Sunday, March 19, 2017

AAC 101: So How Do I Do This?

Over the past 2 months I’ve been talking a lot about beginning with augmentative communication; including what it is and who needs it.  The next question I most often get from parents, teachers and SLPs is about what kinds of materials are needed for intervention (and “where the heck do I find them”)?

We all know that genuine communication interactions in context are the best for teaching any communication skill.  Too often in AAC implementation we “test” more than teach.  We ask students to identify symbols at random, or find target words outside of any social engagement or genuine interaction.

Since many of our students require additional specific, structured practice beyond the opportunities throughout their school day, I encourage role playing and simulations.  There are a lot of ways to do this; such as including using props, dress-up, role playing, and using books and apps.

We also know that our students need to have a robust communication system; either no/light tech or high tech systems.  Again, there are dedicated devices that use core words as well as categories of fringe words, AAC apps that are similarly robust with sufficient vocabulary to meet all of their communication needs, and dynamic communication books that have robust vocabulary to meet a variety of communication functions.

Systems that are either totally core word based (with available fringe words) or are function/pragmatically based but include the same high frequency words, are robust enough to meet many needs.

Much research has been done on language development in general, and on the acquisition and use of early words; especially those words we know of as “core words.” But, somehow, we often seem to get stuck with those first 15, 25, or 32 core words.  Sometimes even SLPs forget about 2-word combinations when teaching AAC users.  But isn’t that the natural next place to go?
I love it when I hear SLPs or teachers exclaim, “Look! He’s putting two words together.”
Two word combinations are necessary to convey meaning when one of those words is a noun.  “Apple.”  Well, what about an apple?  Do you want an apple?  Did your apple fall on the floor?  Did someone take your apple?  Are you tired of apples?
But think of the magic of communication when combining two core words.  All of the  multiple meanings of both words create powerful combinations.  “Want apple.”  “Not apple.”  “Give apple.”  “Bad apple.”  Good apple.”  “More apple.”   I’ve made meaning intelligible, and I’ve covered - how many functions?

I have made a great many resources available in my TPT store for AAC implementation.  One that I particularly enjoy is my AAC Starter Kit, because it provides a robust picture communication book that employs basic core and adds a variety of fringe topics and concepts.
When the book is assembled, it shows the easy to access to core words, as well as the variety of fringe words available.

The kit also includes my 10 Weeks to 40 Core Words.  The activities for teaching use of core words in this resource are similar to my other Activities and Games for a Year of Core and Teach Me Core Words resources.  I have attempted to provide both suggestions for using core words in every day routines and activities, as well as activities to simulate other real-life activities that you may not have access to within your intervention setting or classroom.

There are 4 target core words per week, planned out over 10 weeks.  You may need a different pace for your students, and that is certainly fine.  Move at a pace that works for the students you are working with; making sure to always presume competence, provide maximum opportunities for genuine communicating, and use the least intrusive cues and prompts possible. Consistent partner use of Aided Language Stimulation is crucial.

For each of those 4 word groups, there is a different lesson plan/activity suggestion/contextual idea(s) for each day of the week.  The words are provided on large cards (approximately 4.5 X 3) for use in the classroom, as well as on a complete 40-location communication board.  Each week you will get a small book to read with the student(s) on Day 2 that uses those words.  When possible, act out the statements in the book in real time, giving a context with real objects and people.

The books can be interactive;  having students place the appropriate symbol on each page of each book.
Simulation activities for each week include activities such as an Animal Escape game, making a volcano, blowing bubbles, playing a familiar game, building a pizza, doing a group puzzle, and more.  3X5 sized cards for use on a classroom board come in white background as well as red & yellow for students with cortical vision issues.

Also in the starter kit is my Teach Me 6 Core Words resource and Teach Me More Core Words resource; each of which has a variety of simulation activities.  Order a pizza, order animals back to the barn, get dressed for the weather, go to the store are some of the activities.

And my 3 Games for AAC practice are also in this set.  The first game involves students picking a card from a pile and finding the words in their AAC system.  The second game uses dice to provide a single core word and asks students to create a phrase using that word.  The third game is a bit like Scrabble, but uses core words tiles rather than single letter tiles, and has students build phrases and sentences using the words they’ve picked.

There are more than 500 pages in this resource, with enough activities to keep your AAC users learning to use language throughout the year - and beyond!

However you choose to do it, keep your AAC users “talking!”

Sunday, March 12, 2017

For Your Viewing Pleasure: AAC Resource Montage

Ok, I admit it. I didn't get my blog post written for today. I thought I had. But, nope, I was wrong. Imagine my surprise when I opened the blog this morning only to find last week's post still there.

So, given that I've been sick, I was just going to dazzle you today with a video I made last year that is a slide deck of various resources I have for implementing AAC practice.

But, technology gods just weren't on my side today. I promise more "meat" next week.
In the mean time, keep on talking!

Sunday, March 5, 2017

What Did We Do Before Technology?

Before all children begin speaking they learn to use communicative gestures.  Some of these gestures continue to be extensions or variations on other actions; for example pointing is a more refined version or reaching.  Some gestures are more formal and some, like signs, only become communicative when a group of people assign a consistent meaning to them.

In addition to gestures, a variety of body movements can be communicative.  Facial expressions are very communicative, as are shaking and nodding our heads, shrugging our shoulders and turning away.  We learn to hold up objects for others to see, wave hello and good-bye, hold out two items to make a choice. 

Sometimes in AAC intervention we forget that we all use gestures to communicate, and the gestures and communicative body actions of the nonverbal individual continue to be valuable communication tools.  Too often those gestures are extinguished or ignored in favor of “more appropriate” communication.  While actions that are disruptive or destructive certainly want to be eliminated, many gestures continue to be appropriate for communication, and should not necessarily be replaced by more formal symbolic communication.

The truly no tech AAC system is sign language.  Sign language was used with populations other than the deaf in the 1960’s through the 1980’s as research found that many persons with developmental disabilities and autism were able to learn to use signs more easily than speech.   It must be noted, however, that what was being taught to these individuals were individual signs; not sign language per se.  There are many more subtle hand positions and other cues that go into sign language that are not present in the teaching of signs to other populations.  Additionally, most of the individuals with developmental disabilities and autism using signs use poorly articulated signs as well as idiosyncratic signs.  Lack of comprehension by others in the community is a problem for communication via sign; often even members of the signing community do not understand the poorly articulated signs these individuals use.

©smarty symbols; all rights reserved

Stephen Calculator devised a system of Enhanced Natural Gestures (ENGs).  These are natural intentional gestures that may already be in the individual’s repertoire, or can be easily taught, and that represent what they mean so are easily understood by others.  Unlike contact gestures, such as taking objects from partners or pulling partners toward preferred activities, ENGs do not require physical contact with items or persons and are readily understood by others in context.  They have been found to be easily taught to and effectively used by individuals with Angelman’s Syndrome. ENGs are motor behaviors that are already used by the individual or can be easily taught, and are understood by an observer.  For example, an individual might be taught to hold a cup to his mouth to indicate a desire for a drink.

No tech is also considered to include object-based systems, as well as paper based systems that may or may not be created with a computer, using letters, words, and/or picture symbols.  Examples can include:
1. Object boards (with or without symbols or text).  Object boards are sometimes used for individuals who relate better to concrete objects, or those who have severe vision impairments, or who are deaf-blind, and who have difficulty understanding the symbolic nature of pictures.  This often limits those students’ available vocabulary and restricts their access to a variety of communicative intents.
2. Single pictures (or photographs) that are good for labeling items in the environment or for making simple requests. Even without technological solutions and equipment there is a lot that can be done in classrooms for students who need AAC (but might not yet have it) using pictures taken from software, websites, magazines, or other educational sources.  
Pictures/symbols can be used to teach categorization and to define and describe.  They can be used to learn and sort words/symbols by parts of speech.  They can be used to teach phonological awareness skills for literacy learners; such as initial and final sounds, word families and rhyming words.  They can be used to create word webs to teach vocabulary skills and help to strengthen the connections needed for finding vocabulary within some AAC systems.  You can also teach prepositional concepts and the concept of same and different. 

Pictures or symbols can be used for playing a variety of thematic “Guess Who” games similar to the popular Milton-Bradley game (to build describing skills and questioning skills), and to create language-based cards for a variety of card games.  

Use single pictures to teach a single core vocabulary word.  Use 2 pictures to teach a yes/no response or to teach choice-making.

Next week, we'll talk more about communication books and boards.
Until then.... Keep on Talking!

Sunday, February 26, 2017

AAC System - Just What Are We Talking About?

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.
We need to recognize that different modes of communication are useful and necessary in different contexts while also remembering that we need to provide users with sufficient vocabulary - in whatever mode- to allow them to communicate genuine messages.
In terms of fostering the most “robust” AAC system, it is important to teach flexibility and have alternative means available for when the primary mode of communication is not practical at that time, or is unavailable for whatever reason: if the high tech device is broken or malfunctioning, for example. In addition, students might need to be able to use different communication modes in different social circumstances. For example, what might seem appropriate with friends in an informal interaction would be totally out of place interacting with a teacher, or in a formal social situation with adults. Similarly, a student who communicates with his familiar classroom aide using signs would need to have the flexibility to communicate via a different mode in the community with individuals who do not understand sign.

We all use a variety of modes of communication; the mode at any given instance being reliant on context and intent.  The same should be true of our nonverbal clients and students.  In fact, use of multiple component systems has been shown to be more effective and more natural (Erickson).

Any system must provide well organized language, both core and fringe words, and stability of vocabulary and location.  

So, when asked the question, “Does this individual need a low-technology system or a high-technology device?” the answer is “Yes.  All of the above.”  At all times we should remember to focus on the individual and their communication; NOT the technology.

Next week, I'll talk about some of the no-tech to high-tech options.  I have a fairly robust communication book in my store at Teachers Pay Teachers that focuses on core vocabulary, but with added fringe vocabulary for a variety of functions and topics.  You can find it here.

I also have a variety of topic boards that have core vocabulary as a base, with additional topical vocabulary and messages for purposes of protest, escape, or change. You can find them in the AAC section of my store.

In the meantime, Keep on Talking!

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.