Seven years ago I wrote about and created a new prompt hierarchy, designed for use with those who have apraxia.  Soon after Shelane Neilsen collaborated with me to create a visually more appealing Adapted Prompt Hierarchy. Quickly translations began appearing, at first with or Shelane's my consultation and, eventually, without it.  Eventually new versions appeared, usually copying my premise, and often times my exact language, sometimes with credit or consultation and most times not.  Sometimes these were sold by others.  They are making money off of work I have deliberately only offered for free.  Work I've only offered for free because it is so vital to what we do as AAC caregivers and practitioners. 

The Adapted Prompt Hierarchy came into being because of my experiences observing a traditional, ABA based hierarchy used with AAC learners.  Those prompt hierarchies always started with an adult who had something specific that they thought the user should say.  It was assumed the adult was always correct in their choice of what should be said and no other response was acceptable.  As a means to that end the prompts had the end goal of encouraging, and if that didn't work, forcing the individual to say what they adult wanted them to say.  Such procedures ignored the humanity and human rights of the AAC user to be in charge of if, when and what they communicate.  These procedures, especially physical prompting, could create learned helplessness.  Furthermore, AAC users are taught that the AAC system doesn't belong to them, it is merely a tool that someone else is in charge of, that they can be pressured or forced to use to say anything someone else wants, regardless of their desires.  This may make the AAC system aversive, which will limit the success of it's use.

One of the frequent things we see in the field of AAC is a struggle to determine how many buttons per page to start with on a new AAC system.  Though there is a myth that one should start small and have a very limited system at first this is no longer best practice, best practice is to consider the users ability to  "Perceive and Access" the buttons on the system.

Perceive and Access
Start with as many buttons, the maximum, the user can perceive and access (often times called "see and touch", a brilliant approach from the folks at AssistiveWare, but perceive and access is more accurate as it includes visual needs, fine and gross motor needs, memory and working memory needs, alternative access and more).

This means determining the skills needed to perceive the buttons including vision and visual scanning for most users, but also memory and working memory (especially for those using indirect selection like switches) and hearing for those using auditory supports for access.  

As perception issues are considered, access is also considered.  How will the individual make selections?  Will they use direct selection like their finger, a stylus, a joy stick, eye gaze or head tracking? Will they use switches?  What supports will be used for the selection method? Do they need the button they are about to select to enlarge or change color? Do they need an auditory preview or auditory scanning? If switch scanning will be used how many options are they able to recall during a scan?  Can they do row/column or group/item scanning? Are they able to use their cognition and executive function to make selections while they hold their whole message in their head? Overall, how many buttons per page can they access - remembering that less is not necessarily easier! Less buttons per page means more navigation.  More navigation increases the need for executive function skills, working memory, attention span and patience of both the user and communication partner.

(One place to start is watching the individual use other technology or do other activities.  Can they navigate YouTube? Find the X to close the video? Visually scan over selections and make a choice? Yes? Then chances are you can go pretty small with the buttons, which means more buttons per page.)

When you base the size of the system on what they can perceive and access you meet visual and fine motor needs because you chose based on criteria that includes what can be seen and what can be selected.  Once all these factors have been considered and tried a decision should be made to use as many buttons as they can perceive and access WITHOUT considering if they know the words and symbols on the buttons, if they can combine words or anything else beyond perception and access.  They will learn the symbols, words and the system as a whole because we will teach it to them.

​Like all children the AAC user must be exposed to exponentially more words than they can currently "say" as they learn to communicate.  In the case of AAC this is done using aided language input (aka modeling). They need words to prove they can use words.  This is important to understand as the old belief was that they have to prove they can use words to get more words added to their communication system.  That myth's time has passed.  You also need words to model. You can’t model what’s not there! We might hide/mask words, use "progressive language" features or similar during learning activities (though I don't), so that we can have a smaller number of words during the activity, but then return the system to full access. Using these features ensures the buttons stay in the same location as buttons per page changes and a new motor plan doesn't have to be learned for each increase. 

There are some other things to think about when you decide to give a user a limited number of buttons per page:

• you limit the language they can use and since language is about connection there is less to use to connect with others which minimizes motivation
• you are attempting to mind read to know what they might need and since no one can mind read you will be wrong
• you make assumptions about their ability and, worse, others seeing the limited vocabulary start to perceive the user as unable to use more language and doubt their cognitive abilities, stigmatizing them
• you cause them to need to learn a new motor plan everytime you increase the grid size, limiting progress
• you make words transactional as the student must earn the right to have words
• “proving ability” becomes next to impossible since you need words to prove you can use words
• you are allowing the needs of the caregivers/stakeholders to outweigh the needs of the user as often concerns about "too many buttons" are based on the erroneous idea that if the stakeholder is overwhelmed then the user must be

​Remember, when you choose how many words someone "deserves" you are choosing the size of their world.  Choose carefully!