Sunday, January 29, 2017

AAC 101: Who Should Use AAC and Why?

People who use AAC are those individuals whose current mode of communication does not meet all their communication needs; restricts the quality and quantity of interactions with others.  

All individuals are considered potential candidates for AAC; ASHA and the Joint Commission for Persons with Disabilities have a “zero exclusion” criterion and consider not whether an individual is eligible for services, but rather consider where along the continuum they are currently operating as a starting point .  As long as there is a discrepancy between needs and abilities, an individual qualifies for services in AAC.  

Best practices also dictate that, while there is a relationship between cognitive and linguistic skills, this is not a causal relationship.  Language skills are just as likely to affect cognition as vice versa.

There is no such thing as the typical or average AAC user.  You will find individuals who need access to AAC from all age groups and a wide range of diagnostic categories.  There is almost no group of clients or students you will work with where you will not find some need for AAC.  Many congenital and acquired disabilities will require the use of AAC.  You will find users who have a communication disorder due to a congenital disorder, and those for whom it is acquired; such as aphasia, traumatic brain injury, and ALS.

Children who do not have speech or whose speech is not meeting their communication needs need to be considered as candidates for AAC intervention.   Among children cerebral palsy, Autism Spectrum Disorder and other developmental disabilities probably are the largest groups of AAC users; however, there are a variety of other disabilities or disorders that will require you to think about AAC access.  Children with Angelman’s Syndrome, girls with Rett syndrome, developmental apraxia of speech and a host of less common or low-incidence disorders can show up on the SLP’s caseload. 

Among adults, cerebral palsy  and developmental disabilities continue to be a large group of AAC users.  Also adults with ALS, MS, and those who have suffered a stroke/ CVA or spinal cord injury.  

In both adults and children traumatic brain injury (TBI) also accounts for too many AAC users.  

Not all of these users require high technology AAC systems to communicate.  But they do require a robust system that allows them to be effective communicators.  The “…ultimate goal of an AAC intervention is not to find a technological solution to the communication problem, but to enable the individual to efficiently and effectively engage in a variety of interactions.” (Beukelman and Mirenda, 1998)

They all also require that there be partners who keep them motivated and stimulated, who provide opportunities for them to communicate, who assess their AAC systems on an on-going bases, and who provided the aided input and modeling needed for them to learn how to use their AAC system and language.   These partners also need to know the wide range of communication functions that need to be represented in the users’ toolbox. 

As we continue to talk about AAC systems, bear in mind that a functional AAC system is a compilation of strategies that allow the individual to communicate effectively a variety of intents in a variety of contexts, with a variety of partners. 

Sunday, January 22, 2017

AAC 101: Myths and Misconceptions

The myths of AAC are a combination of misconceptions and misinformation.  Unfortunately they are both pervasive and dangerous.  

They may continue to be perpetuated by beliefs 
  • that communication must be verbal 
  • that AAC is restricted to specific options
  • that use of AAC will prevent children from developing speech
  • that there are prerequisite skills that must be developed before an individual is able to use AAC 
  • that AAC systems are too complex for individuals with intellectual disabilities

Not too long ago I got a call from a mother.  She was interested in looking into AAC for her child, but the school district said the child was too young.  How old was he?  He was 6.  

Last week I had the same experience.  This time, however, the child was 3.  As soon as I put a dynamic display device in front of her with core words to use in our play interactions she began to use the system independently to direct my actions and her choice of activities, including which colors of markers she wanted.  

Too soon for AAC?

Two years ago I attended an IEP meeting for a girl for whom I was providing consultation.  The school district was appalled when I suggested an AAC system as a repair strategy.  She was verbal; but with a repertoire of less than 3 dozen words.  Their response; “We’re not giving up on speech.  It’s too soon!”  How old was she?  She was 9.  

And note that I suggested an AAC system as a repair strategy, not as a replacement for speech.**
Some parents and professionals believe that AAC is a last resort for their nonverbal or minimally verbal children, and should only be used when there is no more hope for developing speech.  

Unfortunately, this all too often means that children (and some adults) have no means of communicating for far too long; resulting in frustration, negative behaviors, and significant limitations on their language development, access to curriculum in school, access to social interactions at home and in the community, and in adapted living skills.  

Waiting too long to provide a mode of communication denies the child the opportunity to learn language, acquire vocabulary, and express himself appropriately.  Waiting too long to provide an appropriate mode too often means communicating with an inappropriate mode.  Research shows that any intervention delayed beyond a child’s first three years has less significant impact, and that children - including those with disabilities - learn faster and more easily when they are young. Lack of access to communication results in the individual being excluded from appropriate educational and vocational placements, restricting social development and quality of life.
Rather than being a last resort, AAC can serve as an important tool for language development and should be implemented as a preventative strategy - before communication failure occurs.   Withholding AAC intervention not only impacts building language skills, but also has an impact upon cognitive, play, social, and literacy skills development.

Parents and professionals may also believe that use of AAC will stifle the child’s potential verbal skills and/or serve as a “crutch” upon which the child will become reliant.  However, research has shown that use of AAC often stimulates verbal skills in users with the potential to be at least partially verbal.  

Children need access to appropriate and effective modes of communication as soon as possible.  Without an appropriate way to communicate genuine messages, individuals frequently use inappropriate behaviors to communicate, or withdraw.  Struggling to learn to speak, while having no other way to communicate, leads usually to frustration.  
Further, those who have access to AAC tend to increase their verbal skills.  So, not only is there no evidence to suggest that AAC use hinders speech development, there is evidence that suggests access to AAC has a positive impact on speech development.  

Why AAC use promotes speech development is not precisely known.  Theories include the possibility that use of AAC reduces the physical and social/emotional demands of speech and that the symbols/words provided visually serve as consistent cues and the speech output provides consistent models.  Although the goal of AAC intervention is not necessarily to promote speech production, the effect appears to be that it is a result.

Many times parents are told children need to have a set of prerequisite skills in order to qualify for or benefit from AAC, and that their young and/or severely disabled children (and adults) do not yet possess those skills.  

In addition, some professionals believe that there is a hierarchy of AAC systems that each individual needs to move through; utilizing no- or low-technology strategies before gaining access to high technology systems.

In fact, this outlook only tends to limit the type of supports provided and limit the extent to which language may be developed.  

First, there are NO prerequisites for communication; everyone does it.  And as we’ve seen above, all children learn to communicate before learning to speak.  

Second, research does not support the idea of a hierarchy of AAC systems, and shows that very young children can learn to use signs and symbols before they learn to talk.  Research has also shown that very young children with complex communication needs have learned to use abstract symbols, photographs, and voice output devices during play and reading activities.

Requiring an individual to learn multiple symbol systems or AAC systems as they develop skills merely serves to make learning to communicate more difficult.   

Many parents and professionals believe that AAC is only for individuals who are completely nonverbal.  Students who have some speech skills are frequently not provided access to AAC systems in the belief that intervention should focus only on building their verbal skills.  

However, if speech is not functional to meet all of the individual’s communication needs - that is, if the student does not have sufficient vocabulary, is not understood in all environments, or if speech is only echolalic or perseverative - AAC should be considered.  

“Any child whose speech is not effective to meet all communication needs or who does not have speech is a candidate for AAC.  Any child whose language comprehension skills are being claimed to be ‘insufficient to warrant’ AAC training is a candidate for aided language stimulation and AAC.” (Porter, G.)
When working with individuals with severe disabilities - particularly intellectual disabilities - many professionals assume the individual is too cognitively impaired to use AAC.  

Kangas and Lloyd (1988) wrote that there is no “sufficient data to support the view” that these individuals cannot benefit from AAC because they have difficulty paying attention, understanding cause and effect, don’t appear to want to communicate, are unable to acquire skills that demonstrate comprehension of language,  are too intellectually impaired.
The relationship between cognition and language is neither linear nor one of cause and effect; they are correlative.  They are intertwined in a very complex way.  We cannot say that a specific level of cognition or skills needs to happen before language develops.  They are interdependent.  We often see language skills in the (supposed) absence of expected cognitive skills.  

Research and observation continue to indicate that there is no benefit to denying access to AAC to individuals with significant disabilities.  Intervention should be based on the idea that learning is based on the strengthening of neural connections through experiences and that repetition of these connections through multiple modes facilitates learning.  Providing users with rich experiences with their AAC systems builds on the neural patterns and facilitates communication skills building.  Not providing AAC services based on preconceived ideas about the cognitive skills of the individuals simply continues to segregate and limit access to life experiences for them.
Unfortunately, there are also those who believe that simply providing access to an AAC system will solve the communication problems of the user.  

The AAC system cannot “fix” the individual or their communication difficulties.  While use of AAC will facilitate development of speech or language, and of literacy skills, and will increase the individuals’ ability to communicate effectively, it will not do so simply by being there.  

The AAC system is a tool and, like any tool, the user needs to know how to use it.  And for most of those individuals, direct, specific, and structured intervention and opportunities need to be provided.  

Users and their partners need to accept the AAC system; they also need appropriate instruction in how to use the system and how to develop effective communication and further language skills with the system.  

 The success of the AAC system is not dependent upon only the individual’s skills and cognitive abilities.  It is also not only dependent upon the completeness or robustness of the AAC system.  It is strongly dependent upon the willingness, training, and responsiveness of partners.  Partners who do not understand the need for the AAC system are less likely to respond to the individual’s communication attempt with it.  If the partners have low expectations of the AAC learner, do not respond consistently, do not use aided input consistently or do not provide sufficient communication opportunities the AAC learner is not likely to progress.  Communication partners have a significant responsibility.  

I know this has been a really long post!  But I hope it proves you with some good information with which to arm yourself.
Until next time, Keep on Talking!

Sunday, January 15, 2017

AAC 101: AAC Terminology

There are some terms that will reoccur throughout discussions of AAC.  They are briefly defined here, and will be discussed in more depth throughout this course.

Aided Communication 
An AAC system that utilizes something that is external to the user; such as a communication book or device. (In contrast, speech, vocalization, gestures, and signs are examples of UNaided communication.)

Instead of speech; replacing speech.

In addition to the user’s speech to supplement and/ or provide support and additional communication.

Complex Communication Need (CCN) 
Usually used to refer to those AAC learners who have significant disabilities and needs beyond simply replacing their speech.

Something that represents or stands for something else.  In the simplest form, a symbol is a signal that is interpreted the same way by at least two people.  

There are 2 types of visual symbols; graphic and lexical.  Graphic symbols include line drawings, photographs, color or black & white images. Lexical symbols are with letters or words.

A general term for movements that are made with hands, arms, and facial expressions.  

Signs are more conventional gestures that have been ascribed meaning by a group of users and become a part of the lexicon (which is, essentially, a catalogue of a language’s words)

SGD (speech generating device) or VOCA (voice output communication assistant)

Voice output can be either digital (recorded speech) or synthesized (computer generated) speech.  

High tech devices are referred to as SGDs because the speech can be computer generated.  However, many high tech devices also have the capability of using digitized speech in some instances.

Low tech static display devices use recorded speech only to provide the voice output. 

Partner Assisted Scanning (PAS) 
A strategy in which the communication partner scans through the choices available on the (low-tech)  AAC system, always in the same order, looking for an agreed-upon response from the individual to accept an option.  Partners present the choices in the same sequential order every time.  This strategy is usually used with an individual with significant motor or visual problems who has difficulty accessing an AAC system independently.  

The human partner is called a “smart partner” in contrast to computer assisted scanning because the computer cannot adapt to the individual’s day to day or minute to minute fluctuations or read facial expressions and body language the way a live partner can.

Aided Language Stimulation (AlgS) 
A strategy in which a communication partner teaches the AAC user the meanings of symbols, their locations, and how/when to use them through modeling their use while providing verbal input for genuine communication interactions.

The way in which the individual makes a selection of a word or message on the AAC system.  

Direct selection access involves the user pointing or touching the system directly.  

Scanning involves using a switch to activate the system’s movement through the messages available in sequential order until the user activates the switch again (or a second switch) to make a selection.

Eye gaze is an access mode for those with significant motor disabilities wherein a built-in camera tracks the eye movements of the individual, allowing the user to point to the message button with their eyes.  Eye gaze is faster and more efficient than using a scanning system.

Core Vocabulary 
Those high frequency words which we use the most often.  These words are usually useable in a variety of contexts on a variety of topics, and can be combined together in a large number of ways to create novel messages.  A variety of parts of speech are represented in core words, but rarely nouns.  About 80% of what we say is comprised of core words.

Fringe Vocabulary 
Those topic specific words that are used less often and are less useful in a variety of contexts; they are usually nouns, and make up only about 20% of the words one would find in a 100 word sample.

Symbol Transparency and Opacity

AAC systems can use concrete objects, photographs, life-like drawings, or line drawing symbols.  Symbols are said to be transparent when what they represent is obvious to any communication partner either immediately or with an initial explanation.  Opacity refers to symbols that are abstract, don’t have any resemblance to the word or concept, and which are not easily identified without the accompanying label or direct instruction.

Next post: I'll revisit myths and misconceptions
Until then, Keep on Talking!

Sunday, January 8, 2017

AAC 101: What is Augmentative-Alternative Communication?

According to the American Speech–Language–Hearing Association (ASHA), it is, “…a set of procedures and processes by which an individual’s communication skills (i.e. production as well as comprehension) can be maximized for functional and effective communication.  It involves supplementing or replacing natural speech… with aided… and/or unaided symbols…”
Note that this definition
  • refers to communication approaches that augment speech or serve as an alternative
  • refers to all methods that make communication easier or possible
  • may include facial expressions; gestures; an alphabet, words or picture board; a computer; and other similar systems.

According to ASHA, too, the “goal of augmentative and alternative communication use is the most effective interaction possible.  Anything less represents a compromise of the individual’s human potential.”

Ultimately, the most effective communication is achieved through spontaneous novel utterance generation (SNUG). 

SNUG allows someone to say anything they want, by combining words, word combinations, and commonly used phrases.  It’s based on normal language (moving from single words to word combinations), and on the notion that most sentences we use we’ve never used before.  

Consider:  if most sentences we use we’ve not used before, then how can we predict which number of limited number of sentences someone else will want to use?  

In fact, pre-stored messages (as have been found on many AAC users’ systems) are rarely used in social contexts by AAC users, according to the research (Hill, K, and Balandin & Iacono). **

Thus, it needs to be the goal of AAC intervention to provide our clients and students with the words to say whatever they want to, whenever they want to, wherever they want to.

Next post: AAC terminology
Until then, Keep on Talking

Monday, January 2, 2017

AAC 101: What is Communication?

As speech-language pathologists, we tend to focus on the development of speech and language skills, while sometimes forgetting to focus on their ultimate purpose:  to communicate.

So, what is communication?  

The National Joint Committee for the Communicative Needs of Persons with Severe Disabilities defines communication as, “any act by which one person gives to or receives from another person information about that person’s needs, desires, perceptions, knowledge, or affective states.  Communication may be intentional or unintentional, may involve conventional or unconventional signals, may take linguistic or nonlinguistic forms, and may occur through spoken or other modes.”
Note that the focus in this definition is on the shared meaning between communication partners.  It is not on speech, or even on language, but on interaction.  

Note, too, that per this definition, unintentional behaviors and nonlinguistic forms can signal communication.

Communication, then, can more simply be defined as the process of exchanging ideas and information; involving the encoding, or formulation, of ideas and the decoding, or processing of them.

In order for communication to happen, the partners involved need to: 
  • be aware of the cause-effect relationships between one’s behavior and the other’s 
  • have something to communicate or exchange

Language, on the other hand, is a code that has been developed in a culture that uses specific symbols that have arbitrarily been determined to mean something.  (A symbol stands for something else, with no apparent prior relationship.)

Next post: What is AAC?
Until then, Happy New Year, and Keep on Talking!