Evidence-based AAC Interventions for Infants,

Toddlers, and Preschoolers

Janice Light and Kathryn DragerPenn State University

Seminar presented at ASHA 2007, Boston

The Penn State Team• Emily Angert• Julia Birmingham• Jacky Cammiso• Jen Curran• Elizabeth Hayes• Melissa Ihrig• Lauren Karg• Line Kristiansen• Wendy Lewis• Ashley Marzzacco

• Jen May • Holly May• Ashley Maurer• Rebecca Page• Elizabeth Panek• Sarah Pendergast• Kate Shapiro• Nicole Sherman• Kristin Stoltzfus• Melissa Witte

The challenge

• How do we provide access to the magic and the power of language and communication for young children with complex communication needs who require AAC?

What did I learn watching my kids learn language?

• Young children– Start learning communication & language at birth– Learn language during daily activities in their

environment, especially play– Learn language in the context of social interactions with

familiar partners– Communicate not just to express needs and wants, but

also to build social closeness and share information• Social interactions are prime times to build language

– Depend on context to learn language• “First words” are context-bound

What did I learn watching my kids learn language?

• Young children– Receive scaffolding support from their parents to help

them learn language• Parents provide opportunities for communication & language

learning• Parents adjust language input to children’s understanding• Parents respond to children’s communicative attempts

– Receive 100,000s of models of language use • Parents say words to children before they “know” the words

– Learn language rapidly– Have fun learning language

Principles to guide AAC intervention with young children

• Start as early as possible– Intervene with infants, toddlers, preschoolers who are at

risk• Intervene in natural environment during daily

activities– Maximize functionality, familiarity, meaningfulness

• Focus on sustained social interactions with familiar partners– NOT just expressing needs and wants, – but also building social closeness & sharing information

in sustained social interactions

Principles to guide AAC intervention with young children

• Provide contextual support to help children learn language – Use context to support comprehension & expression– Infuse familiar experiences /contexts into AAC systems

• Show parents how to provide appropriate scaffolding support– Provide frequent opportunities for communication– Provide appropriate language input– Respond to child’s communicative attempts

Principles to guide AAC intervention with young children

• Provide models of AAC & speech– Use AAC & speech when talking to child

• Sign & speech• Aided AAC & speech

– Expand on child’s messages using AAC & speech

• Ensure that AAC systems are dynamic– Support language learning– Regularly introduce/ add new concepts for child– Model their use

Principles to guide AAC intervention with young children

• Ensure that intervention is FUN!!– Integrate communication & play– Enhance motivation of child and family– Ensure that AAC systems are appealing and

fun!– Ensure that AAC systems are easy to learn and

use!

Goals of the presentation• Share the results of a research study that

developed, implemented, & evaluated the effects of AAC interventions on the language and communication skills of young children with complex communication needs– Multiple baseline across participants

• Share case examples to illustrate AAC intervention and outcomes

AAC-RERC

• Project is part of the AAC-RERC II– Collaborative virtual research center funded by

the National Institute on Disability and Rehabilitation Research

– Grant #H133E030018 (2003-2008)• For more information

– http://www.aac-rerc.com to access the webcast or

– Janice Light JCL4@psu.edu

Participants• Single subject multiple baseline design• 9 participants to date

– 6-40 months old upon referral– Significant communication disabilities– All nonsymbolic or minimally symbolic at baseline

• 0-25 symbols expressively

• Evaluated impact of AAC intervention– Collected longitudinal data to track language

development• Pragmatic, semantic, syntactic development

Goals of AAC Interventions• The overall goal is to build social interaction

between young children & familiar partners• Maximize child’s functional communication • Enhance child’s language development

– Increase participation /turn taking– Express range of communicative functions– Develop breadth of semantic concepts– Build greater complexity of language structure to

support more complex communication– Build phonological awareness skills /foundations

for literacy development

AAC Interventions

• Scheduled for 1 hour per week• In natural environment

– Typically at home – Sometimes at preschool

• Within play and other activities of daily living

• Involved parents and other primary facilitators

Departure from typical AAC intervention

• Focus on sustained social interaction– Don’t just focus on needs and wants

• Redesign AAC to better meet young child’s needs and skills– Provide contextual support to support language

learning• Encourage language learning through AAC

– Don’t require language learning prior to AAC

Components of effective evidence- based AAC intervention

1. Identify meaningful social contexts for communication

2. Develop appropriate AAC systems for the child3. Set up the environment to support social

interaction4. Use appropriate strategies to support child’s

communication• Meaningful opportunities for communication• Appropriate supports to ensure successful

communication

Case #1 AAC intervention with infants - Initial intervention

• Goals– To increase active participation in social

interactions with familiar adults– To increase communicative turns /social bids– To introduce range of communication purposes

Identify meaningful contexts for social interaction

• Meet with parents; observe child• Select contexts that are

– Interactive • Rich in opportunities for participation

– Reciprocal– Easy to sustain over multiple turns– Motivating to the child– Meaningful / familiar for the parents and child– Frequently occurring– Valued by the family– Fun!!

Identify meaningful contexts for social interaction

• Focus on contexts that provide – Sustained social interaction

• Offer multiple opportunities for participation /communication

– Not just expression of needs and wants• Single opportunity for communication e.g., snack

• Initially choose contexts that – Involve only the infant and the partner (and AAC)

• Minimize the joint attention demands

– Have predictable structure

Identify meaningful contexts for social interaction

• Social games – E.g., Peek-a-boo, So Big

• Songs (line by line)– E.g., Itsy Bitsy Spider

• Musical instruments & toys– E.g., Winnie the Pooh, crib toy / mobile

• Books – E.g., Brown Bear, Who’s hiding?, Baby Faces

Develop appropriate AAC systems

• Communication is multimodal• Identify modes that are used currently by child

• Vocalizations• Facial expressions

• Introduce additional modes to augment /enhance communication

• Signs• Light tech symbols• Speech generating device (SGD)

Introducing AAC to parents• AAC intervention results in significant gains in

– Functional communication– Language development

• Will AAC inhibit speech development? • Meta-analysis (Millar, Light & Schlosser, 2006)

– 0% demonstrated decreases in speech production– 11% showed no change– 89% demonstrated gains in speech

• Gains observed were modest ones +20 spoken words or less– Ceiling effects in many cases

– AAC does NOT inhibit speech development

Develop appropriate aided AAC systems

• AAC systems should– Be fun– Be easy for infants to understand and use– Be dynamic

AAC systems should be fun (from Light, Drager, & Nemser, 2004; Light, Curran, Page, & Pitkin, in press)

• AAC systems should appeal to infant– Multiple bright primary colors– Familiar motivating content

• Preferred people and activities

– Fun interactive play activities– Engaging characters

• Expressive faces

– Engaging speech output, songs, musical instruments, sound effects, laughter

– Child’s preferences

AAC systems should be easy to use• AAC systems should be easy for infants to

understand & use– Use touch screen for selection if possible

• Immediate cause and effect / direct relationship• Selection upon activation not release

– Provide scaffolding support to assist with navigation• Set up menus / arrows for future navigation• Model use, but do not require use

– Use visual contextual scene displays to provide meaningful interactive contexts to promote social interaction

Traditional grid layout• Vocabulary represented by separate AAC

symbols in “boxes”– Language is taken out of context– “Decontextualized”

• Concepts are presented separately– Visual-spatial relationships are not preserved– Contextual relationships are not preserved

• Imposes greater cognitive /linguistic demands

Visual scene display layout

• “Graphic metaphor” (Shane, 1998)

• Vocabulary embedded under “hot spot” in visual scene display (VSD)– Digital photo of child’s experiences– Scanned image of familiar book

• Vocabulary presented in meaningful context– Concepts related visually and conceptually as in

life

Develop appropriate VSDs

• Develop visual contextual scene displays that represent the selected interactive contexts to expand the child’s communication– VSDs are designed to provide a high level of contextual support – VSDs provide a context to support the communication of young

children and their partners• VSDs can be implemented

– On dynamic display speech generating devices (SGDs)– As low tech systems

• Choose appropriate representations for VSDs• E.g., digital photos, scanned images

What makes a “good” VSD?

• Visual scene displays for young children should– Be meaningful and relevant– Represent motivating contexts /activities– Portray interactive social experiences– Provide a rich context for communication– Reflect the child’s perspective on the event /experience– Reflect the child’s conceptual development

/understanding– Be appealing

Develop appropriate VSDs• Adapt VSD as required to accommodate

– Visual skills • Reduce complexity for very young children,• Remove background to increase contrast for

children with visual impairments– Motor skills

• Number of hotspots• Size of hotspots

– Cognitive/ Language skills • Amount of vocabulary • Type of vocabulary provided

Select appropriate vocabulary • For each interactive context, select appropriate vocabulary

to expand the child’s communication• Individualized• Motivating / fun • Functional• Developmentally appropriate

• Kids should sound like kids!• Culturally appropriate • Supportive of language learning

• Include a range of developmentally appropriate & functional concepts• people, actions, objects, places, social words, relational concepts,

questions, etc.• Support participation in social interaction not just expressing wants

• Young children can only learn language if we provide access

Select appropriate vocabulary• Identify appropriate “hot spots” in the VSD for

vocabulary related to the context– Be sure hot spots are an appropriate size

• accommodate child’s motor & sensory perceptual skills– Consider child’s language and cognitive development

when adding vocabulary• Initially beginning communicators may only have a single

hotspot in a VSD• Gradually add more hotspots / vocabulary concepts

– Observe child’s interests in VSD• If child selects same area of the VSD, add vocabulary to this

area of interest to reflect the child’s intent / meaning

Develop appropriate VSDs

• VSDs can be very simple or more complex depending on the needs and skills of the child – Single image with a single hotspot– Single image with a few hotspots– Single or multiple images with multiple hotspots– Hybrid displays including a visual scene as well as

additional vocabulary items organized outside the scene in a grid

– Traditional grid displays with symbols displayed in rows and columns

Introduce appropriate AAC systems

• Light tech symbols– Meaningful & appealing representations of

concepts• Digital photos, scanned images, color line drawings• Covered in contact paper & backed with Velcro• Taught in meaningful contexts; paired with the

referents

AAC systems should be dynamic

• AAC systems should be dynamic– Start with systems that provide potential access

to 1,000 of concepts• Do not let AAC systems limit language

development

– Gradually build language

AAC systems should be dynamic

• Young children experience qualitative & quantitative changes in development

• AAC systems must reflect these changes– Introduce new activities regularly

• Respond to child’s preferences – Introduce new concepts regularly

• ***Provide access to range of language concepts• Model their use in meaningful contexts• Don’t wait for child to “prove” comprehension

– Introduce more hotspots as motor skills develop• Embed more language

Set up the environment to support social interaction

• Ensure appropriate positioning to maximize attention and participation – Accommodate motor skills & cognitive skills

• Minimize joint attention demands and maximize the child’s attention to partner and AAC system– Sit directly in front of the child at eye level– Hold the AAC system directly in front of the child, just

below the partner’s face

Use appropriate strategies to support child’s communication

• Have FUN!!• Engage in social interaction using

appropriate strategies to ensure• Meaningful opportunities for communication• Appropriate supports to ensure successful

communication

Initiate the context / identify opportunities for communication

• Initiate the interactive context / start the activity• Locate the appropriate display for the child

– Initially do not expect the child to navigate independently

– As the child develops competence, model navigation to the appropriate display

• Identify numerous opportunities for the child to participate within the context– Initially context may be repetitive– As child develops competence, build in numerous

varied opportunities for interaction

Mark opportunities for child to communicate

• Clearly mark each opportunity for the child to communicate

• Use expectant delay• Focus attention on child; maintain eye contact• Use expectant body posture• Wait and allow the child time to communicate

Respond to the child

• If the child attempts to communicate, respond immediately

• Fulfill the intent • Repeat or expand on the child’s message

• Model AAC + speech• Continue the activity

• Continue to provide meaningful opportunities for child to communicate

• Repeat over successive turns • Introduce new context as required

• Watch for loss of interest

• If the child does not attempt to communicate, • Model an appropriate turn

• use AAC + speech• Use a third party model to demonstrate if

available• Parent, sibling, or aide demonstrates for the child

what to do• Present the opportunity again

Model AAC + speech• When talking to child, always model AAC

• Speech + sign/ gestures• Speech + aided symbols• Speech + SGD

• Model AAC use to• Support child’s comprehension• Show the child how to communicate• Provide opportunities for child to learn new language

concepts & new structures• Make note of gaps in available vocabulary; add

required concepts

Work with parents to enhance participation

• Identify opportunities for communication• Infuse into familiar, meaningful, motivating, social activities• Opportunities to sustain social interaction

• Model use of AAC plus speech• Demonstrate how to use AAC to communicate

• Provide scaffolding support in AAC use• Locate appropriate light tech symbols to offer choices• Help locate appropriate pages in VOCA

• Recognize and respond to child’s communicative attempts • Fulfill communicative intent• Expand and model more complex messages using aided AAC

• Have fun!

Intervention Stage 2 Developing semantic concepts

• Goals– To continue active involvement in social

interactions with familiar adults– To expand expressive vocabulary to

communicate more diverse meaning– To teach questions gradually to provide control

over vocabulary acquisition /language learning

Work with parents• Continue to

– Set up numerous opportunities for communication – Recognize and respond to child’s communicative

attempts • Model use of aided AAC

– Model known concepts as well as new ones– Expand on child’s messages

• Teach new concepts– Link new symbol to the concept directly– Demonstrate concept– Model use

• Provide scaffolding support in AAC use– Help locate appropriate pages in VOCA as

required– Teach organizational system

• Organize vocabulary according to meaningful events

• Use appropriate menu symbols

Intervention - Stage 3 Learning syntax and morphology• Goals

– To continue active involvement in social interactions with familiar adults

– To take turns with peers with adult scaffolding– To continue to expand expressive vocabulary

• e.g., question words, etc• Read, read, read

– To encourage communication of more complex, novel meanings by combining symbols

– To introduce early morphological structures to specify meaning

Developing the foundations for social interactions with peers

• Important to develop the foundations for peer interactions– opportunities to develop friendships– “testing ground” for communication skills

• Develop repertoire of activities as contexts for interactions with peers – books– songs– games– play activities

Learning the form of language

• Begin to introduce more complex forms of language

• Model AAC + speech– Build up sentences– Break down sentences– Use message bar with VOCA to provide visual

/auditory feedback• Teach in context; demonstrate appropriate use

– Explain rules as appropriate• Expect use only in contexts where obligated

– E.g., “writing” activities / publishing books

• Gradually introduce expression of morphology/ syntax– e.g., present progressive, plurals, past tense,

auxiliary• Challenges

– How do we represent grammatical parts of speech?

Intervention Stage 4 Phonological awareness / literacy• Goal

– To continue active involvement in social interactions with familiar adults

– To interact socially with peers– To continue to expand expressive vocabulary – To continue to develop syntax and morphology – To teach phonological awareness skills and

literacy skills

• AAC systems– Introduction of alphabet board – light tech– Access to alphabet on high tech system

• Speech output letter sounds not names

• Introduction to literacy curriculum– Letter-sound correspondences– Phonological awareness skills

• Sound blending• Initial phoneme segmentation

– Early decoding & shared reading– Early writing activities

Ongoing literacy instruction

• Ongoing reading of books, talking about stories

• Teaching reading skills • Decoding of more complex words• Sight word recognition skills• Reading simple stories• Building comprehension

• Teaching writing skills• Writing stories

Summary of results to date

• All children have demonstrated significant increases in their rate of turn taking– All children sustain interactions with others for

significantly longer

• All children participate in interactions that involve – Social routines– Play activities– Not just expression of needs and wants

• Children use their AAC systems independently for play & learning as well

• Children use their systems as contexts to interact with peers– Shared books– Shared singing– Play

• All children have demonstrated significant increases in their expressive vocabularies

• All children have acquired a range of semantic concepts

• Children are combining concepts to communicate more complex meanings

• All children have been able to use VSDs on initial introduction once use is modeled– seem to be more interested & motivated when

scene displays are used to integrate AAC & play, book reading, music

• Children have learned to use other displays – Hybrid displays– Grid displays

• All children started with adult scaffolding support to find appropriate pages in aided systems– Children have learned some navigational tools

• Menu• Forward and back arrows to change pages

– Some children navigate independently • Some children are developing phonological

awareness and literacy skills

• Early AAC intervention supports language development and communication – Increase participation and build social

interaction– Develop breadth of semantic concepts

/vocabulary to support more diverse communication & conceptual development

– Build greater complexity of language structure to support more complex communication

– Build phonological awareness skills and foundations for literacy development

The art and science of AAC intervention

• The science of AAC intervention– Implementation of evidence-based intervention

procedures• Research is available to guide in planning and

implementing AAC intervention with young children

– Monitoring effectiveness with individual child– Evaluating outcomes

The art of AAC interventionThe belief and the commitment to the right of

all individuals to express themselves fully and seek their full potential

For further information, Visit www.aac-rerc.com for the webcast on young

children who require AAC or E-mail JCL4@psu.edu

This research is part of the AAC-RERC II and is funded by the National Institute on Disability and Rehabilitation

Research of the U.S. Department of Education, under grant # H133E030018 (2003-2008). The opinions contained in this presentation are those of the grantee and do not necessarily

reflect those of the U.S. Department of Education.