2001 Conference Proceedings

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OVERCOMING BARRIERS TO EXCELLENCE IN AUGMENTATIVE COMMUNICATION

Penny Reed & Paula Walser

Many people become bogged down with questions and barriers that seem to keep them from moving forward in providing effective augmentative communication services. Following are many of the problems that we encounter, with suggested solutions.

When there is a question of whether or not to try AAC with a student, ask critical questions.-Is the student's ability to speak meeting his or her need to communicate with others in various environments? Is the student's ability to speak holding back his or her opportunity to practice language? Could AAC provide new opportunities for the development of both speech and language ability? If the answer to any of these is yes, then AAC should be considered.

There has been a great deal of research conducted regarding the impact of augmentative communication interventions on the attempts at speech communication. In a review of 25 studies, Silverman (1995) found that in the overwhelming majority of cases, the use of augmentative communication actually increased natural speech production. In addition, Blischak (1999) specifically studied the effect of using voice output communication aids and found that there was a marked increase in production of natural speech by children following the use of the voice output devices. We include this information to point out that there is absolutely no basis to believe that it is an either /or choice. The use of augmentative communication will absolutely not limit the development of or increase in natural speech. In fact, it has a high likelihood of promoting it.

However, all children's need for augmentative communication is not the same. Martinsen & von Tetzchner (1996) identified three groups of children who require augmentative/ alternative communication. They called these the: alternative language group, expressive language group, and supportive language group. Each of these groups is very different and requires AAC for different reasons.

The Alternate Language Group is made up of children who use little or no speech to communicate and have a difficult time understanding spoken language. Children with Autism and severe cognitive impairment fall into this group, as do children with auditory agnosia (Problems recognizing sounds as meaningful linguistic elements.). Children in this group often use gesture as their primary means of understanding language. The primary goals of AAC with this group are to provide input to assist the student in the understanding of language, to develop interaction skills for that student and to increase the opportunities for expressive communication.

The Expressive Language Group includes students who have severe motor involvement, thus severe speech motor dysfunction. As they mature these children experience a widening gap between what they understand and what they are able to express using speech. Children with athetoid cerebral palsy and severe dysarthria of speech are examples . The main goal for AAC intervention with this group is to provide a means to express their interests, needs, and comments, provide opportunities to actively participate in the curriculum and focus on the development of literacy skills.

The Supportive Language Group includes students with moderate motor speech dysfunction. These children often have problems with both speech and language. Speech is poorly articulated during the birth through preschool years, although many of these children will become intelligible speakers. This group may include children with: Down syndrome, apraxia of speech, severe oral-motor impairments, severe articulation disorders and developmental delay. The primary goal of AAC intervention for this group is to provide a bridge for the development of speech and language and a means to enhance participation and increase communicative competence.

When a student does not have a means to communicate, create low tech opportunities using real objects, pictures, or symbols, while investigating voice output devices as part of a comprehensive augmentative communication assessment.-You do not have to start with expensive or high tech augmentative communication devices. Low tech communication boards are not difficult to create and can begin to provide information on what effect augmentative communication might have. For students who may be ready to use symbols, BoardMaker is a great tool for educators or parents to create communication boards about a variety of topics and activities. If a child has not previously had any augmentative communication intervention, a comprehensive AAC assessment needs to take place. This may be part of the process of assessing a student's need for various assistive technology or it may be the only area of concern. In either case, standardized tools to complete this type of assessment are few and seldom address all of the unique needs of the individual student. Therefore, an AAC assessment is often completed by combining information collected through standardized testing procedures, combined with interviews, observations, and a period of diagnostic intervention which includes trial use. The period of diagnostic intervention itself is complex and may include trials with different devices or combination of devices. It is important to use all components of a planned system within all routine environments with the child before large purchases are completed. In fact, many funding sources require a trial period of use with the desired system before funding approval is given.

Fortunately there is increased recognition of the importance of conducting an assessment of the need for AAC as soon as it becomes apparent that a child's speech and/or language is not developing at a typical pace or is not meeting his/her communication needs. Many children are now provided AAC options in Birth to Three and Early Childhood programs when in the past that intervention would have been delayed until mid elementary school. Beukelman and Mirenda (1992) suggest that if an AAC system is not in place by the time a child begins first grade, the child will not be an active participant in the regular education curriculum. We also recognize the fact that children who are unable to verbally communicate are likely to be significantly environmentally disadvantaged when learning language. Research in the areas of the brain, learning and language acquisition overwhelmingly emphasize the importance of addressing the language needs of children at a very early age. When there is a question of whether or not the student is intentionally activating a switch, consider using Every Move Counts (Korsten, Dunn, Foss, & Francke, 1993)-Every Move Counts is a comprehensive sensory based communication program. It includes assessment and intervention strategies to use with children who are unable to use formal language systems. The program was developed for individuals perceived as unable to communicate due to severe multiple disabilities and who are functioning below the 18-month level in the area of communication. The manual includes a specific assessment strategy to identify what sensory experiences (e.g. auditory, visual, olfactory, tactile, gustatory, or vestibular) are having an effect on the child, either positive or negative. It includes all record keeping forms, activities, and carry over materials to then implement an intervention that starts where the student is at. Almond, Boutilier, Frey, Korsten, Nettleton, and Van Dusen (1999) report dramatic changes in the performance of their students using the Every Move Counts program.

When a student does not seem to understand or anticipate a routine schedule or steps of activities, use a concrete object or picture schedule.-A schedule using objects, parts of objects, pictures or symbols can be a useful tool to help a student begin to understand and anticipate the events of the day or the steps of a specific activity. The items are presented in the order in which they will occur (or need to be completed). They are then crossed out, covered up, or put away as each one is completed.

When a student does not attend to or use pictures or picture symbols, use Aided Language Stimulation.-Aided Language Stimulation is a technique of directing the child's attention to pictures or symbols using a small flash light to model the use of communication boards and increase a child's understanding of messages receptively. As the teacher or parent gives directions to the child or asks questions, she use a communication board and shines the flash light on the objects, pictures, or symbols as she speaks. This models the use of the communication board and helps the child to understand what is being said to him.

Aided Language Stimulation can also be used when a student needs receptive vocabulary increased. Students in the Alternative Language Group especially benefit from an environment where communication partners use alternative language forms on a regular basis. So it is important to use Aided Language Stimulation, to provide picture schedules and to accompany spoken language with graphic symbols when communicating with a child in this group.

When a student uses an augmentative communication board or device (or even their own voice) to respond to communication, but rarely or never initiates communication, increase communication opportunities through Environmental Communication Teaching.-Environmental Communication Teaching (ECT) uses incidental teaching episodes that are short, positive and geared towards functional communication, not language training. There are three major components to ECT training: (1) Use of structural analysis and modifications, (2) use of cues, prompts, and descriptive feedback, and (3) use of AAC techniques and approaches (McCloskey & Fonner, 1999). Structural analysis and modifications specifically focus on knowledge of the different contexts for interaction, how the contexts are socially regulated, and how communicative functions are utilized within those contexts. Within the ECT training, cues, prompts, and feedback strategies are used to facilitate the initiation of communication interaction. These strategies are also utilized to encourage the use of age- and activity-appropriate communication. The prompt hierarchy listed below is employed when target students do not exhibit the level or amount of communication expected.

Prompting hierarchy:

Pause to provide the student the needed time to respond.
If no response, ask the student an open ended question, then pause.
If no response, provide the student with a partial prompt, then pause.
If no response, request a verbalization from the student, then pause.
If no response, provide the student with a full model of an appropriate
communicative response.
When a student has limited access to vocabulary, increase the options for communication.-More communication vocabulary can be provided through multiple boards, multiple voice output devices located strategically for specific activities, or the provision of a voice output device with levels, dynamic display, or semantic compaction. See the continuum of Augmentative Communication Devices and the section on Assistive Technology for Augmentative Communication earlier in this chapter. One single message devices such as a BIGmack is not sufficient to meet the communication needs throughout every activity of the day. If more ideas are needed for beginning communication, Making Connections (Locke & Levin, 1999) is recommended.

When the student has only had access to low tech boards, try voice output.-Even if a student is communicating effectively with low tech boards, he or she deserves the opportunity to experience the power of voice output. You can't call out to someone with a picture on a piece of cardboard. There is power in having voice. Each student deserves the opportunity to experience that power. The student also deserves the right to reject it, if it has no appeal. Often students with Autism Spectrum Disorder prefer low tech communication techniques rather than voice output. That should be their choice.

When trying to determine exactly which device or devices will work best for a specific student use Feature Match.-The systematic matching of features on a device with the specific, unique needs of a given student is called feature match. There are some exciting resources which can make the process much easier. Each of them is a software program that assists you in making selections and matching the students' unique abilities and needs with features of various devices.

Two programs that specifically do feature match for augmentative communication devices are AAC Feature Match and Needs First . Needs first is only available for the PC and AAC Feature Match is available for either the PC or Macintosh. These software programs ask specific questions about the student's language, size of vocabulary needed, ability to direct select, need for specific keyboard, switch or other input, type of display, mounting, etc. The software then selects the devices that might meet the student's need. Each of these programs contains over 100 devices and contact information for vendors. In addition, you can add information on new devices as you become aware of them.

References

Almond, S., Boutilier, D., Frey, S., Korsten, J, Nettleton, A., & Van Dusen, H. (1999). From the Titanic to a Carnival Cruise: Hope for our most challenging population and the teams who work with them. Closing the Gap 18, 1, April/May, 1999.

Beukelman, D. & Mirenda, P. (1992). Augmentative and Alternative Communication: Management of Severe Communication Disorders in Children and Adults. Baltimore: Paul H. Brookes Co.

Blischak, D.M. (1999). Increases in natural speech production following experience with synthetic speech. Journal of Special Education Technology, 14, 2, Fall, 1999, 44-53.

Korsten, J., Dunn, D., Foss, T., & Francke, M.K., (1993). Every Move Counts: Sensory Based Communication Techniques. San Antonio, TX: Communication Skill Builders.

Martinsen, H. & von Tetzchner, S., (1996). Situating augmentative and alternative language intervention. In non Tetzchner, S. & Jensen, M.H. (Eds.) Augmentative and alternative communication: European perspectives. Whurr Publishers, Ltd. pp. 37-48.

McCloskey, S. & Fonner, K. (1999). ECT Training. Portage, WI.

Muller, C. & Oberstein, J. (1995). Selecting Augmentative Communication Devices: A Transdisciplinary Feature-Match Process. Paper presented at ASHA Convention, Orlando FL

Silverman, F.H. (1995). Communication for the speechless (3rd ed.). Needham Heights, MA: Allyn & Bacon.

Resources for Augmentative and Alternative Communication

Internet Sites

Barbara Couse Adams at Computer Options for the Exceptional has developed this web site to provide information and discussion about AAC: http://www.augcomm.com/

The Communication Aid Manufacturers Association (CAMA) web site provides links to vendors of AAC devices and software: http://www.aacproducts.org/

United States Society for Augmentative and Alternative Communication web site provides contact information for prospective members: http://aac.unl.edu/ussaac.html/

Barkley Augmentative and Alternative Communication Center from the University of Nebraska - Lincoln web site provides an excellent source of AAC academic resources and device tutorials: http://aac.unl.edu/

International Society for Augmentative and Alternative Communication web site: http://www.isaac-online.org

The Discover Technology site features a list of links to other sites, a catalog of adaptive software and hardware, research and demo packets of products offered in the catalog (in development), a pen pal section and a Banner Exchange Program:

Linda Burkhart's web site provides excellent suggestions for simple integration of AAC into all environments: http://www.lburkhart.com/

Augmentative and Alternative Communication (AAC) Connecting Young Kids (YAACK) is a web site that covers issues related to AAC and young children. Its purpose is to provide information and guidance to families, teachers, speech/language pathologists and anyone else who is involved with a child with special communication needs: http://www.mrtc.org/~duffy/yaack/

Julie Maro and Carolyn Musselwhites web site provides practical suggestion for the implementation of augmentative communication: http://www.aacintervention.com

For beautiful pictures of objects with no background to distract, look at Picture This...Pro from Silver Lining Multimedia, Inc., www.silverliningmm.com

Journals/Newsletters

Augmentative Communication News, Augmentative Communication, Inc., 1 Surf Way, Suite #237, Monterey, CA 93940.

Augmentative and Alternative Communication, ISAAC, 49 The Donway West, Suite, 308,Toronto, ON ,M3C 3M9 Canada

Books

Burkhart, L. (1993) Total Augmentative Communication in the Early Childhood Classroom. Eldersburg, MD: Linda Burkhart, 6201 Candle Court, Eldersburg, MD 21784

Glennon, S. & DeCoste, D. (1997) Handbook of Augmentative and Alternative Communication. San Diego, CA: Singular Publishing Co.

Locke, P. & Levin, J., (1999). Making Connections: A Practical Guide for Bringing the World of Voice Output Communicaqiton to Students with Severe Disabilities. Minneapolis, MN: AbleNet, Inc.

Light,J. & Binger,C. (1998) Building Communicative Competence with Individuals Who Use Augmentative & Alternative Communication. Baltimore: Paul H. Brooks Publishing Co.

Software

AAC Feature Match Software, (1996) Doug Dodgen & Associates, P.O. Box, 180503. Arlington, TX 76096; (817) 467-0627.

EvaluWare, (1999) Assistive Technology, Inc., 7 Wells Avenue, Newton, MA 02459; (800)793-9227

Needs First, (1996) George Adams Consulting, 49 Overlook Road, Poughkeepsie, NY 12603; (914)452-1850.


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