted of one to nine sub‐items to be rated on a 7‐point Likert scale (ranging from −3 to 3) with labels on the scale steps −3, 0 and 3. Space for writing open‐ended comments was offered for each of these items.</p> <p>Items 10–11 addressed the implementation of various AAC methods and tools. Items 12–14 targeted implementation frequency in various situations and barriers to AAC use. Items 15–17 focussed on collaboration with team members, parents and external partners (such as the habilitation services) in decision‐making concerning AAC.</p> <p>Items 18–19 were entirely open‐ended, and the respondents were asked to write down their answers freely. In item 18, the respondents were asked to describe the most crucial prerequisites for successful AAC implementation. Item 19 offered the possibility to write additional comments on the survey. Closed‐ended items were mandatory, while answering open‐ended questions was optional. Open‐ended comments could be of any length (no restrictions were applied). An English translation of the survey is available as an Appendix S1.</p> <p>The survey was accessible to the respondents through a web link and administered within the platform Sunet Survey. The respondents could activate the survey on any digital device, and it was expected to take 10–15 min to complete the survey.</p> <hd id="AN0186527083-7">Analysis of closed‐ended survey data</hd> <p>Quantitative analyses were performed using IBM SPSS Statistics 28. Descriptive analyses were used on demographic data and survey item 10 and items 12–17 and presented in median, means, range, percentages and visual representations. In items 12 and 13, differences between teachers/special educators and respondents with other educational backgrounds were analysed using the Mann–Whitney U test, with a benchmark level of significance set at <emph>p</emph> ≤ 0.05. A non‐parametric test was used as the items of interest were not normally distributed (the Shapiro–Wilk test for normality was conducted).</p> <hd id="AN0186527083-8">Analysis of open‐ended survey data</hd> <p>The applied qualitative approach was qualitative description, an approach that aims to transparently describe participant perceptions of a phenomenon from their own viewpoint and to stay close to the data throughout the analysis in a low inference way (Sandelowski, [<reflink idref="bib38" id="ref69">38</reflink>]). This is a suitable approach within mixed methods research, as well as in research addressing stakeholder perceptions of why interventions may or may not work in practice (Doyle et al., [<reflink idref="bib15" id="ref70">15</reflink>]). Analytically, we followed the principles of thematic analysis (Braun & Clarke, [<reflink idref="bib5" id="ref71">5</reflink>]). Firstly, all open‐ended data (95 comments from 33 respondents) were compiled into one document and read through repeatedly. In step two of the analysis, codes were assigned to data segments deemed valuable and relevant to factors contributing and hindering the AAC use with students with S/PIMD, that is, research question three. Each item comment could be divided into several segments with different associated codes. Thirdly, codes with similar meanings were grouped, and themes were considered and discussed. Finally, three themes were determined, which highlighted the most central shared meanings in relation to research question three. To ensure that all useful data were included and that all coded segments were consistent with the overall thematic structure, all data were read through several times during the process.</p> <hd id="AN0186527083-9">Ethical considerations</hd> <p>The current study was methodologically modelled after a study on the practice of SLTs in Sweden (Rensfeld Flink et al., [<reflink idref="bib36" id="ref72">36</reflink>]). The study protocol for that study was submitted to the Swedish Ethical Review Board (ref. no: 2020‐05228) but waived for review on the motivation that research of this type does not fall under the Swedish Ethical Review Act. According to a formal statement, the board had no objections to any part of the study. Consequently, no formal ethics vetting was conducted for the current study. Importantly, the study followed the principles of the ethical guidelines of the Swedish research council (Stafström, [<reflink idref="bib45" id="ref73">45</reflink>]). Each respondent received written study information declaring: (<reflink idref="bib1" id="ref74">1</reflink>) the purpose of the study, (<reflink idref="bib2" id="ref75">2</reflink>) that the survey only collected completely anonymous data and (<reflink idref="bib3" id="ref76">3</reflink>) how these data were handled. Respondents also had the opportunity to contact the study group should they have any questions. Only respondents who stated that they had read the study information and actively consented to participate in the study could respond to the remaining survey items.</p> <hd id="AN0186527083-10">RESULTS</hd> <p></p> <hd id="AN0186527083-11">Frequency of AAC use and applied AAC modes—Analysis of closed‐ended data</hd> <p>Respondents rated their overall frequency of AAC use by responding, 'When you communicate with a student with S/PIMD, how often do you and/or the student use some type of AAC?' (Item 12). They rated on a seven‐step Likert scale ranging from −3 (never) to 3 (always). See the ratings in Figure 1. Most respondents (80.5%) indicated either of the two upper scale steps (2 or 3). Only 2.4% of the respondents indicated that they used AAC less than half of the time. Thus, most staff perceived that AAC was used most of the time when communicating with the students. No significant difference in overall implementation frequency (<emph>U</emph> = 203, <emph>p</emph> = 0.85) was found between teachers/special educators (<emph>Mdn</emph> = 2.0, range = 3) and the group with other educational backgrounds (<emph>Mdn</emph> = 3.0, range = 4).</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/0LC/01jul25/jrs312742-fig-0001.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="jrs312742-fig-0001.jpg" title="1 The two groups' ratings of overall AAC use (item 12) and AAC access in various situations (item 13). Lines represent median values, and squares represent mean values. Numerically specified mean values are included in the figure. Scale: −3 = Never, 3 = Always. *Significant difference between groups using the Mann–Whitney U test, p = 0.05." /> </p> <p></p> <p>Regarding AAC implementation throughout the school day, respondents rated the students' access to AAC in various situations (item 13). Access to AAC was characterised as follows: '(<reflink idref="bib1" id="ref77">1</reflink>) the communication tools that the student may need are at hand, (<reflink idref="bib2" id="ref78">2</reflink>) you as a communication partner support the student in using the AAC and, when possible, you yourself use the AAC mode'. This item had five sub‐items of different situations with a Likert scale from −3 (Never) to 3 (Always). See the ratings in Figure 1. Among the respondents who indicated the option 'Other', the following situations were mentioned: excursion, leisure time, meal, going home and taxi journey. When comparing the groups, a significant difference was demonstrated between the groups during classes (<emph>U</emph> = 131, <emph>p</emph> = 0.03), where teachers/special educators used AAC to a greater extent than the group with other educational backgrounds. For the other targeted situations, no significant differences were seen between the two groups.</p> <p>The frequency of AAC use with respect to various modes of AAC modes was addressed in the question, 'Picture the student(s) with S/PIMD that you have worked with over the past two years. To what proportion of students have you used the AAC modes that are listed below?' (Item 10). This item had nine sub‐items with various AAC modes on a Likert scale from −3 (none) to 3 (all). The ratings are displayed in <emph>Figure</emph><emph>2</emph>. Overall, manual signs were used to a high degree, followed by tangible objects and one‐message SGDs. Computer/tablet‐based AAC systems and multiple‐message SGDs had the lowest ratings. No significant differences were seen between the groups.</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/0LC/01jul25/jrs312742-fig-0002.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="jrs312742-fig-0002.jpg" title="2 Ratings of various AAC modes, in the proportion of students with S/PIMD in which the respondent had used the mode (item 10). Lines represent median values, and squares represent mean values. Numerically specified mean values are included in the figure. Scale: −3 = None, 3 = All." /> </p> <p></p> <hd id="AN0186527083-14">Stakeholder collaboration—Analysis of closed‐ended data</hd> <p>Regarding stakeholder collaboration, the respondents first rated to which degree they agreed with the sub‐items 'My team members prioritise AAC highly, expecting a collaborative effort to grant students with S/PIMD access to AAC' and 'Caregivers of students with S/PIMD often have high expectations that students have access to AAC in their daily communication at school' both in item 15 with a Likert scale from −3 (do not agree at all) to 3 (totally agree). Regarding the first sub‐item related to the prioritisation of team members, the median rating was 2.0 (range = 5, mean = 1.46), one scale step below 'totally agree'. Regarding caregiver expectations, the median rating was 0.0 (range = 6, mean = 0.46), corresponding to the middle rating.</p> <p>Secondly, they responded to the item, 'When selecting appropriate AAC methods (if any) for a student with S/PIMD, and deciding how to implement AAC with the student, what stakeholders are typically involved?' (item 16). Nine stakeholders were listed as sub‐items on the Likert scale ranging from −3 (never) to 3 (always). Responses are shown in Figure 3. The stakeholders rated as the most often involved in decision‐making were classroom teachers, with a median value corresponding to 'always'. Classroom assistants and SLTs at the habilitation services were rated as the second most common stakeholders involved. Personal assistants had the lowest rating, corresponding to one scale step above 'never'.</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/0LC/01jul25/jrs312742-fig-0003.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="jrs312742-fig-0003.jpg" title="3 Ratings of stakeholders typically involved in AAC decision‐making (item 16). Lines represent median values, and squares represent mean values. Numerically specified mean values are included in the figure. Scale: −3 = Never, 3 = Always. *At the habilitation services." /> </p> <p></p> <p>Third, the respondents rated to what degree they agreed with the sub‐items 'I usually agree with caregivers on the appropriate AAC methods and their implementation for students with S/PIMD' and 'I usually agree with external collaborators (e.g., the habilitation services) on the most suitable AAC methods and their implementation for students with S/PIMD,' both in item 17 with a Likert scale from −3 (do not agree at all) to 3 (totally agree). On both sub‐items, the median was 2.0, one scale step below 'always' (caregiver item: range = 6, mean = 1.44; external collaborator item: range = 4, mean = 1.51).</p> <hd id="AN0186527083-16">Factors that influence AAC use among staff—Mixed methods analyses</hd> <p>Influential factors with regard to the use of AAC were explored with a combination of descriptive statistics of Likert scale data and qualitative description of open‐ended data.</p> <hd id="AN0186527083-17">Factors contributing to rejection of AAC—Analysis of closed‐ended data</hd> <p>The closed‐ended data consisted of the respondents' ratings of how various factors potentially contributed to their rejection of using AAC with students with S/PIMD (item 14). The respondents rated seven sub‐items on a Likert scale ranging from −3 (do not agree at all) to 3 (agree completely). See the ratings in Figure 4. No sub‐items had medians at the top end of the scale. A fairly common reason for opting out of using AAC seemed to be 'I have not had the time to adapt the AAC method/tool so that it works in the activity'. This sub‐item had the highest number of respondents who agreed fully (39%) or in part (i.e., indicated any of the upper three scale steps) and the lowest number of respondents who estimated that they did not agree at all (22%, scale step −3). The sub‐item 'I find it particularly difficult to use AAC with students with S/PIMD' was the sub‐item with which most respondents did not agree at all (58.5%), suggesting that most participants did not perceive increased difficulty when implementing AAC with their students with S/PIMD compared to other students.</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/0LC/01jul25/jrs312742-fig-0004.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="jrs312742-fig-0004.jpg" title="4 Ratings of factors that potentially contribute to staff AAC rejection (item 14). Lines represent median values, and squares represent mean values. Numerically specified mean values are included in the figure. Scale: −3 = Do not agree at all, 3 = Agree completely." /> </p> <p></p> <hd id="AN0186527083-19">Factors contributing to successful AAC use—Analysis of open‐ended data</hd> <p>Qualitative description was performed through thematic analysis of all qualitative comments deemed valuable and relevant to factors contributing and hindering AAC use with students with S/PIMD. Most comments stemmed from the entirely open‐ended item 'Which prerequisites do you find most crucial for AAC to work successfully with students with S/PIMD?' (Item 18). The teachers/special educators provided a slightly higher number of open‐ended comments than staff with other educational background. They also had a tendency to be more elaborate in their open‐ended comments and thus provided somewhat more open‐ended data. The four themes derived from the analysis are presented in Figure 5 below. The quotations below are referenced with the participant's anonymised id number followed by T (teacher or special educator) or O (other educational background).</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/0LC/01jul25/jrs312742-fig-0005.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="jrs312742-fig-0005.jpg" title="5 The themes of the analysed open‐ended survey data." /> </p> <p></p> <hd id="AN0186527083-21">Being guided by the student's needs and abilities</hd> <p>This theme describes various aspects of the shared meaning that the AAC implementation can be facilitated by staff being guided by the student's needs and level of functioning when choosing, adapting and using an AAC system. The patterns in the data that shaped this theme were found mainly in comments from teachers/special educators. Hence, this shared meaning was seemingly more prevalent among teachers/special educators.</p> <p>It was considered important to use an AAC system that matched the student's abilities in terms of cognition as well as motor and sensory functioning. Individual adaptation to each student was seen as fundamental: 'That it [AAC system] is adapted according to the student's needs and conditions. Not too difficult and not too easy' (respondent 60T). Sometimes the adaptation to students with S/PIMD posed challenges to the staff, as expressed by respondent 58O: 'I work a lot with students with severe visual impairments, so standard pictures don't work' and by respondent 41T 'SGDs with buttons that are sunken in [key guards] work very poorly for our students as they cannot shape their hand to push [such buttons]. [...] SGDs with multiple protruding buttons work well, but few students get those kinds prescribed.'</p> <p>Individual customisation appeared to be an ongoing process of continuous adaptation. Respondent 46T described: 'It is sometimes necessary to lower the bar a little and make the necessary adjustments [simplify the AAC system] to enable the student to communicate actively'. Multimodality was mentioned as one way of adapting to the students' individual needs. Respondent 2O found that the availability of multiple AAC modes may increase the likelihood that a student eventually would respond: 'To immerse with communication options even if the student does not seem to understand or perceive'. Different AAC modes were also perceived to complement each other to fulfil the student's needs in different situations: 'The student may have an eye‐gaze controlled computer which is difficult to use in certain situations where it is easier to use a picture board' (R. 46T).</p> <p>The respondents found that the AAC system should be selected, adapted and applied not only with the student's cognitive and physical abilities in mind but also with regard to their interests, preferences and motivation: 'One must carefully take into account what they [the students] think and want' (48T). Some staff described how they strove to make the AAC system enjoyable, fun, and useful from the student's point of view: 'To work toward the student seeing the benefits of using AAC' (10T) and how they built motivation and sparked interest by building on existing communication: 'Create opportunities and build on the manual signs and movements they already use, interpret these and create meaning, encourage' (41T).</p> <hd id="AN0186527083-22">Staff competence</hd> <p>This theme describes shared meanings regarding staff's knowledge, skills and attitudes in relation to successful AAC use with students with S/PIMD. Both teachers/special educators and staff with other educational backgrounds contributed with comments that were used as analytical segments in this theme.</p> <p>Staff attitudes toward and beliefs about students and their communication were perceived to impact their AAC use: 'The view of children and all individuals' right to communication' (26O). Several respondents pointed out the importance of having the appropriate knowledge to be able to implement AAC with this vulnerable and complex group of students. Both basic pedagogical training and continuous knowledge‐gaining throughout their professional practice were considered important: 'Staff with some form of pedagogical training' (26O), 'Training (recurring)' (8T), 'Courses' (30T). At the same time, respondent 44T described the need to be aware of the limited available evidence regarding communication with this group of students: 'Stop pretending that you know what to do with a child with multiple disabilities'. This respondent requested more research on students with S/PIMD and their development and situation in order to enhance the quality of AAC and educational practice.</p> <hd id="AN0186527083-23">Time: A valuable resource</hd> <p>Time as a crucial resource for successful AAC use was a patterned response that was particularly prevalent among respondents who were not teachers or special educators. Time was mentioned in relation to adaptation and maintenance of AAC systems and in relation to gaining adequate knowledge and skills, for example, 'Organisational conditions of, for example, time for the staff to receive further training and supervision' (respondent 26O). Moreover, staff needed to allocate enough attention to each student to engage them in high‐quality interaction: 'Enough time and space for communication' (3O). One respondent described that the consequences of lack of time were particularly negative for students with S/PIMD: 'AAC [...] is, unfortunately, one of the first things to decrease when staff are overloaded. There is a big risk that students with S/PIMD have to stand back and thus be shoved around in a disrespectful and undignified way' (6O).</p> <hd id="AN0186527083-24">The necessity of collaboration</hd> <p>This theme highlights shared meanings regarding the importance of the student's entire social network being involved in the AAC implementation and collaborating with one another. The entire school staff was considered important for implementation, but also other stakeholders such as the regional habilitation services or family members. This theme is anchored in comments from both teachers/special educators and staff with other educational backgrounds.</p> <p>When all the student's main communication partners used the AAC system in a similar manner, the school staff described that the student's AAC use was facilitated and then, secondly, their own use too. Several respondents described that everyone in the network needs to know how the AAC system should be used and implement it consistently: 'That the people around the student have understanding, knowledge, and always use the AAC system together with the student' (10T). Respondent 46T mentioned that for a student to truly learn to communicate with AAC, it would not be sufficient to learn solely in the school context. Hence, the staff would try to encourage other communication partners as well: 'From our school perspective, we always highlight in conversations with parents the importance of using AAC in all situations to provide opportunities [for the students] to learn how to manage the communication aid'. Similarly, 16O stated:'That the students have access to it [AAC] at home as well as in school and that it is used in all situations, if possible'. However, sometimes there was a perceived lack of knowledge and resources in the home context: 'Unfortunately, a lot of parents don't know what AAC is. Too little knowledge. There is a lack of material, such as access to software to produce visual schedules at home, and so on.' (43O).</p> <p>The importance of collaboration was also noted in a broader sense. Many respondents mentioned how parents, the habilitation services and school staff needed to set common goals in a structured way; for example, respondent 56T: 'That everyone around the student works towards the same goal, meet in networks, agree on how communication support should be carried out'. Making use of parents' experiences with their child could be helpful to staff: 'Sometimes ideas come from caregivers, which we build on, of course. They know their children best' (41T). At the same time, there were also views that the choices and priorities regarding AAC systems by parents and the habilitation services sometimes contrasted with the school staff's perceptions of what would be most appropriate: 'That the selected method is at the student's level, not according to the wishes of the parents or the habilitation services' (45T). In a similar way, another respondent found that: 'The habilitation service staff is also very concerned with the [student's] social network; that they need to be competent communicators for a child to receive a communication aid. They do not consider that the child is actually a competent communicator' (41T). In a sense, the habilitation services seemed to sometimes be perceived as gatekeepers when it came to the students' (and hence also the staff's) availability to aided AAC.</p> <hd id="AN0186527083-25">DISCUSSION</hd> <p>This mixed methods survey study explored school staff's self‐reported AAC practices, views on stakeholder collaboration, and perceived barriers and facilitators related to AAC use when it comes to students with S/PIMD in Swedish schools. School staff reported to use a variety of AAC modes, with manual signs the most used. They reported using AAC in structured classroom activities, as well as in less structured activities such as break time or personal care. The frequency of AAC use did not seem to differ depending on educational background, apart from teachers/special educators appearing slightly more inclined to use AAC in planned classroom activities compared to staff with other educational backgrounds. The respondents perceived that AAC practice was influenced by factors associated with the individual student, conditions surrounding the staff and collaboration with other stakeholders. Even though the respondents oftentimes agreed with other stakeholders in matters regarding the AAC practice, stakeholder collaboration still seemed to pose some challenges. The results will be discussed further below.</p> <hd id="AN0186527083-26">Frequency of use and applied AAC modes</hd> <p>The vast majority of the staff used AAC with their students with S/PIMD more than half of the time, according to self‐reports. To the best of our knowledge, there are no other published studies quantitatively assessing staff‐reported frequencies of AAC use, specifically with students with S/PIMD in school settings. However, the ratings agree fairly well with another study in Swedish schools involving a broader population of children with ID (Frostlund & Nordgren, [<reflink idref="bib17" id="ref79">17</reflink>]).</p> <p>This study's results show that a variety of AAC modes were used with students with S/PIMD. Staff also reported that they valued multimodality and considered multimodality to enhance AAC practice. This notion has also been found among school staff within segregated special education in Scotland (Norrie et al., [<reflink idref="bib32" id="ref80">32</reflink>]).</p> <p>The research field of AAC interventions for individuals with S/PIMD has primarily investigated one‐button SGDs, yielding promising results (Simacek et al., [<reflink idref="bib42" id="ref81">42</reflink>]). The fact that these devices were reported to be used relatively frequently by the respondents is encouraging. However, previous observational studies in Swedish school environments, although for the broader population of students with ID, have shown limited use of SGDs, especially outside of activities with routine‐based and preplanned content (Wallin et al., [<reflink idref="bib50" id="ref82">50</reflink>]). It remains unclear whether this discrepancy reflects a gap between staff perceptions and actual SGD use, if SGDs are primarily utilised in S/PIMD‐focused settings, or if it simply indicates variation in SGD use across Swedish schools.</p> <p>The school staff further reported using manual signs with their students to a rather large degree; it was, in fact, their most frequently applied AAC mode. To the best of our knowledge, the efficacy of manual signs with students with S/PIMD is an unexplored issue (Sigafoos et al., [<reflink idref="bib41" id="ref83">41</reflink>]; Simacek et al., [<reflink idref="bib42" id="ref84">42</reflink>]). Nonetheless, previous studies corroborate that manual signs are commonly used in Swedish, as well as British, classrooms for students with ID (Norburn et al., [<reflink idref="bib31" id="ref85">31</reflink>]; Wallin et al., [<reflink idref="bib50" id="ref86">50</reflink>]). Likewise, Swedish SLTs report high frequencies of implementation of manual signs with the same population (within the health care sector) (Rensfeld Flink et al., [<reflink idref="bib36" id="ref87">36</reflink>]). Promising results have been found in studies addressing professional practice with adults with ID (including severe ID), where staff use of keyword signing seemingly increased signing in adults with ID (Meuris et al., [<reflink idref="bib27" id="ref88">27</reflink>]; Rombouts et al., [<reflink idref="bib37" id="ref89">37</reflink>]). Given the motor disabilities of students with S/PIMD, one could expect that it would be very challenging for those students to sign themselves, as also suggested by Wallin et al. ([<reflink idref="bib50" id="ref90">50</reflink>]). It may be that the manual signs used by staff mainly function as augmented input, that is, the partner uses AAC to support comprehension, which is encouraged for partners of students with S/PIMD (Bruce & Bashinski, [<reflink idref="bib6" id="ref91">6</reflink>]; Siegel‐Causey & Bashinski, [<reflink idref="bib39" id="ref92">39</reflink>]). Aided augmented input is suggested to increase turn‐taking and positively impact early language abilities in emerging communicators (Wandin et al., [<reflink idref="bib51" id="ref93">51</reflink>]). Whether the same is true for <emph>unaided</emph> augmented input is seemingly still unexplored (Dada et al., [<reflink idref="bib12" id="ref94">12</reflink>]).</p> <hd id="AN0186527083-27">AAC practice in relation to staff education</hd> <p>It has been suggested that formal education and training related to AAC and to students with communication difficulties are important for successful AAC implementation, but paraeducators often lack that kind of training (Chung & Stoner, [<reflink idref="bib8" id="ref95">8</reflink>]). Hence, different patterns of AAC practice could be expected depending on the educational background. On the contrary, when it comes to the specific S/PIMD population, De Bortoli et al. ([<reflink idref="bib13" id="ref96">13</reflink>]) described that teachers did not always experience benefits from their formal training, as the communication‐specific content could not be applied to students with S/PIMD due to their broad and complex range of difficulties. Our results indicated only minor differences in the frequency of self‐perceived AAC use between teachers/special educators and staff with other educational backgrounds, suggesting that there is a tradition of valuing and using AAC by staff with different professional backgrounds. The teachers/special educators did, however, report a significantly higher frequency of AAC use during classes and tended to have more comments related to being guided by student characteristics and needs in their AAC use than the group with other educational backgrounds. It should be noted that the survey data we gathered provided very little insights into the nature of the actual AAC use and whether there might be differences between the staff groups in <emph>how</emph> AAC was implemented. Thus, further research is clearly needed on the role of pedagogical training in the implementation of AAC in school settings.</p> <hd id="AN0186527083-28">Contributing and hindering factors to staff's AAC use</hd> <p>When it comes to this study's results concerning factors that impacted AAC practice, they echoed previous research such as Chung and Stoner ([<reflink idref="bib8" id="ref97">8</reflink>]), Hanley et al. ([<reflink idref="bib20" id="ref98">20</reflink>]) and Norrie et al. ([<reflink idref="bib32" id="ref99">32</reflink>]), as they emphasised student factors (e.g., their interests/motivations and level of functioning), staff factors (e.g., resources in terms of time and further training) and stakeholder collaboration and partnership.</p> <p>The staff found additional training to be important to use AAC with students with S/PIMD, in line with previous studies (De Bortoli et al., [<reflink idref="bib13" id="ref100">13</reflink>]; Martin & Alborz, [<reflink idref="bib26" id="ref101">26</reflink>]; Norburn et al., [<reflink idref="bib31" id="ref102">31</reflink>]; Norrie et al., [<reflink idref="bib32" id="ref103">32</reflink>]). However, it was not detailed what this training should look like or what form of training was most appropriate. Given the broad range of educational levels within the targeted staff, one could expect a complex pattern of different training needs ranging from basic pedagogic skills to expert knowledge in specific AAC tools and methods. In a Scottish study addressing a broader scope of students with complex communication needs, it was found that school staff's AAC use oftentimes was a matter of 'learning by doing' rather than receiving designated training and that this strategy was found to be particularly challenging and unsuitable when it came to learning to use and handle high‐tech AAC systems (Norrie et al., [<reflink idref="bib32" id="ref104">32</reflink>]). According to Australian teachers, specialised formal training combined with long practical experience of the specific population were both important to build competence in how to support communication and apply AAC with students with S/PIMD due to the students' complex and idiosyncratic functioning (De Bortoli et al., [<reflink idref="bib13" id="ref105">13</reflink>]). From the perspective of paraeducators, a British study suggested that regular planned communication training delivered by the class teacher was warranted to strengthen practical skills and underpin those skills with theoretical understanding (Martin & Alborz, [<reflink idref="bib26" id="ref106">26</reflink>]). The value of recurring training opportunities was also mentioned in our data.</p> <p>Lack of time was a factor that was mentioned predominantly by staff other than teachers/special educators. The group consisted largely of paraeducators who, in Sweden, generally spend their working hours in very close proximity to the students, leaving limited or no time for educational planning and co‐planning (Östlund et al., [<reflink idref="bib35" id="ref107">35</reflink>]). Lack of time for educational co‐planning for this staff category has also been noted outside of the Swedish context (Biggs et al., [<reflink idref="bib4" id="ref108">4</reflink>]).</p> <p>The crucial value of stakeholder cooperation and collaboration was sufficiently stressed among the respondents to be considered a theme of its own in the qualitative analysis. Similarly, interprofessional collaboration in dialogue with family members has been stressed in multiple publications as challenging, yet necessary, to reach educational goals within communication for students with severe disabilities (Biggs & Hacker, [<reflink idref="bib3" id="ref109">3</reflink>]; Bruce & Bashinski, [<reflink idref="bib6" id="ref110">6</reflink>]; Cooper‐Duffy & Eaker, [<reflink idref="bib9" id="ref111">9</reflink>]; Hanley et al., [<reflink idref="bib20" id="ref112">20</reflink>]; Mandak et al., [<reflink idref="bib25" id="ref113">25</reflink>]; Norrie et al., [<reflink idref="bib32" id="ref114">32</reflink>]; Ogletree et al., [<reflink idref="bib33" id="ref115">33</reflink>]). The results of our study paint a somewhat complex picture. According to the quantitative results, school staff generally agreed with both parents and other external stakeholders in issues involving AAC practice. On the contrary, the qualitative analysis illuminates the fact that they still struggle to meet the need of effective collaboration in specific cases. The quantitative results indicate that interprofessional collaboration may be more influential on the AAC practice than collaboration with the parents of the students. Collaborations with SLTs in the habilitation services seem common. However, professional partnership with the habilitation services was also occasionally mentioned in the open‐ended data as somewhat problematic. Professionals and their organisations could benefit from utilising theoretical frameworks such as the ecological systems theory (Biggs & Hacker, [<reflink idref="bib3" id="ref116">3</reflink>]; Mandak et al., [<reflink idref="bib25" id="ref117">25</reflink>]) or evidence‐based models such as the interprofessional collaborative practice model (IPCP) (Bruce & Bashinski, [<reflink idref="bib6" id="ref118">6</reflink>]; Cooper‐Duffy & Eaker, [<reflink idref="bib9" id="ref119">9</reflink>]) to build working strategies for AAC stakeholder collaboration and partnership. However, it appears that such models are not implemented in a structured manner in the organisations, hence seemingly leaving staff (and families) to find ways to collaborate as efficiently as possible in each individual case.</p> <hd id="AN0186527083-29">Limitations and future directions</hd> <p>There are some limitations of this study that need to be acknowledged. A first limitation has to do with the anonymous nature of the data collection, which means that we have no knowledge of non‐responders on the survey. This means that we have no way of knowing if our participants differ in certain regards from those who did not complete the survey. Similarly, we do not know the detailed characteristics of the individual students that the respondents referred to in their replies, for example, the proportion of students with severe ID versus students with profound ID, or profiles of other co‐occurring conditions such as sensory impairments or autism. A second limitation relates to the group of respondents with other educational background. These participants had a very diverse educational background—ranging from other academic educations relevant to AAC implementation (i.e., one SLT and one OT) to non‐academic educations relevant to children with disabilities or no education at all. In a study with a larger number of respondents, it would be possible to explore the role of educational background in a more fine‐grained manner.</p> <p>Despite these caveats, we hope this small‐scale study of AAC‐related practices and attitudes will inspire more research on communication support for students with S/PIMD, which is still very much needed. For instance, future research could employ observational and intervention studies addressing AAC use specifically with students with S/PIMD in various school contexts and with different staff categories in order to explore practices as well as improvements to practice.</p> <hd id="AN0186527083-30">CONCLUSIONS</hd> <p>The results of this study indicate that the staff of various educational backgrounds working with students with S/PIMD in Swedish schools hold a favourable view of AAC use and a high self‐perceived degree of multimodal AAC implementation. The staff are motivated to support and enhance interaction with the students in collaboration with various stakeholders and to expand their own knowledge through further training. However, they perceive a lack of resources, for example, in terms of time to sometimes meet those needs. The results also corroborate previous research stating that collaboration between stakeholders (such as school, family and the habilitation services) is fundamental to successful AAC implementation but that there are challenges when it comes to building efficient collaborations between stakeholders.</p> <hd id="AN0186527083-31">ACKNOWLEDGEMENTS</hd> <p>We are thankful to the school staff who dedicated time and effort into participating in this research. The study received financial support from the Sävstaholm Foundation (grant number ST 2020‐006).</p> <hd id="AN0186527083-32">CONFLICT OF INTEREST STATEMENT</hd> <p>The authors report no conflict of interest.</p> <hd id="AN0186527083-33">DATA AVAILABILITY STATEMENT</hd> <p>The data may be shared upon reasonable request.</p> <hd id="AN0186527083-34">ETHICS STATEMENT</hd> <p>Ethics approval was not required.</p> <p>GRAPH: Appendix S1.</p> <ref id="AN0186527083-35"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref3" type="bt">1</bibl> <bibtext> In the UK the term learning disability is commonly used, that is, severe or profound multiple and learning disability (S/PMLD).</bibtext> </blist> </ref> <ref id="AN0186527083-36"> <title> REFERENCES </title> <blist> <bibtext> Arthur‐Kelly, M., Foreman, P., Maes, B., Colyvas, K. & Lyons, G. 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  Data: <searchLink fieldCode="AR" term="%22Anna+Rensfeldt+Flink%22">Anna Rensfeldt Flink</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-2006-8569">0000-0002-2006-8569</externalLink>)<br /><searchLink fieldCode="AR" term="%22Sofia+Wallin%22">Sofia Wallin</searchLink><br /><searchLink fieldCode="AR" term="%22Johanna+Larsson%22">Johanna Larsson</searchLink><br /><searchLink fieldCode="AR" term="%22Ellen+Westling%22">Ellen Westling</searchLink><br /><searchLink fieldCode="AR" term="%22Jakob+Åsberg+Johnels%22">Jakob Åsberg Johnels</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Journal+of+Research+in+Special+Educational+Needs%22"><i>Journal of Research in Special Educational Needs</i></searchLink>. 2025 25(3):500-513.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 14
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2025
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22School+Personnel%22">School Personnel</searchLink><br /><searchLink fieldCode="DE" term="%22Attitudes%22">Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Augmentative+and+Alternative+Communication%22">Augmentative and Alternative Communication</searchLink><br /><searchLink fieldCode="DE" term="%22Severe+Disabilities%22">Severe Disabilities</searchLink><br /><searchLink fieldCode="DE" term="%22Students+with+Disabilities%22">Students with Disabilities</searchLink><br /><searchLink fieldCode="DE" term="%22Severe+Intellectual+Disability%22">Severe Intellectual Disability</searchLink><br /><searchLink fieldCode="DE" term="%22Multiple+Disabilities%22">Multiple Disabilities</searchLink><br /><searchLink fieldCode="DE" term="%22Incidence%22">Incidence</searchLink><br /><searchLink fieldCode="DE" term="%22Educational+Attainment%22">Educational Attainment</searchLink><br /><searchLink fieldCode="DE" term="%22Cooperation%22">Cooperation</searchLink><br /><searchLink fieldCode="DE" term="%22Stakeholders%22">Stakeholders</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Sweden%22">Sweden</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1111/1471-3802.12742
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1471-3802
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: This mixed methods survey study aims to investigate school staff's perspectives on using augmentative and alternative communication (AAC) with students with the most severe disabilities in Swedish school settings. The study employed a convergent mixed methods design, where both quantitative and qualitative data were collected and analysed in parallel and then integrated and compared in the discussion and conclusion section of the paper. The study's respondents consisted of school staff who worked with students with severe or profound intellectual and multiple disabilities (S/PIMD) in Swedish schools. Results showed that almost all staff reported using AAC with students at least half of the time. The frequency of AAC use did not seem to differ between staff with different educational backgrounds, apart from teachers/special educators appearing slightly more inclined to use AAC in planned classroom activities when compared to staff with other educational backgrounds. The results also corroborate previous research stating that collaboration between stakeholders (such as school, family and the habilitation services) is fundamental to successful AAC implementation but that there are challenges when establishing efficient collaborations between stakeholders.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1476578
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1476578
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1111/1471-3802.12742
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 14
        StartPage: 500
    Subjects:
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: School Personnel
        Type: general
      – SubjectFull: Attitudes
        Type: general
      – SubjectFull: Augmentative and Alternative Communication
        Type: general
      – SubjectFull: Severe Disabilities
        Type: general
      – SubjectFull: Students with Disabilities
        Type: general
      – SubjectFull: Severe Intellectual Disability
        Type: general
      – SubjectFull: Multiple Disabilities
        Type: general
      – SubjectFull: Incidence
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      – SubjectFull: Educational Attainment
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      – SubjectFull: Cooperation
        Type: general
      – SubjectFull: Stakeholders
        Type: general
      – SubjectFull: Sweden
        Type: general
    Titles:
      – TitleFull: School Staff Perspectives on Using Augmentative and Alternative Communication with Students with Severe or Profound Intellectual and Multiple Disabilities
        Type: main
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            – D: 01
              M: 07
              Type: published
              Y: 2025
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            – Type: issn-electronic
              Value: 1471-3802
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            – TitleFull: Journal of Research in Special Educational Needs
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