Stuck on AAC Implementation? My Five Step Plan for Intervention

Communicative competence was defined by Janice Light (1989) as:

"– the state of being functionally adequate in daily communication and of having sufficient knowledge, judgment, and skills to communicate effectively in daily life."

I advocate for a 4 step process to building AAC use: Choose, Plan, Prepare, and Implement.

Step 1: Choosing vocabulary - We want to make sure our AAC user has a robust vocabulary so that he can say whatever he wants.  We don’t fill the system with preprogrammed phrases that may not represent what he wants to say; but we may use some often-used phrases for speed of interactions in social situations.

Step 2: Once you have the vocabulary set in your AAC system, you wan to plan your intervention strategy.  Think about what words you want to target first. Are you going to focus on core words used in a single activity or those identified core words whenever they occur in the environment naturally?

Step 3: Next, Prepare. Prepare with a modeling plan. Become comfortable with the child’s AAC system sufficiently to be able to model the words you have set as targets.  This is important. You might even want to practice ahead of time.  But don’t worry if you make mistakes or have to stop and think about where a word is.  These are perfect times to use verbal referencing and talk about what you are doing.

Step 4: Implement.   Provide Aided Language Stimulation (ALgS)/Modeling.  The AAC system needs to be available at all times. The partner will model each of the words, showing the child how the word is used in that context and where to find it in the AAC system.  Be careful not to give directions, test, make the child perform.  Don’t ask the child to “Show me _” or “What is _?” or “Where is _?”  Remember that communication for real purposes and messages is the goal, not trying to find out how much the child knows.  Use expectant pauses, natural cues.

Step 5: Collect data.  Assess and revise the plan as needed.

It is easy to implement AAC in the classroom by

1 Offering choices as often as possible

2 Using consistent vocabulary and sequences within frequently repeated classroom routines

3 Sabotaging the environment during a routine task so that students need to communicate

4 Utilize simple scripts within routines so that staff are consistently modeling the same vocabulary and sentence types

5 Make sure to model vocabulary used during routines that goes beyond requesting; to include commenting, providing information, asking questions, and other communication functions

 AAC implementation does not need to take a significant amount of planning time or equipment.  Just think about the language you use routinely.

Looking for more information about AAC implementation?  Take a look at my book: Make the Connection!  Available on Amazon. (affiliate link)

Are You Drowning in Alphabet Soup?

We all use acronyms way more than we’d probably like.  There are acronyms everywhere; television stations, directions, and, of course, in our professional language.  

And sometimes we forget that not everyone knows the acronyms we use; especially in our clinical capacities.  Even using SLP can confuse some people.  Many call us Speech Therapists and have no idea of the full professional title.

So, I am going to clear up some of the confusion around acronyms used in AAC.  Let’s start with that one:

AAC - Alternative - Augmentative Communication; those modes of communication that replace or supplement natural speech.

PAS - Partner Assisted Scanning; a process by which the communication partner scans through the selections either auditorily (saying the words), visually (by pointing to the symbols) or both.  The partner scans through the choices available on the (no/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.

ALgS - Aided Language Stimulation is also called Aided Input (AI) and refers to the process of modeling use of the AAC system to the user while speaking.

AT - Assistive Technology; an umbrella term used to talk about assistive and adaptive devices or systems for individuals with disabilities. It includes any piece of equipment or software program or app that can be used to increase the functional abilities of students with disabilities.  This umbrella includes AAC.

CCN - Complex Communication Needs; used to refer to those AAC learners who have significant disabilities and needs beyond simply replacing their speech. These AAC users have a combination of physical, sensory, and other challenges that make communication difficulty

CVI - Cortical Vision Impairment; refers to a brain based vision disorder

SGD - Speech Generating Device; or VOCA (voice output communication assistant)

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

Those are my top 7 picks for confusing acronyms I hear in IEP meetings that leave some people shaking their heads.  Do you have any others?

If you're looking for more information about AAC, morew terminology explained, and a step-by-step guide to implementation, try my book Make the Connection!  (affiliate link)

Modeling to the Max: Using Aided Input to Teach AAC

Much has been made of using modeling to teach AAC use to children.  The term Aided Language Stimulation was first coined by Carol Goosens et al.

They said, “A language stimulation approach in which the facilitator points out picture symbols on the [individual’s] communication display with all ongoing language stimulation. Through the modeling process, the concept of using the pictorial symbols interactively is demonstrated for the individual.” (1992)

Aided Language Stimulation (ALgS) is based on the idea that babies/children learn language the same way; through the models provided by others in their environment.  If we only provide spoken input, how will they learn to use pictures?  Instead, we need to use symbols to say real things in real situations.

Language should not be a specific time in the school or home schedule.  Instead, use of language happens all the time, in all situations, and we model the use of symbols in naturally occurring contexts.  

What we don’t do is to create false scripts or testing-like situations, where we’re always probing and asking pointed questions.

How do I do this?
We start modeling where the child is currently in his communication and move 1 step ahead.  So, if the child isn’t using any words, start y modeling single words.  If the child is using single words, begin modeling 2-word combinations.

Begin with the end in mind.  The child may be limited in his communication now, but where do you expect him to be functioning in a long-term objective?  I usually think about beginning with a 36 or 40 location set-up for children who are emerging. I might hide some of those keys early on, but I want to have them in their “reserved spaces” so that location of the symbols is static. (See my post on stability of location)

When you’re modeling, think beyond “I want.”  Making requests is often the first thing we teach, so that children can get their wants and needs met and make choices or requests.  But too often that’s where people stop.  And there are so so many more reasons to communicate.  What happens when the child is hurt or sick? Or when someone has been mean or is annoying?  How do they ask for something “different?” 

We should be modeling greetings, asking and answering questions, expressing feelings, making comments, and more.  

We should also be modeling self-talk.  By being verbal about what we’re doing to find symbols/words or make a correction the child can take in how we communicate and use language.

Model operational use of the system.  PODD is excellent at this, with the navigation conventions built into the communication book.  With electronic systems, we should be modeling how to use the ‘back’ button, the ‘clear message window’ button, and how to turn the system on and off, among other targets.  Operational competency is often forgotten.

Model while you communicate to the child in all opportunities. It's the way they learn language.  And that's what we're all about!

So, keep on talking!  And keep on modeling!
Looking for some easy to use resources to help staff with modeling core words? Try my AAC Core Word Modeling Plan Posters for Staff.

But He’ll Just Play With It! How a Communication Device is Not a Toy and How This is Not an Excuse

This blog post is going o begin with one of those, “If I had a nickel for every time I heard….” lines.  Over and over parents and professionals alike express their fears that the child will use the voice output AAC system like a toy; either banging repetitively on a single message or bouncing from page to page hitting random buttons.

It is the excuse heard most often after, “He isn’t smart enough.” (Never, of course put quite so bluntly.)  “He just plays with it,” - or some version of that - is tossed around by people who have clearly not learned how to teach a child to communicate. I say this with no disrespect; just a desire to have people be honest with me and with parents.

Yes, kids will often activate the same button repeatedly.  When a toddler says the same (usually new) words over and over again parents may despair, but none actually puts tape over the child’s mouth.  That is exactly what is being done, however, when the device is taken away from a child because he is “just playing with it.”

Yes, when verbal kids are bored they can talk to themselves under their breath or whisper to their neighbor.  And the teacher will admonish them. The AAC user who cannot adjust his own volume (or doesn’t recognize the need) can’t keep his boredom under wraps quite as easily.

And yes, there are undoubtedly kids who haven’t quite figured out the power of genuine communication yet, and just enjoy making verbal noise.

But teaching the child about the power of communication and how and when to use it; teaching the child how to use his AAC system, teaching the child about his ‘voice’ is our job.  I am a big believer in the notion that if a student doesn’t use his AAC system appropriately for genuine communication then we haven’t been successful in teaching him. We haven’t done our job. And we need to do better.

Step 1. Make sure the device is appropriate for this particular child and make sure it is core word based and robust. A system lacking the vocabulary a child wants to use isn’t going to be valued.

Step 2. Make sure everyone who interacts with the child with any frequency is familiar with the system and able to use it.  It’s hard to provide models when you can’t find the words.

Step 3. Make sure everyone is using Aided Language Stimulation - otherwise referred to as modeling.  Nonverbal children learn language through modeling just like their verbal peers. 

Step 4. Make sure the AAC system is always accessible.  Kate Ahern’s motto: “See me, See my AAC” is paramount.  The system should never be left in another room or on top of the filing cabinet.

Step 5. Make sure the environment and the people in it are all encouraging of genuine communication, are reinforcing the child’s communication attempts, and using appropriate strategies to encourage message production.

Playing with one’s voice should be a joyful thing. Don’t stifle that!  

Keep on talking, and let let your AAC users do likewise.

Looking for some materials to help staff know what to do with their AAC users?  Try these:

AAC Implementation Plan Handbook

AAC Core Word Modeling Plan

Make the Connection!: A Practical Guide to Parents and Practitioners....

Location! Location! Location! On the Importance of Stability or: The Number 1 Reason Why We Don’t Move System Symbols Around

In an on-line discussion recently a speech-language pathologist was looking for research that specifically discussed why we do NOT move symbols around on a  child’s AAC system. Doing so to “test” children, to make sure they really are discriminating the specific symbols, has nothing to do with communicating; a fact that practitioners of ABA don’t always “get.”

Now, I’ve worked in some very very rigid ABA programs myself, but there are some principles that we followed regardless of such issues.  

1. Symbols stayed in one place in a communication book (this was in the days before high tech).
2. Symbols were used for communicating, not testing.  Studies I conducted in one setting actually showed that teaching isolated discriminations may have resulted in the students knowing which symbol meant which word, but that definitely did not lead to using the symbols to communicate once they were placed in the communication book.  Modified incidental teaching in context did that.
3. Symbols were always available.  Students had their communication books with them at all times. Symbols were accessible for communicating at all times.  That’s the whole purpose, isn’t it?  You wouldn’t take your mouth off and leave it behind, would you?  

(Yes, that sounds silly, but really it’s the whole point.  Most of us have no idea what it’s like not to be able to speak when you have something to say.  I have often challenged administrators to spend a day with duct tape across their mouths and no pencils in their hands.)

PRC systems, which utilize core words and consistent motor patterns to access words says this:

          “ In typical speech, our attention is directed to the conversation, not to articulating/saying the words. In order for an AAC user to develop this same “speaking” automaticity, he can’t be consciously thinking about interpreting or locating icons.

For automaticity to develop, each word needs to be accessed by a unique motor plan that once learned, never changes. Two words cannot share the same motor plan.”

One analogy that works for some people is to liken the AAC system display to a typewrite/computer keyboard.  As I recall from my 3 weeks in a high school typing class touch typing relies heavily on the motor patterns of hitting specific keys in specific locations.  What typist would keep working if you were constantly moving they keys around?  I can barely find the letters as it is!

LAMP training tells us: 

“Speaking is a motor plan, as are tying shoes and typing. Once the plan is learned it becomes automatic.

     o We don’t have to think about how to make a word with our articulators

     o We communicate well because we have automaticity

     o LAMP helps develop automaticity in a way that other approaches do not.

     o If a motor movement changes each time we say a word, we do not develop automaticity. Consistency of that motor pattern is key for teaching language.

     o A word can be produced in 1-3 keystrokes along a unique and consistent motor pathway. The AAC user can devote more cognitive energy to interacting vs. navigating through category pages.”

In summary, [AAC users need a] “Unique and Consistent Motor Plan: stable word location leads to effortless communication due to low cognitive load”

On the Assistiveware blog is this: “Augmentative and Alternative Communication (AAC) is blocked when users are required to prove themselves as ready and worthy before they can get AAC. Instead we should be presuming competence and not requiring any prerequisite skills before they can be eligible for a full balanced AAC system.”

Our job is to make communicating as easy and possible.  Let’s not use unnecessary demands to make it more difficult.

Keep on talking!

Moving Stories Along

I’m talking some more today about narrative skills in students, including those who do not speak. I can’t stress enough the importance of developing narrative skills in children.

Narratives are important because they allow us to move away from the “here and now,” and to focus less on our personal experiences, while allowing students to talk about what is not immediate, but rather the decontextualized language of the classroom.

Narrative skills begin to develop in young children and are mediated by parental support.  These early interactions build the foundation upon which children build their narrative and academic skills (Boudreau 2008).  The narrative skills of preschoolers are predictive of academic success in school, as well as social success.  As students with narrative language deficits continue having difficulties in academic and social success, we are reminded of the importance of intervention at the narrative levels.

Shared Reading :

These early interactions [between parent and child] build the foundation upon which children build their narrative and academic skills (Boudreau 2008).  The narrative skills of preschoolers are predictive of academic success in school, as well as social success.  As students with narrative language deficits continue having difficulties in academic and social success, we are reminded of the importance of intervention at the narrative levels

“One of the most ubiquitous and powerful discourse forms in human communication is narrative.”  (Bruner 1990).  Narrative is crucial in human interactions, yet often receives the least attention.  Bruner went on to name the 4 areas of grammar critical to narrative production:

1. A means for emphasizing actions towards obtaining a goal,
2. A sequential order should be established and maintained; so that events are stated in a linear way
3. Sensitivity to what forms and patterns of language are acceptable
4. Containing a narrator’s perspective or ‘voice.’

Note:  Take a look at this resource here

     

Narrative has been found (Nelson et al 1989) to capture not only the events of daily interactions, but to encourage interpretation, imagination, and use of self-talk to solve problems. 

One factor that is shown to have an influence on students’ skills in narrative discourse is early interactions around books and experiences.  The interactions with parents or other adults that provide scaffolding of story telling/ experience retelling, that co-construct narratives with children and gradually decrease that support, are critical.  By providing opportunities to interact with partners who provide quality exchanges students develop the narrative skills that they need.

There are 3 basic types of narrative scripts: personal experiences, scripts, and fictional stories (Hudson & Shapiro, 1991). Personal narratives are the easiest place to begin in intervention with children.  And they are the most often used types of narrative.

 “By focusing on narratives in our language intervention, we can explore processing limitations, create opportunities for using decontextualized language, facilitate social relationships, provide practice in constructive listening, improve reading comprehension, and identify language learning strengths and weaknesses.” (Johnston 2008)

For AAC users, focusing on the use of core words and important fringe, and moving from single symbols to sequences of symbols for generating novel utterances (SNUG), we need to keep our AAC users moving on the "oral" - literate continuum.  This means teaching AAC users to construct messages and sequence ideas in order to engage in meaningful conversations.

Boudreau, D. (2008) Forword. Topics in Language Disorders, 28 (2), 91-92

Catts,H et al (1999). Language basis of reading and reading disabilities: Evidence from a longitudinal investigation. Scientific Studies of Reading, 3(4), 331-361.

Gillam, R, & Pearson, N. (2003)The Test of Narrative Language. Austin, Tx: Pro-Ed.

Johnston, J. (1982). Narratives: A new look at communication problems in older language-disordered children. Language, Speech, and Hearing Services in the Schools, 13, 144-155.

Johnston, J. (2008). Narratives: Twenty-five years later. Topics in Language Disorders, 28 (2), 93-98

Can You Tell Me About It? More Evidence for Narratives

I have frequently performed assessments on kids who seem to do ok on standardized tests, which mostly assess at the word or sentence levels.  But when asked to formulate entire paragraphs; to tell about an experience or re-tell a story or make up a store, their difficulties really stand out.

This problem is exacerbated in AAC users, whose language skills are often impaired or delayed, often from a lack of appropriate instruction.

This inability to organize language into meaningful narratives impacts children in social and academic contexts alike.  Narratives are at the heart of our conversations, our classroom performance, and our ability to tell others about…. well, anything.

There have been numerous studies of children’s abilities to construct narratives, and researchers like Carol Westby, Nickola Wolf Nelson, Ron and Sandra Gillam, and Maryellen Rooney Moreau, among others, have given us a wealth of information about how children develop this skill and the steps they need to take.

Narrative discourse is defined as, “at least two utterances produced in a temporal order about an event or experience (Hughes, et al, 1997).  Students with language disorders tend to miss the ability to integrate background knowledge with pragmatics - or social language - to formulate an organized recounting. 

Moreau has defined narrative as a story that involves telling or re-telling events and experiences (Lafontaine & Moreau 2014).

And Jerome Bruner (1990) called narrative skills “One of the most ubiquitous and powerful discourse forms in human communication…”  He went on to name the 4 areas of grammar critical to narrative production:

1. A means for emphasizing actions towards obtaining a goal,
2. A sequential order should be established and maintained; so that events are stated in a linear way
3. Sensitivity to what forms and patterns of language are acceptable
4. Containing a narrator’s perspective or ‘voice.’

One study (D. Boudreau, 2008) looked at narrative skills in academic settings and cited studies showing that 

• students whose narrative skills are greater than their syntax skills performed better than those who had age-appropriate syntactic skills but poorer narrative abilities or tasks for story comprehension and re-telling,
• the single best predictor of students’ future need for remediation or special education or retention was their earlier performance on tasks of narrative abilities,
• that narrative abilities in Kindergarten predict students’ vocabulary and reading comprehension skills in 7th grade  
• that there is a correlation between students’ narrative skills using wordless picture books and their Math skills in school,
• and more evidence for the role of narrative discourse skills.

The bottom line, says Boudreau, is that discourse abilities are crucial in academic success, and, in order to make students with this profile successful, we need to provide remediation in both comprehension and production of narratives.

If you want to learn more about narrative skills assessment and development, Gillam and Gillam have written some terrific articles and presentations. You can grab some amazing CEUs through MedBridge’s courses on narratives by Sandra Gillam here.

     Narrative Intervention for School-Age Children with Language Impairment

     Narrative Proficiency & School-Age Children with Language Impairment

As well as this great course offering from Sean Sweeney:                                         Tell me a story: Targeting narrative skills through the alignment of methodology and technology

And if you’re looking for some resources to help you work with narrative skills, try these I’ve created:

     Building and Expanding Personal Narratives with AAC Users

       Build Narratives and Tell Stories with Story Element Die

      Time to Tell Stories Story Element Cards for Narrative Development

      Using Story Creating Apps to Build Personal Narratives iPad to Conversation (free)

      Visual Cues and Maps for Stories & Narratives

    

Boudreau, D. (2008) Forword. Topics in Language Disorders, 28 (2), 91-92

Catts,H et al (1999). Language basis of reading and reading disabilities: Evidence from a longitudinal investigation. Scientific Studies of Reading, 3(4), 331-361.

Gillam, R, & Pearson, N. (2003)The Test of Narrative Language. Austin, Tx: Pro-Ed.

Johnston, J. (1982). Narratives: A new look at communication problems in older language-disordered children. Language, Speech, and Hearing Services in the Schools, 13, 144-155.

Johnston, J. (2008). Narratives: Twenty-five years later. Topics in Language Disorders, 28 (2), 93-98