Augmentative/Augmentative/Alternative Alternative

Communication Communication Cassandra M. Mariano, M.A., Cassandra M. Mariano, M.A.,

CCC-SLPCCC-SLP

Jessica M. Antioco, M.S., CFYJessica M. Antioco, M.S., CFY

AcknowledgementsAcknowledgements

• Students & FamiliesStudents & Families• Dr. Joanne Gerenser, Executive Dr. Joanne Gerenser, Executive

DirectorDirector• Jan Downey, M.A., CCC-SLP, Jan Downey, M.A., CCC-SLP,

Director of Speech ServicesDirector of Speech Services• Eden II Speech Staff, past and Eden II Speech Staff, past and

presentpresent

What does AAC stand What does AAC stand for?for?

• A – AugmentativeA – Augmentative• A – AlternativeA – Alternative• C – CommunicationC – Communication

Why do we need to talk Why do we need to talk about AAC?about AAC?

• Because more than 50% of students Because more than 50% of students at our Granite Ave school alone use at our Granite Ave school alone use an AAC system.an AAC system.

• Because Autism significantly impairs Because Autism significantly impairs a person’s abilities particularly in a person’s abilities particularly in the areas of language, the areas of language, communication and social relationscommunication and social relations

What exactly is AAC?What exactly is AAC?

• The American Speech, Language and The American Speech, Language and Hearing Association defines alternative Hearing Association defines alternative and augmentative communication and augmentative communication (AAC) as an “area of clinical practice (AAC) as an “area of clinical practice that attempts to compensate, either that attempts to compensate, either temporarily or permanently, for the temporarily or permanently, for the impairment and disability patterns of impairment and disability patterns of individuals with severe expressive individuals with severe expressive communication disorders.”communication disorders.”

Why might a student Why might a student require an AAC system?require an AAC system?

• They do not use verbal speech as a They do not use verbal speech as a reliable means of functional reliable means of functional communication.communication.

• They might require the system:They might require the system:– To Augment their speechTo Augment their speech– As an alternative to speechAs an alternative to speech

Augmentative Augmentative CommunicationCommunication

• Refers to “any approach designed to support, Refers to “any approach designed to support, enhance, or supplement the communication enhance, or supplement the communication of individuals who are not independent of individuals who are not independent verbal communicators in all situations” verbal communicators in all situations” (Niciosi, (Niciosi, Harryman, & Krescheck)Harryman, & Krescheck)

• An augmentative communication system An augmentative communication system supports supports existing language and existing language and communication skills.communication skills.

• Students using a system in an augmentative Students using a system in an augmentative context should be required to verbally context should be required to verbally approximate.approximate.

Alternative Alternative CommunicationCommunication

• Refers to any approach designed to Refers to any approach designed to REPLACE verbal speech.REPLACE verbal speech.

What’s the difference?What’s the difference?

• Augmentative SUPPORTS verbal speechAugmentative SUPPORTS verbal speech• Alternative REPLACES verbal speechAlternative REPLACES verbal speech

• Important to note: Whether or not a Important to note: Whether or not a system is augmentative OR alternative system is augmentative OR alternative depends on the student not the system depends on the student not the system itself. Ex: For Johnny, sign language itself. Ex: For Johnny, sign language may be an augmentative system. For may be an augmentative system. For Billy, sign language may alternative.Billy, sign language may alternative.

Things to consider…Things to consider…

• Does the student have an effective Does the student have an effective communication system?communication system?

• Is the system being used Is the system being used appropriately by the student?appropriately by the student?

• Is the system being used Is the system being used appropriately by the staff?appropriately by the staff?

• Is there carry over between home Is there carry over between home and school?and school?

In other words…In other words…

• AAC systems give students a VOICE.AAC systems give students a VOICE.

Impact of AutismImpact of Autism

Hallmarks are : Hallmarks are : – A breakdown in all three communication A breakdown in all three communication

components (encoding, transmitting and decoding)components (encoding, transmitting and decoding)– Difficulty understanding language conceptsDifficulty understanding language concepts– Failure to comprehend gesturesFailure to comprehend gestures– Lack of spontaneous use of languageLack of spontaneous use of language– Lack of imaginationLack of imagination– Deficits in understanding and using appropriate Deficits in understanding and using appropriate

languagelanguage– Restricted or limited knowledge of vocabularyRestricted or limited knowledge of vocabulary– Difficulty understanding spoken languageDifficulty understanding spoken language

Impact of Autism on Impact of Autism on SpeechSpeech

• 30 – 50 % of individuals with Autism may 30 – 50 % of individuals with Autism may never develop functional speech never develop functional speech

• Functional speech is speech that can be Functional speech is speech that can be understood by people who are not understood by people who are not familiar with the speaker under all familiar with the speaker under all conditions.conditions.

• Many of those students who are verbal Many of those students who are verbal have articulation and phonological have articulation and phonological errors, which makes their speech less errors, which makes their speech less intelligible.intelligible.

Therefore…Therefore…

• Many individuals with autism are Many individuals with autism are candidates for candidates for Augmentative/Alternative Augmentative/Alternative Communication (AAC) systems!Communication (AAC) systems!

What are the modes of What are the modes of communication?communication?

• Verbal speechVerbal speech• Body languageBody language

– GesturesGestures– PointingPointing– Facial expressionsFacial expressions– Body postureBody posture– Eye contactEye contact

• AAC systems AAC systems (Augmentative/Alternative (Augmentative/Alternative Communication)Communication)

Benefits of AAC systemsBenefits of AAC systems

• Enhances communicative competenceEnhances communicative competence• Faciliates the development of language Faciliates the development of language

skillsskills• Research suggests that AAC systems Research suggests that AAC systems

may increase speech productionmay increase speech production• May increase speech intelligibility in May increase speech intelligibility in

some individualssome individuals• Evidence indicates that AAC Evidence indicates that AAC

interventions do not have a negative interventions do not have a negative impact on speech productionimpact on speech production (Light, Millar, (Light, Millar, Schlosser 2006)Schlosser 2006)

Benefits continued…Benefits continued…

• Provides an effective and appropriate Provides an effective and appropriate means of communication in individuals means of communication in individuals who are unable to meet their who are unable to meet their communication needs using speechcommunication needs using speech

• Decreases inappropriate and Decreases inappropriate and maladaptive behaviors that are a result maladaptive behaviors that are a result of an inability to communicate effectivelyof an inability to communicate effectively

• May reduce the pressure from the May reduce the pressure from the demands of speech production in order demands of speech production in order to focus on communicationto focus on communication

MisconceptionsMisconceptions

• Inhibits speech productionInhibits speech production• Negatively impacts the emergence of Negatively impacts the emergence of

speechspeech• Individuals may prefer to use their AAC Individuals may prefer to use their AAC

system and not be motivated to learn to system and not be motivated to learn to use speechuse speech

• Many clinicians perceive that they must Many clinicians perceive that they must make an “either-or” decision; i.e. pursue make an “either-or” decision; i.e. pursue speech development or introduce an AAC speech development or introduce an AAC system. system. (Light, Millar, Schlosser 2006).(Light, Millar, Schlosser 2006).

““No Tech” SystemsNo Tech” Systems

• ““No Tech” systems – do not require an No Tech” systems – do not require an outside power source.outside power source.– Picture Exchange Communication System Picture Exchange Communication System

(PECS) – developed by Andy Bondy, PhD and (PECS) – developed by Andy Bondy, PhD and Lori Frost, CCC-SLP in the 80’s. This is a Lori Frost, CCC-SLP in the 80’s. This is a system where pictures on a board or in a book system where pictures on a board or in a book initially represent desired items and activities initially represent desired items and activities and then moves on to other language concepts. and then moves on to other language concepts. The student exchanges the picture with a The student exchanges the picture with a communicative partner. communicative partner.

– Sign languageSign language– Picture boardsPicture boards– Written scripts Written scripts

PECS bookPECS book

PECS - ProsPECS - Pros

• The picture exchange requires The picture exchange requires interaction with a partner.interaction with a partner.

• You can use it to enhance eye contact.You can use it to enhance eye contact.• PortablePortable• Inexpensive – you can make your own Inexpensive – you can make your own

pictures either with Boardmaker pictures either with Boardmaker (Mayer Johnson pictures) or any digital (Mayer Johnson pictures) or any digital image or photo (Google Image is a image or photo (Google Image is a great place to find some)great place to find some)

PECS - ConsPECS - Cons

• Depending on how many pages a Depending on how many pages a student has, finding the desired student has, finding the desired picture can be slow.picture can be slow.

• SO easy to lose pictures.SO easy to lose pictures.• Can be clumsy.Can be clumsy.

Manual SignsManual Signs

Manual Signs- ProsManual Signs- Pros

• PortablePortable• Cost efficientCost efficient• All communicative functions can be All communicative functions can be

expressedexpressed• FastFast• Easily paired with vocalizationsEasily paired with vocalizations

Manual Signs- ConsManual Signs- Cons

• Multiple motor movementsMultiple motor movements• Slow learningSlow learning• Limited communication partnersLimited communication partners

Picture BoardPicture Board

Picture Boards - ProsPicture Boards - Pros

• Provides direct selectionProvides direct selection• Visual and concreteVisual and concrete• Cost efficientCost efficient• DurableDurable• PortablePortable• Can be made specific to needsCan be made specific to needs• Easily understoodEasily understood

Picture Boards - ConsPicture Boards - Cons

• Exchange is not requiredExchange is not required• No turn takingNo turn taking• Requires a pointRequires a point• May reduce eye contactMay reduce eye contact

Written ScriptsWritten Scripts

Written scripts - ProsWritten scripts - Pros

• Reduces prompt dependency (written Reduces prompt dependency (written prompts are easier to fade than verbal prompts are easier to fade than verbal prompting)prompting)

• Made specific to individual’s nedsMade specific to individual’s neds• Can be easily updatedCan be easily updated• Offers a variety of script fading and Offers a variety of script fading and

prompting options tailored specifically prompting options tailored specifically to a student’s needto a student’s need

• Allows for consistency across instructorsAllows for consistency across instructors

Written scripts - ConsWritten scripts - Cons

• No verbal modelNo verbal model• Requires continuous changes while Requires continuous changes while

fadingfading• Does not promote eye contact (when Does not promote eye contact (when

first introducing a script)first introducing a script)

“ “Tech” SystemsTech” Systems

• ““Tech” systems – require a power Tech” systems – require a power source (batteries or a charger)source (batteries or a charger)

Voice Output DevicesVoice Output Devices

Voice output - ProsVoice output - Pros

• Direct selectionDirect selection• Visual and concreteVisual and concrete• Can enhance syntaxCan enhance syntax• Verbal model remains constantVerbal model remains constant• The user can be responded to as a The user can be responded to as a

competent speaker competent speaker • Can be made specific to needsCan be made specific to needs• Easily understoodEasily understood• Easily updatedEasily updated• Can have unlimited vocabularyCan have unlimited vocabulary

Voice Output - ConsVoice Output - Cons

• Devices can be very expensiveDevices can be very expensive• Can break downCan break down• Requires programmingRequires programming• May promote stereotypyMay promote stereotypy• Can be heavy/bulkyCan be heavy/bulky

What do our students What do our students currently use their AAC currently use their AAC

systems for?systems for?• RequestingRequesting• Exchange of personal informationExchange of personal information

• There are SO many more There are SO many more opportunities for language once the opportunities for language once the system is taught…system is taught…

What COULD our students What COULD our students use their AAC systems for?use their AAC systems for?

• Requesting for preferred or needed items Requesting for preferred or needed items and activities.and activities.

• Requesting for the bathroom.Requesting for the bathroom.• Commenting – “I like this juice.”Commenting – “I like this juice.”• Denying – “No, I didn’t go to the park.”Denying – “No, I didn’t go to the park.”• Labeling – “That’s a dog.”Labeling – “That’s a dog.”• Initiating greetings Initiating greetings • Responding to social questions and Responding to social questions and

exchanging of personal information - “My exchanging of personal information - “My name is Fred. I live in Staten Island.”name is Fred. I live in Staten Island.”

Assessment, Referral and Assessment, Referral and EvaluationEvaluation

• Determine an individual’s Determine an individual’s communicative needscommunicative needs

• Evaluate components of their Evaluate components of their existing communication systemexisting communication system

• Assess prerequisite skills (fine Assess prerequisite skills (fine motor, matching, object/picture motor, matching, object/picture identification etc.)identification etc.)

Now what?Now what?

• Parents, speech therapists and teachers Parents, speech therapists and teachers may recommend that an individual be may recommend that an individual be referred for an AAC evaluation.referred for an AAC evaluation.

• An evaluation by a team of qualified An evaluation by a team of qualified professionals is an important component professionals is an important component in the selection of appropriate systemsin the selection of appropriate systems

• It is essential that someone on the team It is essential that someone on the team has knowledge of Autism and ABA.has knowledge of Autism and ABA.

• An understanding of the unique An understanding of the unique characteristics of the individual student characteristics of the individual student including learning styles and maladaptive including learning styles and maladaptive and stereotypical behaviors.and stereotypical behaviors.

ResistanceResistance

• Sometimes we find that our students Sometimes we find that our students parents are initially resistant to the parents are initially resistant to the idea of an AAC system.idea of an AAC system.

• Why? Because they feel we are Why? Because they feel we are giving up on their children becoming giving up on their children becoming verbal communicators.verbal communicators.

What do we say?What do we say?

• There is no evidence that supports the There is no evidence that supports the assumption that use of an AAC system assumption that use of an AAC system decreases the likelihood of speech decreases the likelihood of speech development.development.

• Research has shown that when an AAC system Research has shown that when an AAC system is introduced, many children actually is introduced, many children actually demonstrate an increase in speech, language demonstrate an increase in speech, language and communication skills.and communication skills.

• At this time, there is insufficient evidence to At this time, there is insufficient evidence to indicate the superiority of one system over indicate the superiority of one system over another to promote speech.another to promote speech.

Issues to consider when Issues to consider when teaching an AAC systemteaching an AAC system

• Identify goalsIdentify goals• Plan your targets beforehandPlan your targets beforehand• Introduce systematically (For Introduce systematically (For

example, we may want to start with example, we may want to start with one icon and add accordingly).one icon and add accordingly).

• Begin with highly preferred items – Begin with highly preferred items – Initially, these items should be “free Initially, these items should be “free access” and immediately available.access” and immediately available.

And the survey says…And the survey says…

• A survey was recently conducted amongst Eden A survey was recently conducted amongst Eden II and Genesis school staff to gauge feelings II and Genesis school staff to gauge feelings and beliefs about AAC systems.and beliefs about AAC systems.

• Of those that were invited to participate, Of those that were invited to participate, respondents included speech respondents included speech pathologists/therapists (40%), teachers (28%), pathologists/therapists (40%), teachers (28%), behavior specialists (8%) and teacher assistants behavior specialists (8%) and teacher assistants (24%).(24%).

• Of those that responded, 75% have been Of those that responded, 75% have been employed by Eden II/Genesis for 5 years or less. employed by Eden II/Genesis for 5 years or less. 4.2% worked between 5 and 10 years. 20.8% 4.2% worked between 5 and 10 years. 20.8% have been with the agency less than 1 year.have been with the agency less than 1 year.

Survey resultsSurvey results

• RespondentRespondents were s were asked to asked to rate how rate how familiar familiar they are they are with with various various systems.systems. 0

10

20

30

40

50

60

70

80

Sign PECS Voiceoutput

Pictureboards

ExtremelyfamiliarSomewhatfamiliarNot familiar

How important is it for a child How important is it for a child with limited speech to have an with limited speech to have an

AAC system?AAC system?

0

10

20

30

40

50

60

70

80

NotimportantSomewhatimportantCrucial

Itdepends

•   For those that chose For those that chose “it depends” we got a “it depends” we got a variety of explanations variety of explanations including - including -

““It depends if the child is It depends if the child is educated or advanced educated or advanced enough to use it enough to use it properly.”properly.”

“ “I feel if a child is I feel if a child is somewhat verbal we somewhat verbal we should be prompting should be prompting them more to talk. If a them more to talk. If a child has no speech child has no speech they should have an they should have an AAC system.” AAC system.”

I work with students who I work with students who use…use…

0102030405060708090

100

types ofsystems

Verbal SpeechSign languagePECSVoice ouputPicture BoardCombination of systems

Staff’s level of comfort with Staff’s level of comfort with systemssystems

0

10

20

30

40

50

60

70

80

90

Always Sometimes Never

Comfortable withvarious systems

That I have beeninstructed on systems

That I understand mystudent without asystemThat my student trulyneeds a system

SpontaneitySpontaneity

0

10

20

30

40

50

60

70

80

Always Sometime Never

Initiates conversationInitiates requestsInitiates social greetings

Spontaneity continuedSpontaneity continued

• 80% of staff feel that students need 80% of staff feel that students need consistent prompting to use their consistent prompting to use their AAC system.AAC system.

• Comments made on the survey Comments made on the survey indicate that most staff feel as indicate that most staff feel as though students act mainly as though students act mainly as respondents with their systems.respondents with their systems.

Favorite deviceFavorite device

• 68.2% of staff reported that their 68.2% of staff reported that their favorite system to work with is a favorite system to work with is a voice output devicevoice output device. (Compared . (Compared with 22.7% who preferred PECS and with 22.7% who preferred PECS and 4.5% that preferred sign language).4.5% that preferred sign language).

• Respondents indicate that they have Respondents indicate that they have more experience with a voice output more experience with a voice output device and see more spontaneity in device and see more spontaneity in requests and initiations with it.requests and initiations with it.

Why do they like voice Why do they like voice output devices?output devices?

• Responses included:Responses included:– Provides a child with a voiceProvides a child with a voice– Commands attention easilyCommands attention easily– Gives students a large vocabularyGives students a large vocabulary– Voice output provides a model for Voice output provides a model for

students to imitate.students to imitate.– Helps promote intelligibility and good Helps promote intelligibility and good

articulationarticulation

Least favorite systemLeast favorite system

• Results of this survey indicated that Results of this survey indicated that staff found staff found picture boardspicture boards to be to be least preferred.least preferred.

• Only 8.3% feel that they have Only 8.3% feel that they have experience with it and 4% feel that it experience with it and 4% feel that it leads to spontaneous requesting leads to spontaneous requesting and/or initiations.and/or initiations.

Why don’t they like picture Why don’t they like picture boards?boards?

• Responses included:Responses included:– Not that familiar with picture boardsNot that familiar with picture boards– Boards are very limitedBoards are very limited– Boards reduce eye contactBoards reduce eye contact– Boards are easily bent and lostBoards are easily bent and lost

ChallengesChallenges

• ““The system is not send in from home or The system is not send in from home or device is not sent in charged.” (62.5%)device is not sent in charged.” (62.5%)

• ““My student has a device that is always My student has a device that is always broken and out for repair.” (54.2%)broken and out for repair.” (54.2%)

• ““Content on the system does not match Content on the system does not match what I need in the classroom.” (41.7%)what I need in the classroom.” (41.7%)

• ““The system or device is too bulky or The system or device is too bulky or takes up too much room on the takes up too much room on the desk.”(29.2%)desk.”(29.2%)

Why aren’t systems out in Why aren’t systems out in the classroom?the classroom?

• We know how important it is to have the We know how important it is to have the student’s system available to them at all student’s system available to them at all times. Why then do we see students without times. Why then do we see students without their systems?their systems?

• 80% of respondents say its because the device 80% of respondents say its because the device was not sent in from home or it was not sent was not sent in from home or it was not sent in charged.in charged.

• 10% say they have not been properly trained 10% say they have not been properly trained on the system.on the system.

• 10% say that they understand their student 10% say that they understand their student without their system.without their system.

Staff need more training – Staff need more training – what is appropriate?what is appropriate?

• 92% of staff 92% of staff feel that they feel that they would would benefit from benefit from increased increased staff staff training.training.

• 58.3% stated 58.3% stated that that quarterly quarterly trainings trainings would would suffice.suffice.

0

10

20

30

40

50

60

Twice a monthOnce a monthQuarterlyTwice a year

Training for StaffTraining for Staff

• Training staff on AAC systems, especially Training staff on AAC systems, especially voice output device, should include:voice output device, should include:– Basic device operation (on/off button, restart Basic device operation (on/off button, restart

button, recording and charging)button, recording and charging)– Teaching methods (correct prompting Teaching methods (correct prompting

procedures, knowledge of whether the procedures, knowledge of whether the system is augmentative or alternative and system is augmentative or alternative and whether we are requiring a verbal whether we are requiring a verbal approximation)approximation)

– AAC systems should be with students at all AAC systems should be with students at all times.times.

Training for Training for parents/caregiversparents/caregivers

• Are parents/caregivers aware of who Are parents/caregivers aware of who to contact regarding AAC system?to contact regarding AAC system?

• Are parents/caregivers trained to Are parents/caregivers trained to use system?use system?

• Are parents/caregivers aware that Are parents/caregivers aware that the system must be sent to school the system must be sent to school daily? And if it’s a device, that it daily? And if it’s a device, that it must be charged?must be charged?

Group ActivityGroup Activity

• What skills do we look for?What skills do we look for?• What system would YOU give a What system would YOU give a

student?student?

Profile 1Profile 1

• Male student, 4 years oldMale student, 4 years old• Non-verbal communicator, will babble Non-verbal communicator, will babble

spontaneously during play, indicates wants spontaneously during play, indicates wants by reaching and grabbing.by reaching and grabbing.

• Can receptively identify 15+ objects and Can receptively identify 15+ objects and between 10-15 pictures.between 10-15 pictures.

• He can match identical objects, pictures He can match identical objects, pictures and objects to pictures.and objects to pictures.

• Poor eye contactPoor eye contact• Limited fine motor skillsLimited fine motor skills

Profile 1Profile 1

• Would this student need an Would this student need an augmentative system or an augmentative system or an alternative system?alternative system?

• What system would you pick for this What system would you pick for this child and why?child and why?

• What “back up” system would you What “back up” system would you recommend?recommend?

Profile 2Profile 2• Female student, 13 years oldFemale student, 13 years old• She is a verbal student with multiple articulation She is a verbal student with multiple articulation

errors, she speaks in a low tone and exhibits errors, she speaks in a low tone and exhibits rapid speech when frustratedrapid speech when frustrated

• Not easily understood by unfamiliar listenersNot easily understood by unfamiliar listeners• Can receptively and expressively identify a Can receptively and expressively identify a

multitude of objects and picturesmultitude of objects and pictures• Is currently matching categoriesIs currently matching categories• Previously used PECS until age 7 when she Previously used PECS until age 7 when she

started using verbal speech.started using verbal speech.• Often requires prompting to make requests.Often requires prompting to make requests.• Fine motor skills intactFine motor skills intact• Exhibits hand flappingExhibits hand flapping

Profile 2Profile 2

• Would this student need an Would this student need an augmentative system or an augmentative system or an alternative system?alternative system?

• What system would you pick for this What system would you pick for this child and why?child and why?

• What “back up” system would you What “back up” system would you recommend?recommend?

Profile 3Profile 3• Male student, 3.5 years oldMale student, 3.5 years old• He is a able to imitate one syllable words but He is a able to imitate one syllable words but

does not use speech to indicate wants and desiresdoes not use speech to indicate wants and desires• He reaches and grabs for desired itemsHe reaches and grabs for desired items• Excellent with non- verbal imitationsExcellent with non- verbal imitations• Good fine motor skillsGood fine motor skills• Can match identical objectsCan match identical objects• At present time, cannot receptively identify At present time, cannot receptively identify

objectsobjects• Behaviors include sweeping objects/materials off Behaviors include sweeping objects/materials off

desk onto floordesk onto floor• Has two one concept commands in discrimination Has two one concept commands in discrimination • Responds to name with head turnResponds to name with head turn

Profile 3Profile 3

• Would this student need an Would this student need an augmentative system or an augmentative system or an alternative system?alternative system?

• What system would you pick for this What system would you pick for this child and why?child and why?

• What “back up” system would you What “back up” system would you recommend?recommend?

Profile 4Profile 4• Female student, 8 years oldFemale student, 8 years old• Student is passive and often prompt-dependentStudent is passive and often prompt-dependent• Utilizes verbal speech to make wants and Utilizes verbal speech to make wants and

needs knownneeds known• Excellent fine motor abilitiesExcellent fine motor abilities• Is matching categoriesIs matching categories• Is stronger receptively identifying picturesIs stronger receptively identifying pictures• Will occasionally cry and/or laugh for unknown Will occasionally cry and/or laugh for unknown

reasonsreasons• Parents requested for a system that would Parents requested for a system that would

enable her to be more enable her to be more independent/spontaneousindependent/spontaneous

Profile 4Profile 4

• Would this student need an Would this student need an augmentative system or an augmentative system or an alternative system?alternative system?

• What system would you pick for this What system would you pick for this child and why?child and why?

• What “back up” system would you What “back up” system would you recommend?recommend?