The Best Laid Plans Can Work: Selecting the Best AAC System

1. The Best Laid Plans Can Work: Selecting the Best AAC System Sarah Scarborough, MA, CCC-SLP Speech and Hearing Center University of South Carolina Carol O’Day, PhD, CCC-SLP South Carolina Assistive Technology Program Center for Disability Resources University of South Carolina School of Medicine

2. Training Objectives Participants will: • identify basic components of an AAC evaluation. • list four different types of symbol systems. • describe characteristics of functional communication messages

3. Keep in mind... The equipment, software, ideas and examples presented today represent a starting place and are not specific recommendations or endorsements. The suggested intervention techniques should be implemented only after careful consideration and under ongoing consultation from a qualified Speech-Language Pathologist.

4. Alternative/Augmentative Communication or “Visual Supports”a definition… …a device or method that helps persons with speech and/or hearing disabilities communicate.

5. Use a Multimodality Approach • AAC can be used with individuals who are verbal, limited verbally, or nonverbal. • Teach and encourage use of many forms of AAC. • Continue to address verbal skills, if appropriate, as you teach AAC skills.

6. Prerequisites for the Use of AAC NONE! Kangas & Lloyd, 1988 Beukelman & Mirenda, 1998

7. AAC Assessment • Before Evaluation: Review case history/ referral. • If you are already working with the child you can complete the case history. • If this child is new to you, then you may want to re-think your usual case history questions.

8. AAC Case History Questions… • Handedness for: ___ Writing ___Throwing ___ Eating • Method of Transportation: Walks: ___ independently___ with assistance Wheelchair: ____ independently ___ with assistance • Other positioning information: ___________________________________________ • Adaptive equipment used or required (e.g. head rest, switch):_______________________________________ • Describe any hearing impairment: __________________________________________ Hearing aid required? : ____ Yes ____ No • Describe any visual impairment: ____________________________________________ Corrective lenses required?: ____ Yes ____ No

9. More Case History Questions • List four activities that occupy the child for most of each day. • Name the people the child communicates with each day (e.g., friends, siblings, teachers, medical personnel, etc). • What are the child’s ‘favorite’ treats, rewards, activities? • What types of augmentative and alternative communication systems have been tried by the child in the past? • What was good about the systems? • What was bad about the systems? • Why isn’t a system being used now?

10. Questions to Ask Communication Partners

11. Performing the Augmentative Communication Evaluation Begin with a standard speech language evaluation… • Assess language level. • Assess pragmatics. • Assess speech, oral motor, voice, fluency. • Screen hearing.

12. How to Assess Language • Whenever possible use standardized assessments… - Boehm Test of Basic Concepts-3 • kindergarten-2nd grade - Peabody Picture Vocabulary Test-4 • age 2.6 through 90 years

13. More Language Assessments • Nonspeech Test by Mary Blake Huer • FCP-R Functional Communication Profile - Revised by Larry I. Kleiman

14. Language Assessment continued • Very often tests or subtests that require pointing response only can be adapted for use with children with deficits in the areas of access.

15. Speech Assessments • There are several tests of speech, e.g., Goldman-Fristoe Test of Articulation-2 or the Arizona Articulation Proficiency Scale: Revised. • Some children need specialty speech assessments, e.g., Frenchay Dysarthria Assessment or Apraxia Profile.

16. Once you complete the Speech Language evaluation, determine the child’s best method of symbolization…

17. Continuum of AAC Symbols • Continuum: - gestures (easiest) - signs - objects - objects with pictures and words - photos, pictures and words - text (most difficult)

18. Language Activities Resource Kit Language Activities Resource Kit - Second Edition (LARK-2), Pro-Ed Richard A. Dressler. Western Aphasia Battery (WAB), Ali-Med Andrew Kertesz, M.D. 

19. Using Pictures/Graphics to Communicate • Test of Aided Communication Symbol Performance (TASP) by Mayer-Johnson - Assesses symbolic skills. - Guides communication board design. - Includes subtests for symbol size and number, grammatical encoding, categorization and syntactic performance.

20. Using Pictures/Graphics to Communicate • EvaluWare Software helps identify the best computer access methods and ideal AAC setups for users with special needs. • Motor/access skills. • Looking skills. • Listening skills. • Other related skills.

21. Adaptivation Object Cards

22. Homemade Symbol Assessment Kit

23. Using Pictures/Graphics to Communicate • Picture Master Language Software • Picture Master Board Designer - Does not come with animated files or speech functions.

24. AAC Symbols • How do you know when you have chosen the correct AAC symbol set? - the child is able to meet functional communication goals. - the child can communicate basic wants and needs.

25. Why Objects Work • Concrete (low cognitive demand) • Static or permanent (low memory demand) • Iconic (close obvious relationship to referent) • Easy to manipulate • Allow tactile discrimination • Support expressive and receptive communication Elizabeth Rush, MA, CCC-SLP, CPM Mary Joan McClure, MS, CCC-SLP

26. Why Objects May Not Work • Object identification is not communication. • Miniature objects are not understood well by some (individuals who are visually impaired or autistic). • Non-motivating objects used. • Difficult to find objects to represent verbs, adjectives, modifiers, etc.

27. Using Objects to Communicate • May need to use the actual object at first. • Use a duplicate object (symbol) as soon as possible. • Begin exchange system. • Mount object on board or voice output device. • Introduce second, but different object symbol (change color, size or texture of object). Elizabeth Rush, MA, CCC-SLP, CPM Mary Joan McClure, MS, CCC-SLP

28. Using Pictures/Graphics to Communicate • Pictures and graphics have varying levels of iconicity. • Size, background color, and number do matter.

29. Once you determine child’s best method of symbolization • Determine how many symbols he/she can handle at one time. • What type of layout does he/she scan/ reach best? • Does he/she prefer sound/voicing feedback? • How best to access this system? Switch, type, point, etc.

31. Back to the AAC Assessment… • Summarize Your Findings: - Symbol Preference - Optimal target/text size - Optimal number of targets (words/pictures/objects) - Recommended layout - Best method of access

32. Use the AAC assessment summary plus your evaluation of the child’s language/speech skills and prognosis to determine the best augmentative/alternative communication system.

33. Considerations: • Look at the child’s language age: - How many words does a child of a similar age with age appropriate communication skills use?

34. 18 months • According to Nicolosi and Collins, children with language ages of 18 months have a vocabulary of 10-20 words and at 24 months their vocabulary increases to 200 words.

35. 2-3 years • According to Nicolosi and Collins, from 2 years to 2 ½ years expressive vocabulary ranges from 200-300 words and from 2 ½ to 3 years receptive vocabulary increases from 400 words to 800 words with an expressive vocabulary of 900 words at 3 years.

36. 3-4 years • According to Nicolosi and Collins, from 3 to 4 years receptive vocabulary is up to 1500 words and expressive vocabulary ranges from 900 to 1500 words.

37. Call for help! • Once you have summarized the results: - Discuss findings with your school district’s assistive technology team or - Contact Carol O’Day (803-935-5301, coday@cdd.sc.edu) to discuss the AAC system that best meets the cognitive/language/access needs of your child or to borrow AAC devices. - Or both!

38. Writing the report • You’ve done the work… • Now write it up!

39. Elements of an AAC Evaluation Report: • Demographic information. • Current communication impairment. • Daily communication needs. • Functional communication goals. • Rationale for device selection. • Treatment plan. • Functional benefit of upgrade (if needed). • SLP assurance of financial independence and signature. • See this website for more details: http://www.aac-rerc.com/pages/medicare/MCAppProtocol.htm

40. Basic Considerations of AAC Devices • Size • Weight • Display size • Battery life • Access method • Does the device meet current and future needs and expectations?

41. Other Considerations… • Compare what you want for the child with other devices/systems you decided against. • What was best about your choice?

42. Making a treatment plan • Consider message selection. • Communication environments & partners.

43. Message Selection • Requesting wants and needs • Making choices • Confirming or denying • Rejecting and protesting • Gaining attention • Providing greetings, farewells, social • niceties • Expressing feelings • Making comments • Asking for information or help • Telling jokes • Connecting with peers • Asking questions Promote Self- Determination!

44. Message Selection • Message Selection: - If neurological and physical potential for speech exists, a preference will be shown towards speech. - Speech is easy and highly accepted . (Burkhart, 1993, p. 38) - Children will tend to use the least restrictive mode of communication.

45. Message Selection • Message Selection: - Avoid starting with messages that are abstract in nature (ie. “yes” and no”). - Avoid programming messages that can be gestured or spoken (ie. “yes” and “no”). - Avoid messages regarding functions that the child has not mastered (ie. “bathroom”).

46. Message Selection • Core Vocabulary: - A few hundred words that make up approximately 80% of what a person says. - Dolch words (see “Unique Websites”). - “Total communication” is the combination of general core vocabulary and extended vocabulary. - Combine general core vocabulary and personal core vocabulary for fastest communication. AAC Institute

47. Message Selection • Use single-word messages whenever possible because they allow for generative language and utterance expansion. (Anderson & Baker, 2004)

48. Message Selection • Why single-word messages can be more efficient: • - Communicating using single-word messages allows more flexibility than sentence messages. • - Generating a message using single-word messages is easier overall than communicating through sentence messages. • - Single-word messages can be used across environments. • - Sentence messages rarely reflect speaker intentionality. • - Language acquisition takes place when single-word messages are combined to make multi-word messages.

49. Message Selection • Effectively programming sentences: • - Use sentences for messages that are used repeatedly. • - Use sentences as a complement to, not as a replacement for, single-word messages. • May consider messages such as, “I want to say something that’s not on my device" or "Please ask yes-or-no questions."

50. Message Selection • When should you start encouraging generative language skills? • May not have to wait until developmental language norms are reached with AAC to begin teaching generative language.