dr. joanne cafiero webinar with autism now may 19, 2011

Autism and Augmentative and Alternative Communication: Research-based Best Practices

Autism NOW WebinarMay 19, 2011

Joanne M Cafiero, Ph.D.

www.cafierocommunications.com

[email protected]

http://www.cafierocommunications.com/

mailto:[email protected]

This presentation will:

• Detail the features & types of AAC

• Correlate AAC with processing styles in ASD

• List evidence-based & promising practices in AAC & ASD

• Discuss latest low and high tech AAC tools

What is “Evidence-Based Practice”?

• Integration of:– Best and current research evidence– Clinical and educational expertise– Relevant stakeholder preferences and

perspectives• (Mirenda, 2009)

Autism and Mental RetardationAutism and Mental Retardation(Edelson, 2006)

• Autism and Intelligence Timeline

• Reviewed 215 articles (1937-2003)

• 74% of claims non-empirical sources

• 53% of 74% not traced to any data

• Empirical data was from developmental or adaptive scores rather than cognitive scores– Language based

– Unanswered questions considered wrong

Joanne M. Cafiero PhD, 2010

Autism and Motor Planning

• Motor Delays, difficulty in executing movements, exacerbated by stress– Bauman, (1992)

• Persistence of newborn reflexes, stereotypies– (Mari et.al, 2003)

• Parkinsonian movements– (Vilensky, 1981)

• Failure to use gestures in communication– (Mari et. Al., 2003)

• Atypical & Impaired Movement Preparation & Initiation

– (Rhinehart et.al. 2005; Rhinehart, Bellgrove, et.al., 2006, Vernazza-Martin, 2006)


Conclusions of Researchers in ASD and Motor Skills

• Motor disturbances are intrinsic to autism.

• Early motor “soft signs” may indicate autism.

• Shift in focus to movement perspective may inform practice and intervention.

• Individuals with ASD may not be able to show what they know.


Autism and Co morbidity with Affective Disorders

• Oppositional-Defiant Disorder• Obsessive-Compulsive Disorder• Anxiety Disorder• Psychosis• Selective Mutism


Progress?

• Deinstitutionalization

• Outcomes better for individuals 70 & above

• Outcomes for 50-70: dependent on others

• Outcomes dismal for individuals 50 and below most of whom are non-verbal


What is Augmentative and Alternative Communication?

(AAC)

– NO pre-requisites required– Compensates for or replaces speech– Multi-modal – Provides supports for development of language– Includes no-tech, low-tech, high tech– Icons, tangible symbols, text– Unaided and Aided AAC

What IS AAC?• Schedules

• Visual cues

• Communication boards

• Communication books

• Keyboards, letter boards

• Speech-Generating Devices

• Portable Electronic Devices (iTouch™)

• Visual Scene Displays

Types of AAC by Vocabulary Format

• Activity-based Communication Displays

• Core Vocabulary Displays

• Dynamic Communication Displays– Electronic

• Linked vocabulary

• Semantic compaction

– Low-tech PODD (pragmatically organized dynamic displays

Myths about AAC and Autism:

• Inhibits speech development• Not needed if an individual has some speech• Providing AAC insures student will use it• Success or failure depends on trial period• No & low-tech or mid/high tech are better options


ASHA Position on AAC

• There is NO evidence-based practice for determining if an individual could benefit from AAC, therefore, no one should be denied based on some arbitrary criteria.

• Eligibility should be based on NEEDS ALONE.

Aided & Unaided AAC (Millar, Light & Schlosser, 2006, Mirenda, 2003)

• Unaided - Manual Signs– Requires good fine motor abilities– Unlimited vocabulary– Portable– Not readily comprehensible– Daily access to signing communicators necessary

• Aided - SGDs, communication boards, keyboards, email, paper and pencil– requires lower fine motor skills– more readily comprehensible– not portable– Limited vocabulary, syntax & semantics (device

specific)

Effects of AAC on Speech Production in Children with ASD

Schlosser & Wendt, 2008

• Systematic review 1975-2007• Stringent criteria for inclusion

– Calculation of % non-overlapping data (SSD)– Calculation of effect size (group studies)

• Peer-reviewed journal or approved dissertation• Included SSD studies and Group

– 5 PECS, 1 Manual Sign, 3 SGDs

AAC (aided & unaided) does not inhibit

speech production; most studies showed modest

increases in speech

(Schlosser & Wendt, 2008)

Current Evidence:

• Vocal imitation is correlated with speech

• Motor imitation is correlated with successful signing

• Object exploration skills correlated with more speech using AAC (PECS)

• Time delay facilitates greater speech production

What is the ultimate goal of AAC?

SNUG • Spontaneous• Novel• Utterance• Generation

– The ability to access individual words, expressions, and commonly used phrases.

– The ability to say anything about anything at anytime.


Interface of AAC (aided) and ASD

ASD AACVisual processing Uses visual medium

Motor planning Requires less motor skill

Multiple Cue Responding Scaffolding for complexity

Social difficulties Buffer and bridge

Interest in inanimate objects

Uses tools & technology

Principles of AAC Assessment

• Profile of learning characteristics

• Communication environments

• Preferences & perspectives

• Communication partners

• Ownership of device/language

• Continuous cycle of assessment and intervention

• Never a gatekeeper

Assessment Tools for AAC

• Participation Plans (Beukelman & Mirenda)– What does the student need to participate? What are the barriers?

What AAC tools facilitate participation and eliminate barriers

• SETT (Zabala)– Student, Environment, Task, Tools (available online)

• Social Networks (Blackstone & Berg)– Circles of Communication Partners

Autism and Aided AAC: What are evidence-based practices?

• Picture Exchange Communication System

• Functional Communication Training

• Augmented Input Strategies

• Speech Generating Devices

Evidence-based Practice: PECS

• Systematic sequential protocols• Exchange a symbol for a desired item• Expressive communication only• Acknowledges communication partner• Approximately 1/2 children developed speech

AAC: Course 101Visual Supports: Receptive Input• Schedules• Picture prompts• Written directions• Visual behavior cues• Token boards• Contingency maps• Power cards• Cognitive picture rehearsal


Preponderant Evidence for Visual Supports:

• Improve receptive language

• Improve expressive language

• Improve independence

• Decrease aberrant behavior

• Decrease prompt dependence

Zach’s Contingency Map


• There is a strong inverse relationship between problem behavior and communication skills.– Sigafoos (2000)

Evidence-based Practice: FCT with Aided AAC

• Functional Communication Training– PCS, objects, SGDs, Ideographs– Views all behavior as communicative– Replaces aberrant behavior with communication– Must be efficient, acceptable and recognizable– FCT produced “immediate, substantial and

sustained” decreases in aberrant behavior (Mirenda, 1998)

AAC and Choice Making

• Visual supports facilitate choice making

• Require less cognitive effort

• Reinforcement is more immediate

• Increases in positive behaviors

• Increases in initiations

No Tech vs. High Tech/SGD

• No Tech– Less costly

– Single stimulus

– Ease of use for communication partner

– Limited vocabulary

– Fewer “repair” issues

• High Tech/SGD– More costly

– Multiple stimuli

– Language within a language

– Repair issues

– Model for speech

– Auditory feedback

– May be “prestigious”

– Summon communication partner

Evidence-based practice: SGDs

• Low-tech (1 - 32 cells, single & multi-level)• High-tech• Summons attention of communication partners• Model for speech• Used alone or with other aided AAC• Augmented input model (SAL, Romski & Sevcik,

1996, 2009)

Case Study: Josh

• 6 years old• 3 years of no-tech communication boards,

books, wallets• “barking” as primary requesting behavior• emergence of SIB• introduction of High-Tech AAC

– Springboard– Training of communication partners

Jacob’s Springboard™ Intervention

• Introduced Springboard during structured academic settings

• Communication partner viewed Springboard as Jacob’s voice and ears & provided augmented input

• Navigation strategies were modeled naturally• Jacob’s requests were immediately acknowledged• Incidences of SIB charted

Josh’s Journey• From engineered environment, picture

exchange and augmented input to…

• High tech device provided with training for staff

• Communication partners provided input & created communication opportunities

• Device used for academics (math, reading)


Josh’s Journey

• Adopted device as his voice

• Maintained some intermittent vocalizations for requests

• Uses multi-modal communication; sign, paper communication boards, writing on white boards and high-tech device


Functional Vocabulary on High Tech AAC and Incidence of SIB

0

5

10

15

20

25

30

35

40

45

8/25

/08

9/1/

08

9/8/

08

9/15

/08

9/22

/08

9/29

/08

10/6

/08

10/1

3/08

SIB

Funct.Vocab.

Observational Results: Josh

• Used device during academics, meals, and preferred activities

• Navigated and found new vocabulary not previously modeled by communication partners

• Vocalized while activating SGD• Continued to use and accept low tech for some

receptive and expressive language• Vocalized to make requests and engaged in SIB

when SGD was not available

Eye-Gaze Communication MyTobii

• Designed for physically disabled individuals• Now piloted with girls with Rett Syndrome• Eye tracking technology• 15,000 symbols or text

Tobii Communicator

Evidence-based practice: Augmented Input Strategies

• Communication partner essential• Receptive language training (INPUT)• AAC viewed as legitimate language• Mother-tongue method• Natural Aided Language, System for Augmenting

Language, Visual Routines, Aided Language Modeling• Effective in increasing spontaneous speech and

augmented communication & decreasing aberrant behaviors (Cafiero, 1995, 2001, 2005; Dexter, 1998, Acheson, 2006)

Toddler Study: SALRomski, Sevcik, Smith, Barker, Folan & Barton-Hulsey, 2009)

• 60 randomly placed toddler/parent dyads

• ACI (input); ACO (output) & SCI (speech)

• Parent Training (8 weeks); parent practice w. feedback (7 weeks); parent solos (9 weeks)

• 30 minutes: 10 minutes of play; 10 minutes, literacy; 10 minutes snack


Toddler Study: Results for ASD Participants

• Retrospective Analysis of 11 of 60 dyads

• ACI & ACO were able to communicate after 18 sessions & maintained skills.

• Only some in SCI acquired speech.

• ACI/ACO: 5% SCI: 1.13%

• Are gains maturational?


Natural Aided Language: An AAC Based Methodology

(Acheson, 2006, Cafiero,1995, 2001)

• Incorporates Developmental, Incidental and Pivotal Response Methodologies

– Engineered environments– Child preference– Shared control– Practitioner extends engagement– Systematic input & prompts – Mixture of novelty & familiarity– All communicative attempts reinforced– Communication outcomes are observable and measurable

Zak

• 3 years old; middle child of 3• Involved parents• Communicates by taking hand of adult

(non-symbolic)• Tantrums• Aggressive• Seems to “read” video material

Objective: will increase communicative interactions

• Intervention– Identify reinforcers– Identify vocabulary– Create Natural Aided Language

comboard– Train communication partners

Number of Communicative Initiations and Responses: Parent and Child with and

without NALS

02468

1012

1 2 3 4 5 6 7 8

Weekly Probes

parent

child

00.5

11.5

22.5

33.5

4

NVComm

BodyUse

VerbalComm

Pre-NAL

Post NAL

Parent Perception of Autistic Symptoms on CARS (mean)

Parent Stress (Mean) on Parent Stress Index Pre & Post NALS

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Pre-NALS

Post NALS

Case Study: Timothy

• 13 years old, non-verbal

• Learned 5 signs in 5 years

• Diagnosis of Autism (severe range)

• Aggressive, bolts from classroom

• Self-stimulatory behaviors

• Screaming

Timothy- Natural Aided Language Intervention

• Increased augmented communicative input

(visual symbols) from 9 to over 60

• Engineered all environments and activities for communication

• All staff trained in Natural Aided Language

Number of PCS Initiations with Natural Aided Language Intervention

0

5

10

15

20

25

30

Baseline INV AfterESY

ResumeNAL

Charting “Bolting” (standing up, leaving instructional group without directions to do so)

Mean Weekly Incidence of Bolting

0

2

4

6

8

10

12

14

16

18

3/4/

03

3/11

/03

3/18

/03

3/25

/03

4/1/

03

4/8/

03

4/15

/03

4/22

/03

4/29

/03

Nu

mb

er

of

Bolt

s p

er

Week

Results of Natural Aided Language Intervention for Timothy

1. Increased compliance

2. Decreased bolting

3. Increase in number of symbols used

4. More complex & academic IEP

5. Greater staff satisfaction

Looking at typical babies & toddlers

• How long do we talk to babies and toddlers giving them receptive input before we expect them to start talking?

– One month?– 3 months?– 1 year?


Aided Language is NOT

• Quizzing with an AAC tool or device

• Saying “Touch this one.” or “Do this.”

• Using hand over hand

• Communication boards only

• Restricted to 100% non-verbal individuals


What are you modeling?

• Verbs, nouns, descriptors

• Syntax and pragmatics

• Operational use of vocabulary

• Mistakes and repair strategies


Aided Language: Backing it up!

• Cafiero, 1995, 2001

• Dexter, (1998)

• Drager, Postal et.al., (2006)

• Acheson, (2008)

• Romski, Sevcik et.al., (2009)


PRT and NAL: How do they compare?

Pivotal Response Treatments

• Shared control

• Natural reinforcers

• Mix new with mastered vocabularies

• Partner extends engagement

• All attempts are reinforced

Natural Aided Language

• Shared control

• Natural reinforcers

• Mixes new with mastered vocabularies

• Communication partner extends engagement

• All communicative attempts reinforced


Communication opportunities don’t just happen!

• They are overtly or covertly embedded in everyday routines

• Practitioner needs to recognize them or…• Practitioner needs to create them

• Engineering the environment

• Creative sabotage

• Interrupted behavior chain

• Time delay

Transitions, PECS and Aided Language Strategies

• Make least harmful assumption• Remember communication must be efficient to be

reinforcing• Include receptive language input always!• Communication is multi-modal, and inclusive.• Students may transition in and out of needing

Picture Exchange

Visual Scene DisplaysDrager, Light & Finke, 2009

• Targeted conceptual framework of CCN

• People, places, objects in backgrounds within which they exist

• “hot spots” were communication targets

• Increases in social language, turn taking and combining concepts for novel utterances

• Increases in navigation of SGD

Pragmatically Organized Dynamic Displays (PODD)

(Porter & Burkhart, 2008)

• Low-tech. augmented input

• Speaking partner intrinsically involved

• Complex architecture

• Symbol or word based displays

• Pragmatic branch starters

• Developed for physically disabled children

• Promising practice for ASD

Michelle: A Promising Practice with PODDS Intervention

• 6 years old Dx ASD; limited speaker; meltdowns with aggression.

• Literacy/Math above grade level

• PODDS used during high stress situations

• Conversation occurred between Michelle and her communication partner.

Pragmatic Organisation Dynamic Display

PODDS & Partner Assisted Scanning(Burkhart & Porter)


Michelle’s PODDs Intervention

• Increased receptive language

• Increased expressive language

• Increased choice making

• Decreased aggression

Core & Fringe Vocabulary: both are required for

communication• Core

– More open ended

– Applicable to many situations

• Fringe– Specific to a particular activity

– Vocabulary size across activities can be enormous

8 Location Phrase-based Core Vocabulary

Picture Word Power

Proloquo2Go Communication Software (iPod & iPad)

Literacy and AAC

• Robust literacy (reading & writing) is essential.

• Impossible to separate AAC from literacy

• Emergent literacy behaviors should be encouraged.

• Opportunity to engage in literacy learning supports functional spontaneous communication.

Why kids with ASD do not have literacy experiences:

• Low expectations

• Behavioral difficulties

• Delayed developmental milestones

• Motor planning challenges

• Medication issues

• Other


Why individuals with ASD should have writing experiences:

• Print is visual medium• Communication is core challenge• Reports from adult autism advocacy

movement– Real time speech, keyboard communication,

later adopters of AAC

• Basic human right• May become primary means of FSC & SNUG


Writing as Input; Writing as Communication

• Keyboards

• White boards

• Post-its™

• Alphabet boards

• Keyboard VOCAs


Writing is an essential part of the communication continuum:

all components are mutually reinforcing

• Receptive Language– Listening, processing graphics or print

(reading)

• Expressive Language– Speaking, using AAC, adapted and

conventional pencils (writing)


Emergent Writing:

• “Children begin reading by writing. People are natural message makers; we want to leave our mark.” (Erikson, 2008)

• Writing challenges children to think about print.

• Provides scaffolding for cognitive development


The Home-School Journal - Tools-No/Low Tech

• Boardmaker Symbols for home and school

• Visible storage bank for symbols at both home and school

• Custom made journal sheets

• Laminated bifold or file folder

• Velcro and laminate


Keyboard Communication

• Adult Autism Advocacy Movement• Keyboard Communication vs. “real time”

communication– Wait time, coordinating listening & communicating– Mechanics of the device, positioning

• Note qualitative difference between our own spoken vs. written language

• Former speaking communicators as adults transitioned to AAC

About Communication Partnerships:

• Speaking communication partner must view AAC as the voice and ears of the student

• Speaking communication partner must use the AAC device, pairing speech with AAC to acknowledge, repair, expand and model the language

• Speaking communication partner’s investment is essential for a successful AAC intervention.

Principles of AAC Interventions

• NEVER use a “wait & see” approach.

• AAC should be ubiquitous; across all environments.

• Augmented input must continue or language will regress

• Communication partners must create repeated planned opportunities.

• Ask: “How can AAC be applied? not ‘If’”.

More Principles of AAC

• Give augmented communicative input.• Assume that every individual, especially those

with the most difficult behaviors has something to say.

• Remember AAC helps develop language.• Do not place arbitrary timelines AAC intervention

- learning a language takes time.• Functional spontaneous communication is the

most important, life-enhancing skill an individual can learn!

dr. joanne cafiero webinar with autism now may 19, 2011

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