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Monday, July 22, 2013

Static Display in AAC

AAC refers to communication approaches that augment (add to) or serve as an alternative to speech.  It includes all methods that make communication easier or possible.  There are a great many options that fall under the heading of Augmentative and Alternative Communication.  A functional aac system is a compilation of strategies that allow the student to communicate effectively in an array of intents in an array of contexts, with all communication partners.  
At the no tech end of the scale are paper based systems that can range from simple picture displays and rotating choice options to complex Pragmatic Organized Dynamic Display books with more than 100 pages and Pixon boards of more than 100 icons.  At the high tech end of the range are a variety of dynamic display computerized systems; including dedicated devices, computer software, and tablet apps.  
In the middle are static display voice output devices.  These can have from 1 to 128 buttons, thought typically there are no more than 16 or 32.  These devices use recorded human speech and paper overlays that require someone with sufficient dexterity to change the overlay and, sometimes, the device ‘level’ button to match that overlay. Problem 1: Access. Those devices that offer multiple ‘levels’ to be pre-recorded to make the change of topic quicker are usually restricted to 7 or 8 or 12 levels.  Problem 2:  Breadth of vocabulary.  Each button can be a word, phrase, or sentence (or more).  But, typically, there is no ability to sequence buttons and retain them someplace from which they can be repeated as a fluid whole message.  Problem 3: Message construction.  Problem 4: Literacy.  If one can’t sequence buttons into a whole, one can’t create words.  There are no text-to-speech options here.
Static display devices are frequently used for choice-making or for responding in a specific context.  There is not sufficient vocabulary to meet all of a student’s needs.  There is not room for off-topic messages, clarifications, or comments.  There is little or no ability for genuine message construction.  Few of them provide scanning access for those who can’t direct select.  In most cases, the vocabulary location is not stable across overlays, making learning more difficult and obviating learning through motor planning.  In classrooms, these displays are most frequently used as activity-based displays.  The vocabulary is provided as needed in order of the activity and messages are chosen based on the steps of the activity. 
At the best possible scenario with static display, one can create overlays that use core vocabulary that is stable on every overlay and fringe vocabulary for specific topics, and have enough to cover a number of contexts - but likely not all.  Most kids can’t change the overlays themselves, so need a way to signal a change of topic to their partner.  Most kids are going to be limited in vocabulary learning and use with these limited displays and topics.  Most kids are not going to learn how to construct novel messages with a limited array of word choices.  Most are not going to learn literacy skills without the ability to sequence sounds. So, as a primary component of an aac system these devices fall a little flat for me.

This is not to say that static display devices don’t have their place.  They can be a valuable piece of an aac system.  And remember, aac is a system with multiple parts.  We all use more than just one way to communicate.  In fact, there are some amazing statistics about just how small a percentage of our communication is verbal.  But, back to the topic at hand - static display devices can be well used in a variety of communication contexts.  Given sufficient ‘buttons’ per page, it is possible to provide some basic core vocabulary for a small array of functions, as well as the fringe vocabulary basics needed for the activity or topic.  But for students to participate in their school environments, communicate effectively with their partners, and learn to use language effectively, I do not believe static display devices are sufficient to meet communication needs.  Click here to download a tech speak overlay template that provides some core vocabulary, as well as spaces to insert your own activity-related words.  
Please note that all symbols used in these displays are from Mayer-Johnson Co., a division of Dynavox.  The Picture Communication Symbols ©1981–2010 by Mayer-Johnson LLC. All Rights Reserved Worldwide. Used with permission.
Boardmaker™ is a trademark of Mayer-Johnson LLC.

Monday, July 8, 2013

The Myths of AAC

In my posts I’m going to talk about AAC - alternative & augmentative communication.  
The vast majority of the kids I work with these days are nonverbal, and need an alternate mode of communication.  

Back in the 1960’s and 70’s we used signs (to say it was sign language would be inaccurate), but as our students got out more into the community, into public school classrooms, and stayed in their family homes instead of institutions, we found that sign language just wasn’t universally understood.  Even deaf folks didn’t understand their signs.  
Picture symbol based communication  went from Blissymbols (from Canada) to the more widely known (now) line drawings used most often.
There is a lot of misinformation and confusion around implementing and using aac.  Little wonder when AAC is not a required course for speech-language pathology students and few get a good background in it.  A combination of this misinformation and tight budget considerations tends to leave students to lose out.  

Among the myths are these:
  1. the belief that aac is a last resort and shouldn’t be used until all hope of being verbal has been given up
  2. the belief that aac is only for students who have no speech at all
  3. the belief that students need a specified list of prerequisite skills before they can use picture based communication
  4. the belief that there is a specific hierarchy of visual representations that all students need to go through systematically
  5. the belief that there is a hierarchy of aac systems through which students need to move before consideration is ever given to a high tech computerized system
  6. the belief that use of aac will hinder speech development
  7. the belief that some children are too young for aac

In fact, according to ASHA (the American Speech-[Language]-Hearing Association), 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.  Intervention should be based on a child’s needs, not on our expectations of his skills.  We need to follow the least dangerous assumption - that which, if we are wrong, does the least amount of harm.
Many children with significant communication needs have some words they use.  However, if speech is not functional to meet all communication needs, if there is not sufficient vocabulary, if the child is not understood by all partners, if the child only repeats what he has heard - then he needs aac intervention.
In addition, AAC does not involve a single mode of communication, but rather a combination of effective systems and strategies that work for a particular individual.  Features of an AAC system should include: ability to express a full range of communicative functions, compatibility with other aspects of the individual’s life, considers the needs of partners, usable in all environments, does not restrict the topic or scope of communication, enhances communication effectiveness, is motivating for the student to use, and fosters the growth of linguistic and related skills.  
Studies have also found there to be an increase in speech production with use of aac intervention.  AAC has been cited as an evidence based strategy for facilitating speech in young nonverbal children.
In addition, waiting too long to provide aac intervention in the belief that the child is too young denies the child the opportunity to learn language, acquire vocabulary, and express himself appropriately.  Research shows that intervention provided after 3 years has a less significant impact.
All children learn to communicate before they learn to speak.  Providing a high tech system provides a child with speech output, which, in turn, provides a speech model for users and gives clear intent to both the users and their partners.  Requiring the child to use multiple systems as they work their way through some artificial hierarchy only makes learning to communicate harder.  
Having different displays, different arrays, and constantly moving vocabulary targets is discouraging to some children and takes the emphasis off of communicating and puts focus on the system - which is not where it belongs.  
Voice output is closer to the back and forth of the natural language learning process, it provides auditory feedback while the child is learning symbol meaning, and allows the child the opportunity to “play” with his voice, the way that typical children do.  
The high tech system also provides better opportunities in most cases for scaffolding and modeling.  Only a ‘smart partner’ assisting in scanning or a good provider of aided language stimulation provides more feedback and models.
One more misconception is that teaching the student to identify and discriminate the pictures is all that is needed by way of teaching students to use them.  Too often, students are given this skill training, provided with a communication system, then deemed to have “failed” because they don’t use it effectively.  

We must remember that we are TEACHERS.  We need to provide appropriate intervention; including operational, linguistic, social, and strategic use.  We need to teach these kids to communicate with this mode - one that they have no prior experience with.  
More on that later.  For a brief handout explaining these myths, click here to download.