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AAC for Children:Strategies for Long-Term Intervention

AAC for Children:Strategies for Long-Term Intervention

Ellen Kravitz, MS, CCC-SLPEaster Seals of Massachusetts

Ellen Kravitz, MS, CCC-SLPEaster Seals of Massachusetts

Krista M. Wilkinson, PhDPennsylvania State

Krista M. Wilkinson, PhDPennsylvania State

DescriptionDescriptionDescriptionDescription

• Construct evidence-based intervention

• Preferred practices for emerging and context-dependent communicators

• Discuss difficult trade-offs and methods forchoosing between available options

• Construct evidence-based intervention

• Preferred practices for emerging and context-dependent communicators

• Discuss difficult trade-offs and methods forchoosing between available options

Learning OutcomesLearning OutcomesLearning OutcomesLearning Outcomes

You will be able to:

• describe the patterns of communication in “emerging” and“context-dependent” communicators and recommend short andlong-term goals for children with these profiles

• identify some of the trade-offs with aided AAC intervention(compared to oral communication) and discuss recommendedpractices for decision-making when balancing these trade-offs

• develop a system (including symbol set, vocabulary, accessmethod, and communication goals) targeting long-term goals fortwo case studies

• discuss the role of communication partners in intervention,including the role of augmented input

• examine several intervention strategies for providing augmentedinput

You will be able to:

• describe the patterns of communication in “emerging” and“context-dependent” communicators and recommend short andlong-term goals for children with these profiles

• identify some of the trade-offs with aided AAC intervention(compared to oral communication) and discuss recommendedpractices for decision-making when balancing these trade-offs

• develop a system (including symbol set, vocabulary, accessmethod, and communication goals) targeting long-term goals fortwo case studies

• discuss the role of communication partners in intervention,including the role of augmented input

• examine several intervention strategies for providing augmentedinput

I. Introduction

• Definition of AAC

• Multi-modal Communication

• Technology Issues

• Today Versus Tomorrow Goals

• Continuum of Communication Independence

II. Case Study: Emerging Communicator (Emily)

• Today and Tomorrow Goals

• Modeling, Symbols and Vocabulary

III. Case Study: Context-Dependent Communicator (Max)

• Today and Tomorrow Goals

• Vocabulary, Symbols and Access

IV. Summary

Program OutlineProgram Outline

I. IntroductionI. Introduction

Augmentative and Alternative Communication:

A compilation of methods and technology designed to aid people whose

speech cannot meet the full range of their communicative needs.

ASHA, 2005, p. 3: “AAC involves attempts to study and, when

necessary, temporarily or permanently compensate for the impairments,

activity limitations, and participation restrictions of individuals with

severe disorders of speech-language production and/or comprehension.”

Definition of AACDefinition of AAC

“Unaided” “Aided”

Multi-Modal CommunicationMulti-Modal Communication

• Use of both unaided and aidedmodes of communication during acommunication break down event

• Uses vocalizations, gestures, facialexpressions, and his speechgenerating device in his attempts tocommunicate his message

Read text on each Video Profile page andthen go to next page to review video

Even for children who have voice output

(“speech generating device,” or SGD)…

Use of each depends on:context,partner,topic,time,goal…

Technology IssuesTechnology Issues

Speed/RateSpeed/Rate

Pre-programmed sentences Generative content -- given a familiar partner

Estimates of Rate for MessagePreparation in Different Modes:

Oral speech: 150-250 words/minute

Preprogrammed electronic: 150-250 words/minute

Direct selection: 6-25 words/minute

Orthography: 1/2-5 words/minute

Scanning: 5-10 words/minute

Review the video and note the difference in ratebetween pre-programmed spoken messagesand novel messages generated by the users.


Preprogrammed Message and SpellingPreprogrammed Message and Spelling

Conclusions

• Preprogrammed Message Video• Young man is accessing whole stored

sentences

• Once he activates the appropriate key hisoutput is as fast as natural spoken speech

• Spelling Video• Young woman demonstrates the dramatic

reduction in rate as she spells her messageout letter by letter

PartnerPartner

Unfamiliar partners (who can’tunderstand idiosyncratic modes)

Familiar partners (who can interpretidiosyncratic modes, allows forfaster message transmission)

EBP Alert

Use of Mode, by Partner Familiarity

0

10

20

30

40

50

60

70

80

90

100

Gestures Vocalizations Speech Sign Light tech VOCA Email

Very familiarSomewhat familiar

Unfamiliar

• Calling out across a room• Participating in a song• Asking someone to be quiet• Interrupting• Telling someone not to walk away while you’re talking• Community activities (“Where is the #58 bus?”)• Talking on the phone• Emergency information (“Help!” or “Don’t give me peanuts.”)

Independence/ControlIndependence/Control

Pre-programmed communication

Highly routinized phrases

Jokes that depend ontiming

Personal stories

Generative communication involving

Eye contact

Face-to-face interaction

Gossip, with familiar partner

Social ClosenessSocial Closeness

TODAY GOALS:

What can we do to support and enhance a client’scommunication, right now?

TOMORROW GOALS:

What can we do to prepare a client to be the bestcommunicator she can be, long-term, across the

variety of specialized environments, partners, andcommunication tasks the client will encounter?

Today and Tomorrow GoalsToday and Tomorrow Goals

What Are “Today” Goals?What Are “Today” Goals?

Self-expressionComprehension

Today Goals (Maximizing Current Skills)

Schedules

Organization

Participation

LiteracyEtiquette

Wants/needs

Information

Social Closeness

What Are “Tomorrow” Goals?What Are “Tomorrow” Goals?Self-ExpressionComprehension

Today Goals (Maximizing Current Skills)

Schedules

Organization

Participation

LiteracyEtiquette

Wants/Needs

Information

Social Closeness

Higher-Level Symbolic Skills

Advanced syntactic skills

Metalinguistic Functioning

Academic Advancement

Advanced Physical Access(communication/education)

Tomorrow Goals (Expanding to New Skills)

Communication IndependenceCommunication IndependenceCommunication levels can be classified along a continuum of

communication independence, which looks like this:

Detailed definitions can be found at:http://depts.washington.edu/augcomm/03_cimodel/commind1_intro.htm

Classifying a child’s level of independence is based on:• expressive communication (not receptive skills)• observable behaviors (not inferred capabilities)

Emerging Context dependent Independent

Il. Case Study:Emerging Communicator

Il. Case Study:Emerging Communicator

Unfamiliar partners

Paid workers

Acquaintances

Friends

Family

Emerging communicators:• no reliable means of expressive, symbolic communication• typically uses nonsymbolic/unaided modes (gesture, vocal)• is often understood only by very familiar partners

Emerging Communicator

• Likely in emerging stages ofcommunication

• Few symbols or understandablevocalizations

• Uses body postures and facialexpressions to indicate engagementand emotions


Emerging CommunicatorEmerging Communicator

Item to Note

After the clinician modeled the use of a yes/nosymbol board, the child’s activation of the boardafter a question from the clinican is accepted andused as an intentional communication act eventhough it could have been a possible randomactivation

Emily: Emerging CommunicatorEmily: Emerging Communicator

• Emily is a six-year-old girl in an integratedkindergarten with children with disabilities and typicallydeveloping peers. She has a 1:1 aide who assists her.

• She’s ambulatory. She has no speech aside from afew vocalizations. The school psychologist estimatesher developmental level to be between 12 and 18months.

What are some important “today” goals forEmily?

Expressive FunctionsExpressive Modes

OtherComprehension

Requests

Information transfer

Social closeness

Etiquette

Communication access

Participation

Unaided, nonsymbolic

Aided symbols

Other

Unaided, conventional

Visual and auditory symbolcomprehension

Transitions/changes Literacy

Emily’s “Tomorrow” GoalsEmily’s “Tomorrow” Goals


Advanced Syntactic Skills





• Modeling and aided input• Instructional techniques

Explicit instruction can be used to teach…•Requesting/rejecting

Reichle, Drager, & Davis, 2002; Sigafoos, Drasgow, et al.,2004

•Conventional alternatives to challenging behaviorHalle, Bambara, & Reichle, 2005; Johnston & Reichle, 1993

•Conditional use of communication actsDrasgow, Halle, & Ostrosky, 1998; Reichle & Johnston, 1999;Reichle & McComas, 1994

Incidental methods include but are not limited to…•Word learning through “fast mapping”

Wilkinson & Albert, 2001•Book reading exposure

Liboiron & Soto, 2006

How do we teach Emily to use the symbolswe have selected for her?

Evidence Based Practice (EBP) Alert: Modeling has been successful inestablishing effective aided communication in children and adolescentswith:

• cerebral palsy (Goossens’, 1989),• severe intellectual disabilities (Harris & Reichle, 2004, Romski &Sevcik, 1996; Sevcik et al., 1995)• autism (Drager et al., 2006; Peterson et al., 1995).

Despite this knowledge, partners still are providing very few aidedlanguage models (Kent-Walsh & McNaughton, 2005)

We will place our discussion within thecontext of modeling and augmented input,

integrated into familiar routines

Modeling

• Clinician integrates the use of speechgenerating device into his own communication

• This type of modeling does not require thechild to respond; rather the clinician is makingsure the child has the input experience that willbe so important to his learning

• Use of the dinosaur toy demonstrates thecreative ways that voice output devices can beintegrated


ModelingModeling

What kinds of vocabulary do we want to puton Emily’s new display?

Remember, we’re now talking about “tomorrow”goals. The integration of these new symbols shouldoccur supplementary to ongoing communicationusing her current functional communication system.In other words, Emily will still have access to hercurrent and effective “today” communication system(objects) while we begin to introduce throughmodeling the new, targeted modes (symbols). We donot expect Emily to enter into our intervention withthe skills to use them (otherwise, these wouldn’t be“tomorrow” goals). Instead, we seek to offer her theopportunity to learn through our targeted exposure.

THANK YOU

Emerging Communicator

Demonstration of horseback riding intervention


Emerging Communicator: Horseback RidingEmerging Communicator: Horseback Riding

IlI. Case Study:Context-Dependent Communicator

IlI. Case Study:Context-Dependent Communicator

Unfamiliar partners

Paid workers

Acquaintances

Friends

Family

Context-dependent communicators:• reliable symbolic and nonsymbolic communication used,• but only with certain (familiar) partners• or within specific contexts

Context Dependent Communicator

• Focus is on child sitting on male clinician’s lap

• Likely transitioning into context dependentcommunicator stage

• Small number of symbols with voice outputalthough they are not a preferred mode ofcommunication

• Uses the symbols deliberately and accurately

• Supplements symbol communication with signand vocal modes


Context Dependent CommunicatorContext Dependent Communicator

Conclusion

The child would be considered a context dependentcommunicator because he has a small numberof reliable symbol uses, and his othercommunication modes are also fairly reliable tointerpret as well

Max: Context-DependentMax: Context-Dependent• Max is a 9-year-old boy in the third grade. He hascerebral palsy and is non-ambulatory (he uses awheelchair). He has a 1:1 aide for most of the day.

• Although he is mainstreamed or “totally included” inthe third grade, Max’s receptive language and academicskills are on a kindergarten level. But he has intellectualdisabilities.

What are some important “today” goals forMax?

Expressive FunctionsExpressive Modes

OtherComprehension

Requests

Information transfer

Social closeness

Etiquette

Communication access

Participation

Unaided, nonsymbolic

Aided symbols

Other

Unaided, conventional

Visual and auditory symbolcomprehension

Transitions/changes Literacy







Max’s “Tomorrow” GoalsMax’s “Tomorrow” Goals

No matter how he accesses them, whatkinds of vocabulary do we want to put on

Max’s display?

That can help to foster…

• symbolic goals

• syntactic goals

• academic goals

(including literacy/metalinguistic)

• Object labels

• People names/symbols/photos

What Kind of Symbols?What Kind of Symbols?

EBP Alert: The importance of gossip in conversations is supported in surveysof speech samples from preschoolers through elders, which show that familyor social networks are frequent topics (Beukelman, Jones, & Rowan, 1989;Marvin et al., 1994; Stuart et al., 1993), including individuals with severedevelopmental disabilities, especially for girls (Wilkinson & Murphy, 1998).

• Object labels

• People names/symbols

• Thought/emotion labels


• Object labels



• Social-regulatory words

EBP Alert: Adamson and her colleagues (1992) studied the effect of addingsocial-regulatory words to AAC vocabulary of 13 youths with severeintellectual disabilities. The youths began using the symbols as soon as theywere available, and the topics of conversation broadened.


Wilkinson et al. (1994) examined the early symbol combinations of the sameyoung men. Seven produced utterances with more than one symbol, but onlyafter social regulatory words were available. Also, 86% of the symbolcombinations contained at least one social-regulatory symbol.

• Object labels




• Action words


EBP Alert: Binger & Light (2007) demonstrated that modeling of symbolcombinations to preschool users of AAC resulted in emergence of symbolcombinations in four of five children. With Wilkinson et al. (1994), this study offersfurther evidence of the effectiveness of modeling as an instructional method, in thiscase for early symbol combinations.

• Object labels




• Action words

• Academic/vocational/developmental words


• Object labels




• Action words

• Academic/vocational/developmental words

• Generative symbols

ABC….


Ways to AccessWays to AccessDirect Selection

• Eye gaze• Head mounted• Other creative ways

AccessAccess

Courtsey AMDi

ScanningScanning

Ways to AccessWays to Access

PartnerPartner--AssistedAssisted

ElectronicElectronic

Switch AccessSwitch Access

Row column scanning example where the entiregroup of items is highlighted.


Row Column ScanningRow Column Scanning

EBP Alert: McCarthy, J., Light, J. C., Drager, K. D., McNaughton, D., Grodzicki, L.,Jones, J., Panek, E., et al. (2006). Redesigning scanning to reduce learning demands: Theperformance of typically developing 2-year olds. Augmentative and AlternativeCommunication, 22, 269-283.

IV. SummaryIV. Summary

Summary: EmilySummary: Emily













Summary: MaxSummary: Max

AcknowledgmentAcknowledgment

Thank you to The Fischler School of Education at NOVASoutheastern University for providing video footage forthis program.

Thank you to the following companies for providing picturesused in this program:

• The Picture Communication Symbols (PCS)• Enabling Devices• Advanced Multimedia Devices, Inc. (AMDi)• AbleNet• Prentke-Romich Company (PRC)

http://www.asha.org/elearning/ssexam.htm

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© 2009, American Speech-Language-Hearing Association

Thank You!Thank You!Thank You!Thank You!

Michele LashInstructional Designer/Program ManagerMichele LashInstructional Designer/Program Manager

Diane Paul, PhD, CCC-SLP, ASHA FellowContent Coordinator/Speech-Language PathologyDiane Paul, PhD, CCC-SLP, ASHA FellowContent Coordinator/Speech-Language Pathology

Parrish SwannInstructional Technology ManagerParrish SwannInstructional Technology Manager

Ghazala OsmanTraining CoordinatorGhazala OsmanTraining Coordinator

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