Augmentative and Alternative Communication (AAC): What is it and how can it help my child?

Childrens 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 childs 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):
Difficulty building social relationships n Difficulty Acquiring Language n Difficulty Meeting Educational Goals n Challenging Behaviors
n

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:
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
n

Common Myths Regarding AAC

n Individuals who have challenging behaviors shouldnt

use high-tech AAC

n

Challenging behavior is viewed as communicative (Mirenda, 2005) n Why? Because it has a function (Durand, 1990)

n

Escape Attention Tangible Sensory

Use of AAC can decrease challenging behaviors (Durand, 1999; Sigafoos, OReilly, & 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 individuals

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

users 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 childs 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. n Learning Style:

synthesized) n Means of encoding language

n n n n

Objects Photos PCS/Symbol Stix Unity

Visual n Auditory n Motor n Language Needs (e.g. Spanish) n Additional Needs/ Considerations:
n
n n n n n

n Ability to navigate
n n n

Categorical Icon sequencing Visual scenes

Computer access Email Phone Text messaging ECUs

n There is no one best AAC intervention n key is matching your childs 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
nCons
nDurability nSound nTechnical

Support nDistraction of other apps ** nLanguage system ** nAccess**

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?

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)
n

Communication Partner Strategies: The Tricks of the Trade!

n n n n n n n n n

Provide increased opportunities for communication (Light, Dattilo, English, Gutierrez & Hartz, 1992) Wait time/Expectant Delay (Angelo & Goldstein, 1990; Light & Binger, 1998) Aided Language Stimulation (Goosens, Crain & Elder, 1992) Re-casting (Lund & Light, 2003) Support with navigation (Light, 2005) Sabotage/Communication Temptations (Wetherby & Prizant, 1989) Peer Partners/Modeling (Buzolich & Lunger, 1995) Open-ended Questions (Basil, 1992; Bruno & Dribbon, 1998) Natural Conversation, Pragmatic Cues, Topic Cues

Parent Perspective
n Always building towards something. Its 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 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 Beukelman, D.R. & Mirenda, P. (2005). Augmentative & Alternative Communication: Supporting children and adults with complex communication needs (3rd ed.). Baltimore, MD: Paul H. Brookes. 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. 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 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 Dowden, P.A. (1997). Augmentative and alternative communication decision making for children with severely unintelligible speech. Augmentative and Alternative Communication, 13, 48-58. 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.

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, 8796. 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. 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 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 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. McBride (2011). AAC Evaluations and New Mobile Technologies: Asking and Answering the Right Questions. Perspectives on Augmentative and Alternative Communication, 20, 9-16 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. Romski, M.A., & Sevcik, R. (1996). Breaking the speech barrier: Language development through augmented means. Baltimore: Paul H. Brookes Publishing Co. What is AAC (2012). (On-line.) International Society for Augmentative and Alternative Communication. Available: http://www.isaac-online.org/english/what-is-aac