AAC All Day, Every Day

Jane FarrallSpeech PathologistAAC Support Services Managerjane@spectronics.com.auTwitter: @janefarrall

What is AAC?Augmentative and Alternative Communication (AAC): An area of specialised clinical and educational practice that provides communication options and interventions for people with complex communication needs. The term augmentative in this context means supplemental or additional to speech. Augmentative techniques (e.g. gestures, and facial expressions) are commonly used when communicating and interacting with others.The use of the term alternative acknowledges that there are some individuals whose speech is sufficiently impaired that they must rely completely on standard and special augmentative techniques, which do not augment speech but are alternatives to speech (Vanderheiden & Yoder, 1996).(Speech Pathology Australia AAC Position Paper 2004)

AAC SystemAAC system: An integrated group of components, including the symbols, aids, strategies and techniques used by individuals to enhance communication. The system serves to supplement any gestural, spoken, and/or written communication abilities(American Speech and Hearing Association, 1991).

Unaided and Aided AACUnaided AAC: All techniques that do not require any physical aids (e.g. gesture, sign, facial expression).Aided AAC: Techniques where some type of physical object or device is used (e.g. object symbols, communication boards, books, wallets). Aided AAC is often divided into high technology or low/light technology systems.(Speech Pathology Australia AAC Position Paper 2004)

AAC Myths and LegendsIntroducing AAC will stop someone from developing speechLow tech before High techHas a little speech so doesn’t need AACToo cognitively impaired for AACAAC will fix all communication difficultiesToo young for AACDoesn’t need AAC as they can express basic needs

AAC Myths and Legends - ResourcesRomski, M.A. & Sevcik, R.A. (2005). Augmentative communication and early intervention: Myths and realities. Infants & Young Children, 18:3, 174-185.YAACK http://aac.unl.edu/yaack/DynaVox Implementation Toolkit http://www.dynavoxtech.com/implementation-toolkit/learning-paths/list/?id=7

Good Practice Approaches to AACAided Language Displays (ALDs)Engineering the EnvironmentChat NowPODDCore Vocabulary

Additional AAC options to support good practiceSmall TalkAbout Me BooksYes/No ++++Social ScriptsPartner Focused QuestionsStorytelling

High Tech AACCustom Speech Generating DevicesMainstream TechnologyiPod touch/iPadAndroid Phones/TabletsLaptops

Communicative CompetenceLight (1989) Linguistic Competence (mastery of the linguistic code)Operational Competence (access methods, on/off)Social CompetenceStrategic Competence (make the most of the vocab they have)

Aided Language DisplaysProspective users must be provided with frequent examples of interactive, generative use to acquire any semblance of proficiency. No one would dispute the fact that it would be very difficult to become a fluent speaker of French, if your instructor seldom used French in your presence. Goossens’, Crain and Elder (1988); Goossens’ (1989)

Aided Language DisplaysLikewise, it is difficult for a nonspeaker to become a proficient AAC user if other people never model interactive use of their system during all aspects of the day.

Aided Language DisplaysAided Language Displays are NOT choice making boards.Choice making boards supplement ALDs.E.g. in music time a choice board of songs is followed by boards for singing the songs.

It is critical for an individual to not only have symbols, but also to have experience with those symbols in a symbol rich environment / print rich environment. The typically developing child will have been exposed to oral language for approximately 4,380 waking hours by the time he begins speaking at about 18 months of age.

If someone is using a different symbol set and only has exposure to it two times a week, for 20-30 minutes each, it will take the alternate symbol user 84 years to have the same experience with his symbols that the typically developing child has with the spoken word in 18 months!!!

The typically developing child will demonstrate language competency around 9-12 years of age having been immersed in and practicing oral language for approximately 36,500 waking hours. For 9-12 years that child has been using and receiving corrective feedback while practicing with the spoken word.

At twice a week, 20-30 minutes each time, it will take the alternate symbol user 701 years to have the same experienceJane Korsten (2011) QIAT Listserv 4th April

Aided Language DisplaysIf children are to gain proficiency in using their aided AAC systems, others must begin to use the children's AAC system to communicate with them.

Aided Language DisplaysBy modelling how to use a display to initiate and maintain communication, you show a student how to initiate and maintain – not just respond!

Aided Language Display DesignIf you (as a person proficient in language) cannot use a communication system or display throughout an interaction then how can you provide Aided Language Stimulation?If you cannot use it, is it designed well?

Engineering the EnvironmentDisplays must be stored in close proximity to where they are neededDisplays must be stored in a way that helps with quick access and set-upE.g. in dress-up box, on back of bookshelf, on walls, in plastic bucket, inside game box, with props, in eye gaze arrangement

CHAT-NowDeveloped by Gayle Porter (Cerebral Palsy Education Centre) and Marnie Cameron (Communication Resource Centre)Children’s Aided Language ToolsConsists of aided language displays for early childhood settings and general interactive board(s)

CHAT-NowA series of ALDs for different activities.Designed for early childhood but suits many special education settingsAlso includes a general interactive board for use throughout the whole day

Special School ProjectApprox 80% of students in school with CCNA few have individual systems – generally not being usedLots of visual supports in place – all staff carry key caddies and all classrooms use visual schedules, first then boards etcCommonly used AAC is all adult focused language

Special School ProjectBaseline observations and videos end of 2010No spontaneous AAC use by students

Term 1 2011Every student establish yes/noBegin using CHAT-NowIntroducing general interactive boardThen aided language displays

Week 1Problem solve how to make general interactive display available in every situation

Week 2Model more and finished all week

Week 5Use whole boardMade up in Tap Speak Choice, AAC App

Weeks 6 - 10Consolidate use of whole boardEnsure all students have yes/no

Special School ProjectRepeat observations and videos end of term one10 spontaneous uses of AAC by students observedNext term introducing ALDs for a range of activitiesTerm 3 introducing multi-page generic displays

CHAT-NowGeneral interactive multi-level

Yes/NoNeed to watch the number of yes/no questions we ask AAC usersBUTEvery AAC user needs to develop a good, clear Yes/No response

PragmaticsPragmatics – social use of languageUsing language for different purposes, such as greeting, informing, demanding, promising, requestingChanging language according to the needs of the listenerFollowing conversational ruleswww.asha.org

PragmaticsNeed to ensure AAC users have access to and know how to use a range of pragmatic skillsDewart and Summers “Pragmatics Profile” (1998)http://wwwedit.wmin.ac.uk/psychology/pp/

PODDPODD is a way of organising whole word and symbol vocabulary in a communication book or speech generating device to provide immersion and modelling for learning.

PODDThe aim of a PODD is to provide vocabulary:for continuous communication all the timefor a range of messagesacross a range of topics in multiple environments.

PODDPODDs can have different formats, depending on the individual physical, sensoryand communication needs of the person who will use it.

PODDPODDs have been developed over the past 15 years by Gayle Porter, a speech pathologist with the Cerebral Palsy Education Centre (CPEC) in Victoria. Each PODD format has been shaped by the experiences of both children with Complex Communication Needs (CCN), and their communication partners.

Core VocabularyUsing common English words on an AAC display to enable a user to construct their own sentences.Approach used in lots of high tech systems but not used as much in low tech due to difficulty of arranging vocabulary for access.

Core VocabularyCORE VOCAHigh frequency wordsCan be combined to get your message across in lots of different situationsFRINGE VOCABLow frequency wordsOnly useful in one or two situationsOften related to a specific topic

Core VocabularyWordPower 24 in TouchChat, AAC App

Pixonhttp://www.vantatenhove.com/showfolder.php?id=57

Core Vocab to supplement ALDSFrom the Disability Services Commission WAhttp://www.boardmakershare.com/Activity/969086/Core-Vocabulary-Display

High Tech and Light TechBoth are just toolsBoth need good vocabulary design and good modelling to ensure successHigh Tech can be less forgiving but can offer more access optionsSome students more motivated by high tech and some don’t like it!!Most people need both – for different situations

Speech Generating DevicesSTATIC DISPLAYDYNAMIC DISPLAY

Static DisplayMay be more durableGenerally cheaperOften run off AA or AAA batteriesOverlay based - require Boardmaker or other toolNeed to work out system for storing and changing overlaysNeed to ensure vocabulary is updatedHarder to maintain in many ways

Dynamic DisplayMay be more durableUsually rechargeableTools for generating pages in device – and sometimes in free software tooCan change vocabulary on the spotCan change pages and levels easilyGenerally offer a wider range of access options

Access OptionsFor a user who need alternative access, SGDs can offer:Large range of access optionsFlexibilityComplete control over device and other software

Low Tech Scanning and Eye Gaze

Mainstream Mobile Devices for AAC

www.spectronicsinoz.com/article/iphoneipad-apps-for-aac

How do I choose?Are they worth the cost?What do they offer that traditional speech generating devices don’t?What don’t they offer that SGDs do?

Media, Stories, Opinionhttp://socialtimes.com/iphoneipad-app-helps-autistic-children-communicate_b10778

Media. Stories, Opinionwww.spectronicsinoz.com/blog/resources/2011/04/aac-apps-speaking-appropriately/

Media, Stories, OpinionApple iPad2 launch

Media Stories and Opinionshttp://www.wired.com/geekdad/2011/03/ipads-are-not-a-miracle-for-autism-geekdad-opinion/

Apps with Symbols and Text-to-speech

Researchhttp://aac-rerc.psu.edu/index.php/pages/show/id/46

Resourceswww.spectronicsinoz.com/blog/applehttp://a4cwsn.com/iTeach Special Education – iDevices in Special Education (Facebook group)Assistive Technology (Facebook Group)

Additional AAC options to support good practiceYes/No ++++Small TalkAbout Me BooksStorytellingSocial ScriptsPartner Focused QuestionsIntroducing yourselfTaking non-obligatory turns

Social CommunicationSocial communication is a BIG part of our day.We use different forms of social communication – small talk, storytelling, greetings, wrap ups and farewells.

Social CommunicationSocial communication is more than 50% of our daily conversation.Light (1998) found that reasons for communication between adults were (in ranked order)Social closenessSocial etiquetteInformation transferWants and Needs

Small TalkA type of conversational exchange used for initiating and maintaining conversational interaction.Some conversation never progresses beyond small talk e.g. at a cocktail party.

Small TalkSmall talk is used as a transition between the greeting and information sharing stage, especially when people don’t know each other well or don’t possess a lot of shared information. Small talk is often the first step towards social closeness.A quick check at Amazon showed 16 books aimed at helping people improve their small talk skills. Including “How to get people to like you in 90 seconds”.There are even websites to teach you how to small talk! e.g. www.ehow.com, www.englishclub.com, www.ivillage.co.uk and many more!

AAC Users and Small TalkMany AAC users use little or no small talkThis can be becauseThey don’t have access to small talk in their communication systemThey don’t see the need for itThey think it is a waste of time.Light and Binger (1998) found that AAC users were seen as more intelligent, valued and competent communication partners if they used small talk.

Generic Small TalkGeneric small talk is small talk that people can use with a variety of different conversational partners because it doesn’t refer to specific shared information.Particularly effective for many AAC users as it has many different uses.

Generic Small TalkSeveral groups of researchers at the University of Nebraska-Lincoln looked at the frequency and types of generic small talk used by speakers of various ages without disabilities.3 – 5 year olds - 48% of all utterances at both home and pre-school/school were generic small talk20 – 30 year olds - 39% of all utterances were generic small talk65 – 74 year olds – 31% of all utterances were generic small talk75 – 85 year olds – 26% of all utterances were generic small talk

Generic Small TalkMost of the age groups used continuers as the most common form of small talk.Really? Yeah? Great! Cool!Go to aac.unl.edu for more detailed information.

Differences in Small Talk VocabularyThe small talk vocabulary lists showed that some words were used more frequently than others e.g. OKSome words were common across all age groups e.g. greatSome words were specific to certain age groups e.g. “bummer” was used by the 25 – 35 year age group but not by the others.Small talk also differs based on your friendship groups, your geographical location, your interests and life experiences.

Small Talk and MealtimesBalandin and Iacono (2000) found that it was nearly impossible to script the content-specific vocabulary needed for mealtimes for an adult in the workplace (although there was a good chance on Mondays and Fridays that footie would be the topic during the footie season).In this situation, the only predictable thing was small talk.

George’s Small Talk21 year old male with athetoid cerebral palsyAttends a day centre for young adultsUses a Dynavox3100 but only uses the spelling pageControls communication device with a head switch

George’s Small TalkOver 20 other people with disabilities and 6 staff attended George’s centre, most of whom talked.George rarely used his device during the day.Staff requested a review of his device because he didn’t “ever” use it.George had previously had a setup with core vocabulary on his device but found it frustrating to find words he wanted when he could just spell them.

George’s Small TalkA speech pathology student observed him in two sessions. He “used” his device constantly but only spoke with it twice.George was accessing his device with a head switch and block/row/column scanning. She observed that by the time he had formulated a message the conversation had moved on and he erased and moved onto a new message.A two pronged approach was used. Firstly, a conversational topic was established before each group e.g. “What are your favourite films?”. This allowed George to compose messages in advance.A small talk page was programmed and George practiced using this in one-to-one and then small group conversation.

George’s Small TalkAt the end of 8 weeks the same speech pathology student observed George in the same two sessions. George used his device 46 times. Five of these were topic setters, 41 were small talk continuers.Several other people in the centre commented spontaneously that “George was much cleverer than they thought” or that “They enjoyed talking to George much more”.And….he’s still using it!

Michael’s Small Talk14 year old with autistic spectrum disorder.Attends a mainstream school with a full-time integration aide.Michael has a DynavoxMiniMo but has recently developed quite a lot of speech, which is only understood by familiar people.Michael’s device has core vocabulary with lots of fringe vocabulary around his topics of particular interest e.g. SpongeBob Squarepants.

Michael’s Small TalkMichael has been very keen to interact with his peers. However, as his peers have got older verbal skills have become more important to these interactions.Michael will often walk up to a group and simply stand there. The other children do not try to include him in their conversations, nor does Michael try to join in.Some of the children Michael was friendly with in primary years will occasionally sit down and talk with him, but always on his terms. These occasions are decreasing in frequency.

Michael’s Small TalkIntroduced Michael to Small Talk.Each of his favourite topic areas had a page built with partner directed questions and small talk continuers.His old friends are very impressed with this change in Michael. They are more likely to have a chat with him and will sometimes call other people over to take part in the conversation.

Sequenced Social ScriptsSequenced social scripts can really help a user toGet a 'feel' for the anatomy of a conversationDevelop turntaking skillsLearn to interact with a variety of partners.

What are Social Scripts?They support students in learning to claim, start, and maintain turns in a conversation.Much of the information in this section is taken from “Can We Chat? Co-Planned Sequenced Social Scripts: A Make It / Take It Book of Ideas and Adaptations”by Caroline Musselwhite and Linda BurkhartAlso called Participation Scripts

What are Social Scripts?Social Scripts are interactions such as joke-telling, sharing life stories and general conversations.They help persons using augmentative and alternative communication (AAC) move beyond wants and needs to using 'real' communication for conversational purposes. Often give developing communicators a sense of the power of communication.

Anatomy of a social scriptAttention gettersStartersMaintainers, holders and interjectionsTurn transfersClosings

Communication PassportsTemplate available from CALL Centre Scotlandwww.communicationpassports.org.ukiPhone App coming soonAlso from SCOPE UK at http://www.scope.org.uk/help-and-information/publications/scope-communication-passport

Communication PassportsUseful for exchanging information about an AAC User between othersOften not a tool used by the AAC user directly

This book is about me!My name is MikePlease read! This book will help you to get to know me and how I communicate.

Page IndexAll about me You need to knowMy FamilyMy Friends Special people, special thingsThings I like to talk aboutHow I communicateHow I communicate (2)You can help me communicateFun things I like to doPlaces I like goingThings I don’t like I’m working on this...Help!Eating and DrinkingWhat’s my eyesight like?

All About Me!CALL Centre page 1

You need to know...I have epileptic seizures. They don’t last for long, please just make me comfortable and let me have a snooze afterwards.2. I am allergic to penicillinCALL Centre page 2

CALL Centre page 3I love my FamilyI like to talk about them so you need to know who everybody isThis is my Mum and DadAnd my sister Larissa.

My FriendsCALL Centre page 4This are my friends. John, Mike,Peter, Sally and Sue.

CALL Centre page 5Special People Special ThingsI love having a weighted blanket on my lap – it helps me concentrate.

You can help me to communicatePlease DOgive me plenty timePlease DON’Task me more than one question at a timeCALL Centre page 9

Personal StorytellingAs we get older the percentage of small talk decreases and the percentage of storytelling increases.Older adults, in particular, use stories to entertain, teach and establish social closeness with their peers.As individuals lose their spouses and move to retirement and care facilities the need to socially connect with individuals their own age becomes important and storytelling becomes a vehicle for this.

Personal StorytellingSchank (1990) discussed story formulation, refinement and storage in detail. He found a few different “types” of stories in common use:First person storiesSecond person storiesOfficial storiesFantasy storiesMarven et al (1994) found that for preschoolers, 9% of their communication at home and 11% at preschool involves fantasy of some sort.

AAC and StorytellingStorytelling with AAC systems has become practical and possible with improved technology.However, we must be careful that the stories are ones which the person would choose to tell.Storytelling is very personal and must be individualised.

John’s “chat” cardsJohn is an 11 year old with autism spectrum disorder.John uses words (which are mostly intelligible to familiar people), signs and a multi-page communication book.John also has some challenging behaviour. Five years ago, John had challenging behaviour every night when he got home from school.His mum felt that this was due to his frustration over trying to tell her about his day.His team decided that “chat” cards about his day would help.They setup a process to write a sentence about each day.

John’s storytellingMany of John’s old chat cards are in a milk crate in his room.John began spontaneously using them with new people a couple of years ago.He selects a few cards and then brings them to the new person. They read them with him and if they show particular interest in one topic e.g. playing basketball he will go and get more things around this topic.He brings out fewer chat cards as people become more familiar with him and understand more of his speech.

Ted’s StorytellingTed is a 78 year old who had a CVA when he was 72.Following the CVA he regained some spontaneous speech, mostly small talk. He can understand everything that is said and can read the paper and magazines. He cannot speak (apart from small talk) and he cannot write.Prior to the stroke he was president of his local RSL Club. His wife and his friends miss his storytelling.His wife was able to work with him and write out many of his stories. These have now been stored in a Macaw, with one of his friends doing the recording.He and his wife are delighted as he is once again able to tell stories and delight his family and friends.

Personal Photo StoriesA series of photos about a person to give the “listener” a sense of who the person isCan be used to let them have a “conversation” with their “listener”

Sarah’s StorytellingSarah is a woman in her sixties who lives in her own house.In her forties she was in a motor vehicle accident and is now a quadriplegic.She has a good understanding of spoken English but very limited expressive communication, including very little facial expression. She has control of a single switch with her left thumb, but tends to fatigue quickly, although her stamina is increasing.She has a multi-level communication book which she accesses with eye pointing.

Sarah’s StorytellingShe has a range of in-house care staff who tend to stay around for between 5 months and 3 years.Many of these staff assume she doesn’t understand what is said to her because she doesn’t give body language feedback.

Sarah’s Chat BookInside this book are some of my photos. The writing tells you about them. The questions are things I am interested in about you. Please read out the writing and the questions and we can find out about each other together - but be warned - it might take more than one visit!Sarah

Sarah’s Chat BookSarah’s chat book has completely changed the way staff see her.Each new staff member sits down and goes through the book with her over a few different sessions.They realise how interested Sarah is in them and they gossip with her more.It also gives them topics to talk about that they think will interest her.

Maggie’s StorytellingA series of photos about a person to give the “listener” a sense of who the person isCan be used to let them have a “conversation” with their “listener”

http://sheldonhickey.com/maggie/All%20about%20me/index.html

Just how important is social communication?In Building Communicative Competence with individuals who use Augmentative and Alternative Communication Light and Binger (1998) looked at just three different social communication skills.1. Use of an introductory strategy when meeting new people2. Use of nonobligatory turns to increase participation in social interactions3. Use of partner-focused questions to demonstrate an interest in the partner.

Use of an introductory strategy when meeting new peopleTeaching a 35 year old with a closed head injury to use an introductory strategy to explain his use of AAC and his communication resulted in much more positive interactions with unfamiliar people, with fewer breakdowns and made the new partners more at ease.Teaching a 44 year old with cerebral palsy to use an introductory strategy allowed her to be more confident and assertive with new people. Twenty adults with no previous experience of AAC viewed tapes of Maureen meeting new people pre and post. 100% of them reported she was a more competent communicator when she used an introductory strategy.

Use of nonobligatory turn takingTeaching a young (4½ year old) child with cerebral palsy to use non-obligatory turn taking via AAC meant that the child was initiating more frequently and was more eager to participate in group activities. One of her peers said she was more fun to play with. Her speech improved and she acquired 30 new words. Teaching a 14 year old with autism to take non-obligatory turns also resulted in a increase in initiating and turn taking. There was a decrease in his inappropriate behaviours and he was less disruptive in class. 20 adults who were not familiar with AAC rated his pre and post videotapes and rated him as a much more competent communicator in the post tapes (although they didn’t know which were pre or post).

Use of partner focused questionsTeaching a 13 year old child with developmental disability to use partner focused questions produced a change in the focus of his interactions. His partners began to see his communication as more appropriate.Teaching a 24 year old with athetoid cerebral palsy to use partner focused questions meant that he became a more valued communication partner with those he regularly communicated with.

So how do I decide what’s important in an AAC system?Beukelman (2004) wrote that “vocabulary selection in AAC can be viewed as the process of choosing a small list of words or items from a pool of all possibilities”

Choosing vocabulary for pre-literate individualsFor people who are pre-literate those designing an AAC system face a hard task. Generally we consider there are two forms of vocabulary for this group – vocabulary that is needed to communicate essential messages and vocabulary to develop language (which includes small talk and narratives).Many people like to make this decision around core vocabulary ie words and messages which are commonly used and occur frequently. Small talk vocabulary fits well within these criteria.

Choosing vocabulary for non-literate individualsAim to meet their daily, ongoing communication needs in a variety of environments.

Choosing vocabulary for literate individualsFor literate individuals, they may need some phrases or words which need to be pre-stored for quick access either so they can participate in the conversation in a timely way or so they can reduce fatigue.

What do we know about aided AAC use?

Many people who use AAC(Kraat, 1985; Light, 1989; Muller and Soto, 2002)Play a passive role Rarely initiate interaction Express a limited number of speech acts Use restricted linguistic forms Limited opportunities to interact with other people

Communication board use is frequently less than one might expect.

When the communication board is used, it is often used primarily to provide information requested by the facilitator.

The range of communicative functions produced is typically restricted.

Functionally non-speaking partners tend to assume a respondent role using primarily yes/no answers and other short provisions of information.

Patterns of turntaking, initiation and conversational control tend to be asymmetrical in nature ie the speaking partner dominates the conversational exchange.

Speaking partners are frequently observed a) to ask closed-ended questions and specific Wh-questions and b) to repeat and rephrase previous turns, often initiating topics without expecting a response from the child.

In the classroom setting, AAC users tend to communicate predominantly with the adults in the class, not their classmates.

Used frequently, interactively and generatively to express a wide range of communicative intents;

Occurring during at least 80% of ongoing classroom programming (as speech or manual sign use is);

Being used to mediate communication with classmates as well as personnel (ie teachers, aides, therapists, clinicians);

Being designed and implemented in as time and cost effective a manner as possible.

What we knowCommunication displays and devices are often not usedAAC users are typically responders not initiatorsInteraction patterns focus on “closed” questions such as “What do you want?”Conversational partners control interactions (turn taking is unequal)Peer interaction is minimal(Kraat, 1985)

Four main issuesLack of ModellingLack of Access to VocabularyCommunicative CompetencePassivity/Learned Helplessness

We know how to fix this...We just need to do it!And model, model, model

AAC All Day, Every Day

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