Sunday, February 19, 2017

Who Needs AAC? Part 2

Communication needs a purpose - an intent.  The individual must have something that he wishes to communicate - impart - to someone else.  It is important to make situations motivating and meaningful in order to create an environment in which an individual who is just learning to communicate has something he wants to say and the means to say it.

A case in point: I was called in to consult a district regarding a boy of 10 with autism.  

He had been using a PECS board with symbols for favorite foods and activities.  

Pictures were also used during specific activities in the class.  These velcro’d pictures were only available during the specific activity, and were limited to symbols required for that activity.  They were also limited to nouns, with a few activity-associated verbs.  

They told me he had been successful for a while with pictures, and was great at using them to request food (he was always hungry), but wasn’t using them for other activities and so they did not think he was “ready” for a more complex system.
When I observed in his classroom, I saw him first during an art activity where he was required to cut and paste, then color.  This was a boy who had poor fine motor skills and did not like or ever want to do cutting and coloring.  But the symbols for the activity required to him say that he wanted scissors, he wanted glue, he wanted the red crayon, etc.  He most clearly did Not Want any of these things – and “Not” was not available among the symbols.
Given an activity he enjoyed and appropriate symbols to use, he was clearly able to use them.  His vocabulary was limited, as he had always been restricted to a noun-based vocabulary, but he clearly knew what the pictures were for and how to use them.
Lessons learned: 

1. Verbal communicators are able to tell you when they don’t want something or don’t want to say what you want them to.  Nonverbal communicators have the same right to say “I don’t want to” as everyone else. 

2. Only giving the individual the words to say specific, limited messages does not give them the ability to communicate.  

3. As Gayle Porter says, “…a child who uses speech will independently select the words she wishes from the vast array she hears/uses every day.  A child who uses AAC will independently select the words she wishes to use from the vocabulary other people have chosen to model and, for aided symbols, made available for her to use.” (Porter & Kirkland)   And a child who uses a limited AAC system will sometimes NOT choose to select words that do not say what he wants them to.

With that in mind, Keep on Talking!

Sunday, February 12, 2017

How the Heck Can He Access That Communication System?

For students who face significant motor, visual, hearing, and/or other multiple challenges, or those for whom device use has not been successful secondary to access or consistency issues, flexibility of thought and knowledge of available options are required in order to determine appropriate access.

All communication relies on perception of sensory input and ability to make a physical response of some sort.  When looking at an individual’s ability to use AAC to develop communication we have to be aware of how he processes input (what type of atypical patterns are used), how the individual moves (what atypical patterns exist, what movements exist to use for responding), how stable those movement patterns are, and what are the effects are of position stability, motivation, other impairments.

Many of these children are caught even more tightly by the “Catch 22” (Porter) for individuals who require aided modes of communication:
  • Aided language does not naturally exist in the environment
  • The individual cannot spontaneously “uptake” something that is not there
  • Professionals intervene based on their perception of what’s possible
  • The individual can only demonstrate what’s possible based on what’s been set up to use

Once again, aided language stimulation is a necessary ingredient in the individual's environment for him to be a successful communicator.  As he responds to what’s provided the assessment can continue.  Dynamic assessment is necessary in AAC.  We intervene -> observe -> intervene -> observe (Porter 1997).

Alternate Ways to Respond to AAC Systems

Modified direct access: 
Such as a head pointer, mouth stick pointer, eye gaze (all low/no tech) 

Partner assisted scanning (PAS): 
Uses partners who have been specially trained for interacting.  Partners show, point, and/or speak each item.
Eye gaze systems:
Can range from no-tech to the ultimate high tech. 

Head mouse, head tracker, joystick, mouse emulators: 
Modifications on direct selection using infrared beams or computer access modes.  The head tracker is more tolerant of head movement than eye gaze technology systems, but shows greater fatigue.

Use of key guards to count spaces as a tactile guide to the display: 
Requires memorizing the displays and sequences.

The slowest way to access an AAC system. 

The specific motor impairments of the AAC user need to be assessed and catalogued.  What are the effects of muscle strength, symmetry of body, disassociation, ATNR (asymmetrical tonic neck reflex) weight bearing and shifting, eye-hand coordination?  Know whether shoulders are forward, elbows flexed or extended.  Determine the ability to grasp a target or use vision.  Know if there is increased response time.  Determine the available movement pattern.
A variety of body parts can be used to activate switches.  Head switches can include toggle-type switches, button-type (such as Jelly Bean and Buddy Button), head, chin, and tilt switches.  The Sip ’n Puff switch is used in the mouth.  There are also foot switches and eye blink switches.  Some very sensitive switches can be activated by very minimal muscle movement.  For using the hand, beyond standard button switches, there are finger, thumb, and pinch switches, as well as switches that use hand grip.

For some users the size of the target area is crucial.  Some individuals need a larger switch for consistent access, such as Jumbo and Saucer switches.
For other users the range of motion needed to find and hit the switch is of utmost importance.  Switches that work well with individuals who have limited range of motion or limited fine motor skills include the Twitch, Finger, Compact, and Gumball switches.
For users who require sensory feedback from the switch there are switches that provide vibration, textured surfaces, lights, or music.  For users with visual impairments there are switches that offer color, contrast, lights and vibration.

There are a variety of access possibilities.  It takes time, knowledge of the individual, and knowledge of his communication needs and environments.
Try everything, and Keep on Talking.

Sunday, February 5, 2017

Did You Know? February is Vision Awareness Month!

Did you know February is Vision Awareness Month?  If you’re a speech-language pathologist or teacher working with students with cerebral palsy or other brain-based disabilities, chances are you have a student with C.V.I.

Vision, more than any other system, allows the individual to take in huge amounts of stimuli from the environment for the brain to act upon.  In the process, the individual gazes at things, does so in specific sequences, and focuses on specific details in order for the brain to make decisions about what to do.
Vision develops as a process of neurological development and maturation.  Our ability to process visual stimuli and attach meaning to them - called “seeing” - involves not only a healthy vision system, but also a healthy neurological system.  
When a child is born with a neurological disorder, it is likely that a visual impairment will exist.  Development of the visual system, learning through interaction with the environment, is also impaired when a child has motor impairment.  Eyes do not tell the individual what to do.  The brain’s experiences do.  Without these experiences, or when the experiences are impaired in some way, the brain cannot tell the individual how to act and react.
“The current leading cause of visual impairment among children is not a disease or condition of the eyes, but Cortical Vision Impairment (CVI) - also known as cerebral visual impairment - in which visual dysfunction is caused by damage or injury to the brain.” (American Printing House)

Cortical vision impairment has nothing to do with acuity.  It is  vision impairment caused by damage or injury to the brain.
Because the areas for vision in our brains are not just localized to one small area, chances are if there is any brain damage at all that some aspect of vision in the brain is impacted.

CVI can be found in individuals who have had a head injury, brain infection, brain maldevelopment, or asphyxia.

There are some specific characteristics of CVI; including color preferences, attraction of movement, response latency, reduced visual fields, difficulty with complex visual stimuli, gazing at lights or at nothing at all, reflexive responses to visual stimuli, attraction to novel visual stimuli and visual-motor mismatch.

Cortical vision impairment is the most common cause of vision impairment in children in the U.S.  It is seen in children who are premature, who have a neurological disorder, or have had acquired brain injury.   Given that 40%-80% of the brain is required to process vision, brain damage in almost any area can lead to CVI.  The brain loses its ability to integrate and organize visual input received from the eyes. 

Improvement is both possible and likely with training.  This requires discovering the CVI at an early age and providing direct intervention. (Roman-Lantzy, C., 2007)  Children with CVI have the capacity to see more effectively and can learn effectively given an adequate plan and intervention.

In general, individuals with CVI experience success with AAC systems that utilize partner assisted scanning; tactile systems with voice output; auditory scanning high tech voice output devices; and two-switch auditory step scanning where the user can control the speed of scanning for processing, that utilize visual tracking of a visual stimulus across the scan (such as a flashlight or finger or bright object).   

Burkhart also suggests “using a communication device (BIGmack Communicator) using color coding. For example pair a 2D picture with a similar 3D object using bright colors.  Have the communicator in the same color (i.e. Have a picture of a red cup, have a red cup and a red communicator that says, ‘I want a drink,’ when accessed.”               

Additional tips for AAC use with these students include:
  • Use Partner Assisted Scanning or use devices with auditory scanning.                                                                                                            These modes of access allow for success by removing the need to visually attend to and shift from pictures the students can’t see; there is now no need for communication success to be dependent upon symbol recognition.
  • Abandon the kind of standard objectives you set for other AAC users.  These students will have difficulty or lack of success with objectives to match objects to pictures, make requests using picture boards a specified number of times, or identify named pictures in arrays. Matching and identification tasks are largely nonfunctional, anyway.
  • Avoid vocabulary that only relates to a single activity and then doesn’t get used again; use of core vocabulary or high frequency vocabulary is beneficial for these individuals.
  • Avoid limited choices that don’t allow engagement.  This is true for many students.  Multiple choice responses do not encourage language development or elaborate interactions.
  • Provide social contact vocabulary so that the individual can maintain social interaction and engagement with others, even when unable to see what is going on.
  • Provide vocabulary that is stable and can be added to as skills develop.  This, again, encourages the use of core vocabulary, where words have multiple meaning uses with a limited number of visual distinctions.
  • Provide vocabulary sets that are organized and stay the same each time.

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!