Augmentative and Alternative Communication (AAC): What is it and how

can it help my child?

Children’s Hospital Colorado Lisa Nobel Martin, MA, CCC-SLP

Augmentative Communication Program Coordinator Speech Language Pathologist

AAC – What is it?

AAC involves using multiple modalities to help people communicate:

n  vocalizations, verbal approximations n  gestures, sign language n  facial expressions, eye-gaze n  postural change/tone n  tactile cue/tangible symbols, objects n  pictures (labels, photographs, Picture Communication

Symbols, Unity) n  speech generating devices (SGDs)

We all use it

n AAC is a set of tools and strategies that an individual uses to solve everyday communicative challenges.

n Everyone uses multiple forms of communication, based upon the context and our communication partner.

n The form is less important than the successful understanding of the message.

Taken from: http://www.isaac-online.org/english/what-is-aac

Communication

n Communication is the essence of human interaction and learning.

n Communication is what makes us uniquely human, all individuals have the right to communicate to their fullest potential (American Speech-Language-Hearing Association, 2005).

“If all my possessions were taken from me, I would choose to keep

the ability to communicate because with it I would win back all the

rest.” n  Daniel Webster

Who could benefit from AAC?

n Anyone with unmet communication needs n This can include children who are verbal,

minimally verbal, or non-verbal, with a variety of diagnoses (e.g., cerebral palsy, autism, Down syndrome, apraxia, traumatic brain injury).

Common Myths Regarding AAC Taken from: YAACK website –www.mrtc.org/`duffy/yaack/toc.html

Supporting Language and Communication For Individuals with Austin, Dynavox Mayer-Johnson, 2010

“AAC should be introduced only after giving up all hope of natural speech”

n  It is virtually impossible to predict the future development of

speech in a young child (Beukelman & Mirenda, 1992). n  Children with severe communication deficits who receive only

speech therapy often endure years of being without an effective means of communication.

n  A child who is not able to communicate effectively is at great risk for cognitive, social, emotional and behavioral problems (Berry, 1987; Silverman, 1980).

Common Myths Regarding AAC

“The introduction of AAC reduces motivation to work on speech”

n  The introduction of AAC correlates with the improvement of natural speech—-even in situations in which no speech therapy has been given (Berry, 1987; Daniels, 1994; Romski & Sevcik, 1993; Konstantareas, 1984; Silverman, 1980).

n  Studies have shown that even normally developing children who

are communicated with in both sign language and speech during infancy appear to begin to communicate (initially with signs) and develop spoken language at a much younger age than would otherwise have been expected (Holmes & Holmes, 1980)

Common Myths Regarding AAC

“A young child is not ready for AAC”

n  There are no known cognitive or other prerequisites that are necessary for a child to use AAC. (Kangas & Lloyd, 1988).

n  Even infants are known to engage in purposeful, communicative behavior well before the development of language. These early exchanges are very important in that they form the basis for later formal, symbolic communication (Reichle, York, & Sigafoos, 1991).

Common Myths Regarding AAC

“A child with severe cognitive deficits cannot learn to use an AAC system”

or “A child must exhibit certain specific cognitive

prerequisites before being able to learn to learn to use AAC ”

n  Children with severe cognitive deficits are capable of learning and benefiting from AAC (Beukelman & Mirenda, 1992; Romski & Sevcik, 1993; Kangas & Lloyd, 1988; Silverman, 1980).

n  It is impossible to accurately predict a child’s ability to learn AAC

Least Dangerous Assumption

n  “The criterion of least dangerous assumption holds that in the absence of conclusive data, educational decisions ought to be based on assumptions which, if incorrect, will have the least dangerous effect on the likelihood that students will be able to function independently as adults” (Donnellan, 1985)

n  www.inclusive-solutions.com/leastdangerousassumption.asp

Common Myths Regarding AAC

n As long as someone talks a communication device is not needed n  Whether speech is echolalic or just limited,

while waiting for functional speech to develop we might see (Light, Collier, & Partners, 1985; National Research Council, 2001):

n  Difficulty building social relationships n  Difficulty Acquiring Language n  Difficulty Meeting Educational Goals n  Challenging Behaviors

Common Myths Regarding AAC

n As long as someone talks a communication device is not needed n  In reality there is room for both AAC and

natural speech. When both are utilized: n  Can see increases in the use of multiple modes

of communication at the same time (Schepis, 1996)

n  AAC can be a catalyst to verbal productions

Common Myths Regarding AAC

n  Individuals who have challenging behaviors shouldn’t use high-tech AAC n  Challenging behavior is viewed as communicative

(Mirenda, 2005) n  Why? Because it has a function (Durand, 1990)

§  Escape §  Attention §  Tangible §  Sensory

n  Use of AAC can decrease challenging behaviors (Durand, 1999; Sigafoos, O’Reilly, & Lancioni, 2008; Wilkinson & Reichle, 2008)

Participation Model

n Historically, guidelines for AAC intervention were based on “candidacy” (i.e., cognitive prerequisites)

n Communication Needs Model emerged

n Now candidacy is based on the individual’s unmet communication needs, rather than a profile of impairments

Why does AAC help?

n  “Information is encoded and remembered better when it is delivered in multiple modes (verbal and pictorial), sensory modalities (auditory and visual), or media (computers and lecturers) than when delivered in only a single mode, modality, or medium. Dual codes provide richer and more varied representations that allow more memory retrieval routes (Graesser, 2008, p.2)

Why use AAC? n  Increase Expressive Language

n  To communicate n  To improve speech n  To improve grammar n  To demonstrate knowledge

n  Increase Receptive Language n  To learn n  To follow directions

n  Increase Social Skills n  To participate n  To improve behavior

AAC Tools

n No tech - do not require anything beyond the user’s body (e.g., sign language)

n  Low Tech - something external to the user that may be nonelectronic (e.g., PECS) or a simple electronic device

n High Tech – electronic devices similar to computers

Examples of levels of representations

• Objects • Photographs • Labels • Picture Communication Symbols (PCS) • Unity • Orthography

Examples of Low Tech Speech Generating Devices (SGDs)

Attainment Company

Examples of Low Tech Speech Generating Devices (SGDs)

Ablenet

Examples of Low Tech SGDs

Example of High Tech SGDs

Is the iPad the Answer for everyone?

n  No n  The limitless possibilities and ever advancing

technology of PCTs creates a scientific lag behind empirically based treatments that target communicative goals. (Alliano, Herriger, Koutsoftas, & Bartolotta, 2012).

n  Recommendations about the use of an AAC high-

tech device should flow from the evaluation and feature matching process.(McBride, 2011)

Where Do I start?

n Communicative Intent n What is the child’s understanding of visual

representations – objects, photographs, pictures?

n WARNING!!! There is a difference between teaching the meaning behind visual representation in a “show me” style versus as a means of communication. Teach visual representations as a means of communication in order to provide context.

Feature Matching: The Purpose of an AAC Evaluation

n  Portability n  Access n  Speech (digitized vs.

synthesized) n  Means of encoding language

n  Objects n  Photos n  PCS/Symbol Stix n  Unity

n  Ability to navigate n  Categorical n  Icon sequencing n  Visual scenes

n  Learning Style: n  Visual n  Auditory n  Motor

n  Language Needs (e.g. Spanish)

n  Additional Needs/Considerations: n  Computer access n  Email n  Phone n  Text messaging n  ECUs

n There is no one best AAC intervention n  key is matching your child’s individual

strengths and needs with the most appropriate type(s) of AAC

n Some children may respond best to a combination of different types of AAC

n A child communication “system” refers to multiple modes of communication (e.g., SGD, sign language, pictures, etc.).

Mobile Devices

n Pros

n Mainstream technology/ Societal norm n Attractive price point n Accessible to people quickly n Other apps: educational, entertainment,

schedules, rewards n Reduced fear factor

Mobile Devices

n Cons n Durability n Sound n Technical Support n Distraction of other apps ** n Language system ** n Access**

Assessment Process

n Use same clinical approach pre and post mobile device era

n  If iDevice is deemed to be the right platform, feature matching needs to be continued to select the appropriate application

Key to Success: Ongoing Support

n Programming n  Language Development n Communication Partner Strategies n Device Maintenance/upgrades n Support with integration of device across

environments n Family buy-in n Consistent expectations/support across

environments

Teaching AAC Strategies n  Why?

n  “Technology alone does not make a competent communicator any more than a piano makes a musician or a basketball and a hoop make an athlete.” (Beukelman & Mirenda,1998)

n  The goal of AAC should be “the most effective interactive communication possible” (Hill, 2005; On-line: www.asha.org)

n  How? n  Need to know in order to teach (i.e., take a hands-on,

exploratory approach to learn systems) n  Just use good language therapy; in normal language

development, children begin using individual words and word combinations; AAC uses the same basic rules (Hill, 2005)

Communication Partner Strategies: The Tricks of the Trade!

n  Provide increased opportunities for communication (Light, Dattilo, English, Gutierrez & Hartz, 1992)

n  Wait time/Expectant Delay (Angelo & Goldstein, 1990; Light & Binger, 1998)

n  Aided Language Stimulation (Goosens’, Crain & Elder, 1992) n  Re-casting (Lund & Light, 2003) n  Support with navigation (Light, 2005) n  Sabotage/Communication Temptations (Wetherby & Prizant,

1989) n  Peer Partners/Modeling (Buzolich & Lunger, 1995) n  Open-ended Questions (Basil, 1992; Bruno & Dribbon, 1998) n  Natural Conversation, Pragmatic Cues, Topic Cues

Parent Perspective

n  “Always building towards something. It’s all about foundation. The talker taught him receptive language, the concept of social exchange, and academics. Using the talker jump started his language and ability to engage in conversation”

§  Steve Hemelstrand, father

Questions & Discussion

References n  American Speech-Language-Hearing Association. (2005). Roles and responsibilities of speech-language pathologists with

respect to Augmentative and Alternative Communication: Position statement. Available from www.asha.org/policy n  Ashley Alliano, Kimberly Herriger, Anthony D. Koutsoftas, and Theresa E. Bartolotta (2012). A Review of 21 iPad Applications for

Augmentative and Alternative Communication Purposes. Perspectives on Augmentative and Alternative Communication 2012;21 60-71

n  Beukelman, D.R. & Mirenda, P. (2005). Augmentative & Alternative Communication: Supporting children and adults with complex communication needs (3rd ed.). Baltimore, MD: Paul H. Brookes.

n  Blischak, D.M., Lombardino, L.J., & Dyson, A.T. (2003). Use of speech-generating devices: In support of natural speech.

Augmentative and Alternative Communication, 19, 29-35. n  Bodine, C. & Beukelman, D. R. (1991). Prediction of future speech performance among potential users of AAC systems: A

survey. Augmentative and Alternative Communication, 7, 100-111 n  Does AAC impede natural speech?—and other fears (1999-2004). (On-line.) Ruth Ballinger - YAACK: AAC Connecting

Young Kids. Available: http://aac.unl.edu/yaack/b2.html n  Dowden, P.A. (1997). Augmentative and alternative communication decision making for children with severely unintelligible

speech. Augmentative and Alternative Communication, 13, 48-58. n  Gorenflo, C.W., & Gorenflo, D.W. (1991). The effects of information and augmentative communication technique on attitudes

toward nonspeaking individuals. Journal of Speech and Hearing Research, 34, 19-26.

n  Gosnell, J., Costello, J., & Shane, H. (2011, September). Using a clinical approach to answer “what communication Apps should we use?”. Perspectives on Augmentative and Alternative Communication, 20, 87–96.

n  Hustad, K.C., & Shapely, K.L. (2003). AAC and natural speech in individuals with developmental disabilities. In Janice

C.Light, David R. Beukelman, & Joe Reichle (Eds.), Communicative Competence for individuals who use AAC: From research to effective practice. Baltimore, MD: Paul H. Brookes.

n  Improving Natural Speech: AAC devices increase word production in children with developmental delays (2004). (On-line.)

Available: http://speech-language-pathology-audiology.advanceweb.com/common/editorial/editorial.aspx?CC=12409 n  Introduction to Augmentative and Alternative Communication (1997-2004). (On-line.) American Speech-Language-Hearing

Association. Available: http://www.asha.org/public/speech/disorders/Augmentative-and-Alternative.htm

n  Lilienfeld, M. & Alant, E. (2002). Attitudes of children toward an unfamiliar peer using an AAC device with and without voice output. Augmentative and Alternative Communication, 18, 91-101.

n  McBride (2011). AAC Evaluations and New Mobile Technologies: Asking and Answering the Right Questions. Perspectives on

Augmentative and Alternative Communication, 20, 9-16 n  Millar, D., Light, J., & Schlosser, R. (2000, August). The impact of AAC on natural speech development: A Meta-Analysis. Paper

presented at the Biennial Conference of the International Society for Augmentative and Alternative Communication, Washington, D.C.

n  Romski, M.A., & Sevcik, R. (1996). Breaking the speech barrier: Language development through augmented means. Baltimore: Paul H. Brookes Publishing Co.

n  What is AAC (2012). (On-line.) International Society for Augmentative and Alternative Communication. Available: http://www.isaac-online.org/english/what-is-aac