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!

Sunday, December 25, 2016

Can You Describe It? Building Skills Around Gift-Giving Season

The commercial aspect of the Winter holidays is well under way.  Even before Halloween was over, ads began for sale prices and get-'em-now deals.  Is it no wonder all kids can talk about it what they want from Santa or their parents?

Many kids spend some time this season writing letters to Santa or sharing their hopes for THE gift of the year with friends.  But for some kids with language disorders these discussions can be difficult.  They might not be able to remember the name of the desired toy if they have word finding problems. 
They might not be able to tell about the cool things it can do if they lack vocabulary or sentence formulation skills.

Last year I made a fun game for students based on an activity I used to do in therapy.  It focuses on describing and defining skills.  Students provide descriptions of what they want (based on cards or game board spaces) and the rest of the group has to guess what he or she is talking about.

After the holiday break is over, play the game based on what they "received" (again, based on pictures in the game, but don't be afraid to have them use what they really got!).
Students seem to enjoy the game, and sometimes the guesses get goofy, but that's part of the language fun.  When the guesses get too "wild," I have students stop and think about why that isn't a logical guess.

There are several different ways to ply the game, all provided in the description.  When you, the adult, provide the descriptions, students are focused on listening and processing skills, as well as the mental shuffling of vocabulary based on the clues.

When students provide the descriptions, they are focused on finding sufficient, concise vocabulary and formulating the phrases and sentences that make sense.

Have fun with your own groups of students.  You can find my version of the game here in my TPT store.  Or, if you prefer, tear apart all of those annoying catalogues that have your postman groaning and make your own picture cards to use.

Happy holidays, and Keep on Talking!

Sunday, December 18, 2016

Your Top Teaching Strategy for Answering Wh-Questions

It's gift giving season again, and tech-related gifts are still high on everyone's wish-list.  For many students with special needs - particularly those with Autism - iPad apps continue to be great gifts that keep on giving throughout the year. 

Apps addressing various speech and language skills are plentiful, and parents are sometimes at a loss to figure out just which skills are important, what is developmentally appropriate for their child, and which apps introduce or teach the targeted skills in a way in which their child can learn.
One of the most difficult skills I have found to teach students with ASD in my almost 40 years as a SLP is how to answer Wh Questions.  And that is exactly why I developed a program to teach kids how to answer different types of Wh- questions.

Research has shown that students with language delays actually learn how to answer Wh-questions in about the same order as typical kids.  They just learn them later.
Typical children do develop more successful strategies for formulating acceptable responses to Wh-questions.  And, as we might expect, the ability to understand and respond with the general category of information required by the type of question develops a while before the ability to provide the correct answer.  
There are studies that have shown that children - both delayed and typical - from 3-7 are significantly less successful in figuring out what category of information is needed, and providing the answer requested; especially when the question refers to something not immediately in front of them. 

Question It and Question It ED are for the iPad only, and provide 4 sequential activities; all with faded color cues, use of errorless learning, and reinforcement for every 5 correct responses.  Students work their way from sorting words by which type of question they answer, through answering questions about simple sentences, then more complex sentences, and, finally, through answering questions about 3 related sentences in a paragraph.

Question It is free for a limited number of questions in each activity, then asks users to make an in-app purchase.  Question It ED offers a single pricing for school districts who can't make in-app purchases.

Best of all?!  Question It ED is on sale for the gift giving season, through the end of December 2016 for 9.99
If you're not into technology, and want a paper-based version of the activity, try A Program to Teach Wh-Questions in my store.

So, grab it, and Keep on Talking.

Sunday, December 11, 2016

AAC From A to Z: P is for Planning

Last week, I told you about the all-important first step for teaching a student to use an AAC system - any AAC system.  Providing Aided Language Stimulation or Aided Input is important.  Students need models of the language system they are going to use.  We know that it is important to immerse them in an environment rich with their mode of communication.  

Emerging AAC users need continuous Aided Language Stimulation and opportunities to see, hear, and practice core words.  More experienced AAC users need Aided Input and scaffolding to support learning new vocabulary and more complex syntax.

For new communication partners this can seem a little bit daunting as tasks go; simultaneously using speech and using the AAC system to highlight key words.  I always tell partners to begin with just one activity.  Find one that is familiar and with which you are comfortable; routines work well, as the language used in them follows a predictable sequence and vocabulary is predictable and repeated.

I suggest that partners start by planning their interactions in advance, in order to get a good grasp of what words they are going to need to use within the activity, and what word(s) they want to target.
Think about the core words - verbs, pronouns, and adjectives in particular - that are a part of interactions within that activity.  Also think about what fringe words - mostly nouns - you need, as well.

Thinking about where your AAC user is linguistically, plan out 1, 2, or 3 word phrases - or longer sentences - you want to include.  Remember, we want to model at about 1 level above where your user is currently communicating.
Think about what communication functions the user is also already using.  Requesting is often what we develop first, but may not be the most functional.  Think about comfort, emotional states, wanting to be left alone, or needing to tell when something is wrong.

The link to watch the video, as well as download the handout, is right here.
Have fun communicating.  Keep on Talking !!