Accessible literature and Augmentative and Alternative Communication: specialist evaluation of a multiformat bookAbstract
Introduction Children with complex communication needs (CCN) often face barriers to participating in shared reading activities. Accessible books with Augmentative and Alternative Communication (AAC) resources can enhance their engagement and language development.
Objective To evaluate the perceptions of AAC specialists regarding a prototype of a multiformat book developed for children with CCN.
Methodology This descriptive, exploratory, mixed-methods study involved 57 specialists in speech-language pathology, occupational therapy, and education. Participants completed an online questionnaire containing items assessed using a 5-point unipolar Likert scale, as well as open-ended questions. Quantitative data were analyzed using descriptive statistics, Student’s T-test, and Pearson’s correlation. Qualitative analysis followed thematic categorization of responses.
Results The material was widely accepted, with mean scores ranging from 4.71 to 4.92 for the evaluated items, particularly narrative clarity, functionality of communication boards, and symbol-text correspondence. Qualitative findings identified textual clarity, child engagement, and participation as central themes. Approximately half of the specialists suggested visual adjustments and increased diversity in characters. The convergence between quantitative and qualitative findings reinforces the book’s potential as a functional and inclusive resource, highlighting the role of occupational therapy and expertise in assistive technology in developing accessible narratives contextualized to children’s daily lives.
Conclusion The multiformat book emerges as an innovative and accessible resource, fostering participation, inclusion, and language development for children with CCN, and stands out for its integration of theory and practice in AAC.
Keywords:
Occupational Therapy; Communication Devices for People with Disabilities; Social Inclusion; Juvenile Literature; Education; Special
Resumo
Introdução Crianças com necessidades complexas de comunicação (NCC) frequentemente encontram barreiras para participar de atividades de leitura compartilhada. Livros acessíveis com recursos de Comunicação Aumentativa e Alternativa (CAA) podem favorecer seu engajamento e o desenvolvimento da linguagem.
Objetivo Avaliar a percepção de profissionais especialistas em CAA sobre um protótipo de livro multiformato desenvolvido para crianças com NCC.
Metodologia Estudo descritivo, exploratório e quali-quanti, com participação de 57 especialistas em fonoaudiologia, terapia ocupacional e educação. Os participantes responderam a um formulário eletrônico contendo questões avaliadas por meio de escala Likert unipolar de 5 pontos e perguntas abertas. Os dados quantitativos foram analisados por estatísticas descritivas, teste t de Student e correlação de Pearson. A análise qualitativa foi realizada com categorização temática dos comentários.
Resultados O material foi amplamente aceito, com médias entre 4,71 e 4,92 nos itens avaliados, especialmente em clareza narrativa, funcionalidade das pranchas e correspondência símbolo-texto. A análise qualitativa identificou como temas centrais a clareza textual, o engajamento e a participação da criança. Aproximadamente metade dos especialistas sugeriu ajustes visuais e ampliação da diversidade nos personagens. A convergência entre achados quantitativos e qualitativos reforça o potencial do livro como recurso funcional e inclusivo, destacando o papel da terapia ocupacional e do conhecimento em tecnologia assistiva para a elaboração de narrativas acessíveis e contextualizadas ao cotidiano infantil.
Conclusão O livro multiformato apresenta-se como recurso inovador e acessível, favorecendo participação, inclusão e ampliação da linguagem para crianças com NCC, e destaca-se pela articulação entre teoria e prática em CAA.
Palavras-chave:
Terapia Ocupacional; Sistemas de Comunicação Alternativos e Aumentativos; Acessibilidade Comunicacional; Literatura Infantil; Educação Inclusiva
Introduction
Shared reading is widely recognized as an essential practice for the development of children’s oral and written language, including those with complex communication needs (CCN). For these children, limitations in verbal communication require specific Augmentative and Alternative Communication (AAC) resources — such as symbol boards, speech-generating devices, and other visual supports — to foster participation and expression (Murphy et al., 2022; Light & McNaughton, 2014; Fonte et al., 2010).
In educational and therapeutic contexts, adapted and accessible books have proven promising in expanding possibilities for engagement and learning. Multiformat books, in particular, bring together visual, auditory, and tactile elements, providing more inclusive reading experiences. Such books may combine simplified text, pictographic symbols, braille, audiobooks, sign language versions, and accessible illustrations, in addition to interactive resources that support different sensory and communicative profiles (Pinto & Pelosi, 2020). In this sense, consideration of diverse sensory profiles is fundamental for the functional engagement of children with ASD and other conditions, as highlighted by Silva et al. (2024), who relate differences in sensory processing to participation in reading activities.
In the field of occupational therapy, communication is understood as a fundamental occupational domain for active participation in everyday contexts, such as play, learning, socializing, and building relationships (American Occupational Therapy Association, 2020). The occupational therapist assumes a strategic role as a communication manager, articulating clinical knowledge, mastery of assistive technology, and sensitivity to adapt materials to the child’s repertoire, interests, and needs. This role is central to selecting, adapting, and implementing AAC resources that promote not only expression but also autonomy, inclusion, and child protagonism.
Familiar themes such as the routine of Activities of Daily Living (ADLs), which comprise routine actions of body care, feeding, hygiene, dressing, bathing, toileting, and mobility (American Occupational Therapy Association, 2020), have the potential to be better understood in inclusive text narratives that seek the child’s active participation (Yorke et al., 2018). The international literature describes advances in the personalization of materials, such as printed boards, interactive e-books, and voice-supported software, highlighting the importance of integrating contextualized vocabulary into reading (Bhana et al., 2020; Johnston et al., 2018; Sennott et al., 2016; Caron et al., 2020). However, studies that evaluate the integration of communication boards directly into the pages of physical books as a permanent and structuring part of the narrative are still rare — an innovation present in the book “O Dia Mágico do Pipo” (Pelosi & Sousa, 2025a).
In addition, adult participation as a mediator is recognized as decisive for the child to interact with the story and intentionally use AAC resources (Yorke et al., 2018).
The book “O Dia Mágico do Pipo” was developed based on these principles. It is a multiformat children’s book that combines visual, textual, and symbolic accessibility and was carefully structured for children with complex communication needs. Six principles guided its development: (1) simple writing, with short sentences and high-frequency vocabulary; (2) written text with pictographic symbols; (3) enlarged font in uppercase letters; (4) images with accessible design; (5) a communication board integrated into each page; (6) a QR Code with an e-book for training communication partners and guidance on modeling strategies, graduated support, and vocabulary expansion (Pelosi & Sousa, 2025b). These principles align with occupational therapy recommendations aimed at adapting accessible materials that simultaneously consider communicative, sensory, and contextual aspects of children’s participation (Manzini et al., 2021).
In this context, material customization — such as the selection of functional vocabulary per page, the use of symbols relevant to the narrative, and visual adaptation — became central to ensuring effectiveness in mediation, engagement, and the child’s participation during reading.
At the time of evaluation by specialists, the book prototype was already completed, allowing analyses to focus on the practical application and functionality of each accessible resource. This stage was crucial to ensure that the work met the communicative and sensory demands of children with CCN before its implementation in educational and therapeutic contexts. The experience of occupational therapy was decisive in this process, as it involved the analysis of physical, cognitive, and sensory barriers, as well as the meticulous adaptation of layouts and communication boards, ensuring an inclusive design aligned with children’s daily lives. As discussed by Manzini et al. (2021), the occupational therapy perspective contributes to aligning technical aspects of accessibility with communicative functionality in real contexts of use.
This specialized knowledge, combined with AAC strategies, gave the prototype greater potential for real-world use, justifying the importance of its formal evaluation at this stage of the project.
Thus, this study is situated in the specialist evaluation stage, an intermediate phase between prototype construction and future testing with children and families. At this stage, the aim is to ensure the technical and conceptual quality of the material, identifying fine adjustments that ensure clarity, relevance, and usability before practical application. The presence of experienced evaluators helps strengthen content validity and increases the chances of positive impact when the book is used in clinical and educational contexts, as recommended by methodologies for the development of instruments and accessible materials (Pasquali, 2010; Vieira & Bressan, 2022).
Given the scarcity of studies that evaluate accessible materials from the perspective of specialists in Augmentative and Alternative Communication, this study aimed to analyze these professionals’ perceptions of the multiformat book prototype “O Dia Mágico do Pipo”, focusing on its adequacy, functionality, and potential to promote engagement, language expansion, and inclusion.
Methodology
The present study corresponds to the third stage of a broader investigation into the production, validation, and evaluation of a multiformat children’s book aimed at children with complex communication needs (CCN).
This is an exploratory, descriptive study with a qualitative-quantitative approach, conducted through an electronic form developed using Google Forms. The instrument consisted of 28 questions, 21 of which were objective in nature and evaluated using a 5-point unipolar Likert scale. This type of scale measures different intensities of the same type of response, ranging from absence to the maximum level of the attribute evaluated. In the present study, 1 represented “strongly disagree” (total absence of agreement) and 5 represented “strongly agree” (maximum agreement), with point 3 being neutral.
The choice of a unipolar scale is related to the need to measure the intensity of agreement along a continuum, without opposing poles. This model allows data to be interpreted parametrically, justifying the calculation of means, comparison tests, and correlations between variables, as adopted in this study. In addition, the unipolar Likert scale is widely used in research evaluating instruments and educational or clinical materials, precisely because it offers greater sensitivity to variations in agreement (Pasquali, 2010; Vieira & Bressan, 2022).
This configuration allowed the score to be interpreted as a continuum of agreement, without opposing poles, enabling the calculation of means and the application of parametric tests, in accordance with common practice in AAC research (Norman, 2010; Carifio & Perla, 2008).
The questions were distributed across five thematic axes: (1) clarity and simplicity of the narrative; (2) adequacy and consistency of the text with the pictographic symbols; (3) quality of the accessible design of the images; (4) relevance and functionality of the communication boards; (5) effectiveness of modeling strategies, graduated support, and vocabulary expansion. In addition, seven open-ended questions allowed the recording of opinions, compliments, and suggestions.
The study was approved by the Ethics Committee under number CAAE: 1 87061625.3.0000.5257.
Participants were invited individually through messages sent via WhatsApp to the official group of the International Society for Augmentative and Alternative Communication – Brazil Chapter (ISAAC-Brasil) (Associação Internacional para a Comunicação Aumentativa e Alternativa, 2025) for the year 2025, as well as by email, using the public email addresses available on the list of members published on the institution’s website. The invitation included the Informed Consent Form (ICF), a presentation of the material to be evaluated with full access to the work and the complementary e-book, as well as the link to complete the electronic form.
Professionals belonging to discussion groups on clinical cases involving children who use AAC were also invited to participate in the research. The inclusion criteria for participation were: having professional experience in the AAC field and consenting to the terms of the ICF. Professionals with less than one year of experience in the field and family members of AAC users were excluded, as these groups will be the focus of future stages of the investigation.
Responses were collected between April and May 2025. In total, 130 invitations were sent to specialists with experience in the field of Augmentative and Alternative Communication, considering the 113 members publicly listed on the ISAAC-Brasil website during the data collection period and other professionals who participated in clinical discussion groups involving children who use AAC. Of this total, 57 professionals completed the questionnaire in full, resulting in a response rate of 43.8%, considered satisfactory for research with this profile. It was necessary to send a second reminder message, both via WhatsApp and email, to encourage participation.
Evaluations were recorded anonymously in a Google Sheets spreadsheet automatically linked to the form. As a means of sample control and validation, participants were asked to provide the first four digits of their CPF, ensuring traceability without compromising the confidentiality of responses.
Quantitative analysis was performed using SPSS (Statistical Package for the Social Sciences), with calculation of means, standard deviations, and minimum and maximum values for each Likert scale item. For inferential analysis, the scale was considered interval, justifying the use of the Student’s t-test to compare means between occupational therapists and speech-language pathologists, and Pearson’s correlation coefficient to verify associations between the evaluated variables, adopting a significance level of p < 0.05.
Open-ended responses were analyzed based on Bardin’s (2020) proposal, following the stages of global reading, coding, categorization, and interpretation of meanings. For the qualitative analysis, the set of respondents who provided at least one open comment was considered (N = 47). Comments were grouped according to the five categories evaluated in the Likert scale (narrative clarity, text with symbols, symbol–text correspondence, accessible image design, overall impression/communication board) and classified into emerging subcategories according to the frequency and recurrence of themes. For each subcategory, the absolute number of respondents who mentioned a given theme and the respective percentage in relation to the total number of participants with open comments were calculated, in accordance with rigor recommendations for qualitative–quantitative analysis (Bardin, 2020). Representative examples were selected to illustrate the main qualitative findings.
Data triangulation involved the systematic comparison between quantitative results from the Likert scales and the emerging themes from open-ended responses, seeking convergence and complementarity between the different methodological approaches.
Results
This study adopted a mixed-methods (qualitative-quantitative) approach, integrating statistical analysis of objective data (Likert scale) with qualitative analysis of open-ended responses. The results are presented sequentially, highlighting the main quantitative (Tables 1 to 3) and qualitative (Table 4) findings, as well as the convergence between findings (Table 5).
Comparison between occupational therapists and speech-language pathologists (Student's t-test).
Most recurring themes in the open-ended responses of the experts (N=47), percentages, and examples of comments.
Characterization of the participants
Fifty-seven specialists participated in the research, with 59.6% being speech-language pathologists, 22.8% occupational therapists, and 17.6% other professionals (pedagogues, psychologists, designers, physiotherapists, and educators). Regarding professional experience, 71.9% had more than five years of experience in the field of AAC, and, among these, approximately 45.6%, about 33% of the total sample, had more than ten years of experience, indicating a highly specialized profile. The participants worked in various regions of Brazil, in public, private, and third-sector institutions.
The quantitative results of the evaluations carried out by the specialists are presented below.
Quantitative analysis
The average Likert scale scores ranged from 4.71 to 4.92, as shown in Table 1. A high degree of agreement among the experts was observed, especially for "Clarity of the narrative" (M = 4.92), "Functionality of the communication boards" (M = 4.85), "Adequacy of pictographic symbols" (M = 4.82), "Vocabulary expansion" (M = 4.79), and "Accessible image design" (M = 4.71). The low standard deviations suggest consistency in the responses, highlighting a positive perception of the textual structure, graphic resources, and communicative potential of the book.
To deepen the understanding of the relationships between the different aspects evaluated, the correlations between the dimensions of the scale were analyzed, as summarized in Table 2.
Table 2 presents the Pearson correlation coefficients between the items of the Likert scales. The strong correlation between "Text with symbols" and "Accessible image design" (r = 0.62) stands out, suggesting a direct influence of visual design on textual comprehension. The significant correlation between "Symbol-text correspondence" and "Vocabulary" (r = 0.59) reinforces the role of symbols in lexical expansion. The association between "Text with symbols" and "Modeling" (r = 0.36) indicates the impact of graphic clarity on pedagogical practices during reading.
Additionally, a comparison was made between the professional groups of occupational therapists and speech-language pathologists in order to verify possible differences in perceptions regarding the evaluated items.
The comparison between occupational therapists and speech-language pathologists is presented in Table 3. No statistically significant differences were observed between the groups (p > 0.05), suggesting similar perceptions regarding the clarity of the narrative, adequacy of the symbols, image design, comprehension of the text with symbols, and overall impression of the work.
In addition to quantitative data, the analysis of open-ended responses provided a detailed insight into the experts' perceptions and suggestions, as described below.
Qualitative analysis of open-ended responses
Qualitative analysis was conducted using open-ended comments recorded by 47 experts, employing content analysis techniques. Table 4 summarizes the most recurrent themes, along with their respective percentages and representative examples from the participants' comments.
Table 4 shows that textual clarity, engagement potential, and symbol-text correspondence were the aspects most valued by the experts, reinforcing the high average quantitative results in these items. At the same time, suggestions for improvement, such as adjusting the detail of the images, greater diversity of characters, and simplification of some plates, demonstrate the evaluators' critical commitment to the quality and usability of the material. These contributions guide future improvements, indicating ways to make the book even more accessible, participatory, and aligned with clinical and educational practices in AAC.
Other positive comments, praise, clinical recommendations, and suggestions for improvement were also recorded, which reinforces the overall acceptance of the material and indicates new opportunities for visual adjustments, expansion of character diversity, and vocabulary improvement in future versions of the book. Among the practical contributions, suggestions stand out for gathering examples of modeling used by the professionals themselves to share in the complementary e-book or in short educational videos. These productions could show different ways to mediate the use of the multi-format book, such as strategies to encourage spontaneous comments, expand vocabulary during reading, adapt the narrative to different language levels, or demonstrate response modeling in everyday situations. Utilizing these ideas can enrich the support material for mediators, expanding the book's applicability in clinical, educational, and family contexts.
Convergence between quantitative and qualitative data
Finally, the convergence between quantitative and qualitative data is illustrated in Table 5, which summarizes the correspondence between the main objective results and the findings from the open-ended responses.
Discussion
The results of this study demonstrate the solid approval of the multiformat book “O Dia Mágico do Pipo” by specialists in Augmentative and Alternative Communication, highlighting its narrative clarity, potential for engagement, and the functionality of the communication boards. This positive evaluation aligns with the literature on inclusive shared reading practices for children with complex communication needs (CCN) and reinforces the importance of accessible materials to expand child protagonism and participation (Light & McNaughton, 2014; Murphy et al., 2022).
Evaluation by specialists plays an essential role in the development of accessible materials, as it allows for the careful identification of technical and functional aspects that may not be perceptible to the target audience in early testing phases. This process corresponds to a methodological stage provided for in the construction of educational materials and instruments, known as content validation. By involving specialists, it is ensured that the work presents clarity, relevance, and pertinence before being made available to the target audience. Thus, the stage in which this study is situated — after the development of the prototype and before practical application with children and families — is fundamental to ensuring scientific rigor and technical quality. As noted by Pasquali (2010) and Vieira & Bressan (2022), the participation of judges contributes to the robustness of the material, increasing its reliability and potential for positive impact in clinical and educational contexts.
In the field of Augmentative and Alternative Communication and Universal Design for Learning, consultation with experienced professionals ensures that elements such as textual clarity, vocabulary relevance, symbolic adequacy, and resource usability are analyzed based on accumulated knowledge and evidence of good practices (Baxter et al., 2015; Cook & Odom, 2013). In addition, the contribution of occupational therapists, speech-language pathologists, and educators in the stage prior to implementation allows for fine adjustments to the prototype, enhancing its effectiveness and facilitating adoption in clinical and educational contexts (Sennott et al., 2016). This approach strengthens the material’s content validity and increases the likelihood of positive impact when applied with the target audience.
In this regard, the occupational therapy literature emphasizes that the functional analysis of accessible materials should simultaneously consider communicational, cognitive, and contextual demands of use, contributing to greater alignment between technical accessibility and the child’s real participation (Manzini et al., 2021).
The role of occupational therapy as a field of knowledge gains prominence in this context, as it involves not only mastery of clinical approaches but also in-depth knowledge of assistive technology and AAC resources. The conception of the book was based on the principle that communication is a fundamental occupation — essential for playing, learning, socializing, and expressing oneself in daily life (American Occupational Therapy Association, 2020). Therefore, the development of the narrative sought to reflect everyday situations experienced by all children, valuing common experiences, functional vocabulary, and real opportunities for choice, autonomy, and interaction, as advocated by Pelosi & Sousa (2025a, 2025b, 2025c) and Pinto & Pelosi (2020).
The qualitative-quantitative method adopted in this study enhanced the understanding of specialists’ experiences, showing that technical accessibility criteria (clarity, symbol–text correspondence, functional design) and subjective elements (engagement, identification with the story) are equally relevant to the success of multiformat materials. The fact that half of the specialists suggested improvements in visual design, diversity, and options for choice reinforces the commitment to the continuous evolution of accessible resources and indicates paths for future improvement, in line with Universal Design guidelines and inclusion recommendations (Bettio et al., 2021; Inclusion Europe, 2009). These suggestions also align with studies that relate sensory processing characteristics to engagement in reading activities, indicating that visual adjustments may favor the participation of children with different sensory profiles (Silva et al., 2024).
The combination of objective measures and qualitative perceptions is particularly recommended in the evaluation of assistive technologies and accessible educational resources, as it broadens the understanding of the material’s effectiveness and acceptability, balancing measurable data with nuances of the user experience (O’Cathain et al., 2010). Images play a central role in the book, serving as a fundamental support for modeling, vocabulary expansion, and the active participation of children during reading. The visual detailing was designed to offer multiple possibilities for choice and comment construction, allowing each page to be explored through questions, spontaneous observations, or simply by telling the story based on the illustrations themselves. The complementary e-book guides adults and mediators to use the book in different ways, including promoting the narrative solely through images, further expanding forms of engagement and expression (Pelosi & Sousa, 2025b). The scenes depict everyday and familiar situations, facilitating the child’s identification and promoting connections with their experiences. Of the fifteen illustrations in the book, only two were pointed out by some evaluators as containing many elements; such suggestions were valuable and will be considered in future improvements of the material. Overall, the images contribute decisively to making the book a dynamic tool for inclusion, dialogue, and language development, enhancing both autonomy and shared participation.
The literature highlights that visual resources with accessible design not only support linguistic comprehension but also promote engagement and active participation, especially when associated with AAC modeling strategies (Bhana et al., 2020; Light & McNaughton, 2014; Baker et al., 2011).
Among the study’s limitations, the participation of professionals already involved and experienced in AAC stands out, as well as the evaluation conducted exclusively by specialists, without the direct voice of end users (children and families). For future stages, participatory studies and longitudinal evaluations involving different contexts and user profiles are recommended in order to measure the material’s real impact on children’s learning and daily lives.
In summary, this study demonstrates that multiprofessional practice, especially the occupational therapy perspective combined with knowledge of assistive technology, is fundamental to the development of creative, accessible solutions aligned with the reality of children with complex communication needs. The multiformat book contributes to expanding participation possibilities, strengthening bonds, and ensuring that every child has the right to full and meaningful communication.
Conclusion
The findings of this study show that the multi-format book "Pipo's Magical Day" was widely evaluated by experts in Augmentative and Alternative Communication, both in objective criteria — such as textual clarity, functionality of the boards, and symbol-text correspondence — and in subjective aspects, such as potential for engagement and participation. The triangulation of quantitative and qualitative data demonstrated high convergence between the high averages of the Likert scales and the themes most frequently cited in the open-ended responses.
The role of occupational therapy and knowledge in assistive technology, especially in AAC, is highlighted for the creation of truly accessible, functionally relevant, and sensitive materials for the daily lives of children. The study also highlights the importance of collaborative evaluation processes and qualified listening by professionals for the continuous improvement of inclusive practices.
It is recommended that the evaluation of the material continue with the participation of children and families, as well as research that investigates the impacts of the book in different contexts and over time, strengthening the commitment to inclusion, autonomy, and full communication for all children.
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How to cite:
Pelosi, M. B., & Sousa, C. M. A. O. A. (2026). Accessible literature and Augmentative and Alternative Communication: specialist evaluation of a multiformat book. Cadernos Brasileiros de Terapia Ocupacional, 34, e4142. https://doi.org/10.1590/2526-8910.cto419741422
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Data Availability
The data supporting the results of this study are available from the corresponding author upon request.
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Edited by
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Section editor
Profa. Dra. Ana Paula Serrata Malfitano
The data supporting the results of this study are available from the corresponding author upon request.
