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Cynthia Cottier, M.A., M.Ed., C.C.C.
Augmentative Communication Therapies
The field of augmentative and alternative communication (AAC) has traditionally focused on enhancing, or facilitating, the expressive component of communication of the user. Unfortunately, while it is critical to also attend to the user's receptive language abilities this is frequently neglected. It is widely agreed that the use of augmentation is can significantly enhance the expressive communication abilities of an individual; however, the use of techniques and strategies to augment the individual's comprehension is not a common thought even though this is especially important for AAC users. While there are authors that have described the importance of augmenting the input provided to AAC users during communication interactions and intervention, and have described ways to provide augmented input through the use of lexigrams, gestures, written words and symbols, they are limited.
In 1998, Wood, Lasker, Siegel-Causey, Beukelman and Ball developed the "AAC Input Framework" (AACIF) which examined the use of various augmented input techniques discussed by various authors (e.g., Romski & Sevcik, 1992; Garrett & Beukelman, 1992; Goossens', 1989). This AACIF presents various augmented input techniques by breaking them down into four components: "(1) augmenting the message, (2) mapping language and symbols, (3) augmenting message retention, and (4) developing a pool of response options using objects and symbols."
The AACIF was developed to focus on how augmented input affects the AAC user's participation during the communication process. This paper presents the examples of each of the four augmented input approaches and a case study which illustrates a positive outcomes for each of the techniques.
This component of the AACIF focuses mostly on enhancing the meaning of the conversational or environmental occurrence. The use of these techniques assist the AAC user to receive information more accurately. When using this technique, the communication partner assists the AAC user in understanding spoken and written messages by "augmenting" the message with symbols, pictures, objects, gestures and/or voice output systems. This technique is not response driven because the communication partner does not necessarily expect the user to reply at the time that the augmented input is provided. This technique can be particularly beneficial for individuals who display auditory comprehension deficits.
Z. P. was 3 years 3 months of age when intervention was initiated. He was diagnosed with autism and presented with severe communication deficits. Z. P. was essentially nonverbal with the exception of crying and screaming. He demonstrated limited intent to communicate and rarely initiated communication. Receptively, it appeared that Z. P. exhibited severe auditory processing deficits. Behaviorally, Z. P. displayed inappropriate behaviors (e.g., playful slapping or pinching) and some self injurious behaviors such as hitting his head with the back of his fist and biting his hand.
Secondary to Z. P.'s severe receptive language deficits, it was necessary to provide Z. P. with augmented input which presented language in a manner concrete enough for him to understand and learn new vocabulary and concepts. Clearly, it was critical to provide Z. P. with a means of understanding and using language which he was able to understand to decrease his communicative frustration that ultimately led to inappropriate behaviors. A therapeutic approach which used a Picture Exchange Communication System (PECS) as an expressive mode of communication was initiated but in addition to this, an augmented input approach for receptive language development was also employed. Therefore, when presenting verbal information to Z. P., symbol sequences consisting of black-and-white PCS line drawings were simultaneously presented as the clinician spoke the message. In this way, Z. P. was provided with a more concrete, visual representation of language which he could more easily understand.
Within 6 months from the initiation of the augmented input approach, Z. P.'s receptive language abilities appeared to increase significantly and, in combination with his expressive language system (PECS), Z. P. was able to follow 2-3 part directions independently, understand instruction within the classroom and home, comprehend stories and interactive conversation appropriate to his chronological age. Z. P.'s comprehension of information presented through augmented input also included the concepts of quantity, size, shape, color, position and location).
Two years after the initiation of intervention utilizing augmented input, Z. P. had acquired significant literacy skills. Therefore, the use of symbols as a method of augmenting the input was discontinued in favor of written words and the use of the key-word technique discussed by Garrett and Beukelman (1992). In this approach, the clinician writes down key words and concepts as well as writing word choices while talking with the AAC user. To date, Z. P. is able to respond to the augmented input presented to him independently and with 90-100% accuracy during age appropriate activities.
The second component of the AACIF focuses on assisting the AAC user to associate a symbol (picture, gesture, object or spoken word) with the environmental stimulus. It is intended to help the AAC user to learn language symbols more accurately. It assists the AAC user to associate symbols with their referents, with the ultimate goal of teaching them how to communicate via symbols. During mapping activities, the communication partner helps the AAC user to associate symbols with their referents by showing, pointing to, or producing the symbols in association with relevant items or events. As part of the mapping process, the user is helped to comprehend the relationship between AAC symbols and their referents. However, unlike "augmenting the message", during the "mapping" process, there is an expectation that users will eventually begin to use these symbols expressively.
When intervention began with L. H., he was 3 year 2 months of age. L. H. exhibited hypotonia, apraxia, and auditory processing deficits. Expressively, L. H. demonstrated an intent to communicate but used a few approximations of words and phrases for communication purposes. Generally, L. H. communicated his needs and wants by using limited single sound vocalizations, pointing, and getting what he wanted himself . His utterances generally consisted of approximately 25 single words or word attempts. Unfortunately, L. H. demonstrated little success communicating his needs , wants and desires to other family members, adults and children which caused them to perceive L. H. as less capable than his true abilities.
L. H. also demonstrated significant receptive language deficits. As with Z. P. from above, L. H. also appeared to demonstrate significant auditory processing difficulties. He was able to comprehend the labels of a limited number of common objects (approximately 10) and almost no phrases or sentences. L. H.'s ability to respond to language presented verbally was negligible.
For the reasons listed above, a therapeutic approach which uses augmented input approach for receptive language development and an augmentative communication system for expressive communication was undertaken. In L. H.'s case, a modified "aided language stimulation approach" (Goossens', 1989) was utilized for receptive language development. The intended use of this augmented input approach was to develop L. H.'s understanding, use, and manipulation of language units/symbols of his augmentative communication system (Picture Exchange Communication System). When using this approach with L. H., Goossens' "aided language stimulation approach" which is a process where communication partners point to AAC symbols on a display while speaking, was modified slightly to utilize individual symbols velcroed onto a symbol strip to present symbol sequences. The purpose of this approach is to assist the user in making associations between the graphic symbols and their referents and provides a model for the use theAAC symbols as a means of communication.
Using this approach, within a twelve month period, L. H.'s receptive comprehension increased to approximately 170+ words including concepts of action, color, size and quantity/number. In addition, he was able to use his PECS system at the Phase VI level (i.e., responding and commenting) by independently constructing symbols sentences of between 3-6 words.
This component focuses on facilitating the AAC user's recall of the event, message, or task by indicating or referring to a symbol after a delay. This technique is designed to help the AAC user retain, or recall, a message by providing a concrete representation of the idea in the form of an object, symbol, photograph, or picture. Common examples of this technique are memory books, memory wallets, and remnant books. The intent this approach is to assist the user to recall, retain, and discuss information about activities that have occurred in the past.
When consultative services began, J. H. was a 9 year 10 month old student who attended a special day class. He was diagnosed with autism and a profound bilateral hearing loss. While J. H. was able to express himself with good efficiency using a light tech communication system (i.e., Picture Exchange Communication System - PECS), and comprehend information presented to him through signs, written words and symbols accurately, he demonstrated significant difficulty remembering and conveying information from school to his home.
To assist B. H. to recall events which had occurred during the school day, he was given the opportunity to compose a symbol sentence on the classroom computer as activities were completed throughout the day using specialized software programs (e.g., "Writing With Symbols" or "PixWriter"). These symbol sentences were then printed and then placed into a notebook which traveled between home and school each day. In this way, augmented input assisted B. H. to recall the events of the school day when he arrived home and, later, using his augmentative communication system (i.e., PECS), discuss what had occurred during his school day with his parents.
This technique encourages the AAC user to make selections from an array of choices and/or possible answers by developing a response pool. When using this technique, the communication partner offers possible choices to the AAC user, who in turn selects one or more topics about which to communicate. This process is often dynamic in that the communication partner offers options, the AAC user makes a selection, and the communication partner offers another set of more topic specific options. Clearly, developing a response pool may also be beneficial for children who have emerging communication skills.
At the initiation of intervention, G. C. was 6 years 8 months of age with a diagnosis of cerebral palsy and developmental delays. Surprisingly for his age, G. C. had never had a communication system of any type provided to him and he demonstrated very little comprehension of the purpose of language or communication in general. Furthermore, G. C. had very little experience in making choices even for functional purposes. In addition, when provided with augmentative systems in the past, G. C. had not demonstrated any degree of success. Clearly, for effective use of an augmentative system to be possible in the future, G. C. needed to increase his receptive understanding of choice making through the use of a response pool of options.
To provide G. C. with access to choices and to increase his understanding of making choices , a notebook was created with various pages of response pool options. For example, at breakfast, a display with "cereal" and "applesauce" was presented. The communication partner then asked G. C. "What do you want for breakfast: cereal or applesauce?" while simultaneously pointing to the graphic symbols. Later, when getting ready for school, G. C. was again presented with a display of response pool choices of "pants" and "shorts" and the communication partner asked "What do you want to wear today: pants or shorts?" while, again pointing to the available choice. In this way, G. C. was assisted to understand that choices were available to him and that the symbols were used to represent these choices.
Within the first 3 weeks of therapy, G. C. had increased his understanding of choice making and had begun to use a light tech communication notebook for expressive purposes as well.
In AAC intervention, the use of augmented input may be critical to successful expressive communication through augmentative communication systems. Historically, many clinician have failed to adequately address the issue of comprehension when designing an intervention plan for the AAC user. Without including augmented input as a significant component of the intervention process, it is felt that the likelihood for success use of an AAC system for expressive communication purposes is diminished.
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