Transcript AAC - March 1, 2013

A Guide to Goal Selection
&
Intervention for AAC Users
Trina Becker, M.S., CCC/SLP
[email protected]
“Personal achievement in life is a function of the
ability to communicate.”
Becker, T. 3/1/13
What is AAC?
• Refers to ways other than speech that are used to
send a message from one person to another
• Includes:
– Gestures
– sign language
– facial expressions
– picture symbol or alphabet boards
– sophisticated computer systems
Becker, T. 3/1/13
Benefits of AAC
•
•
•
•
•
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Provides means to communicate
Increases participation & improves self-concept
Facilitates learning
Improves/restores receptive and expressive language
Reduces frustration and behaviors
Facilitates speech
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Who uses AAC?
• Anyone who has significant difficulty using
speech to communicate
• Used by people of all ages and disabilities
• Etiology either acquired or congenital
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Individuals who use AAC
• Developmental Disabilities
– Cerebral Palsy
– PDD
– Mental Impairment
– Developmental Apraxia of Speech
• Neurodegenerative Diseases (ALS, MS)
• Acquired Disorders (TBI, Aphasia)
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Classification of
AAC Users
Becker, T. 3/1/13
Classification of AAC Users
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Emerging Communicator
Wants/Needs Communicator
Context-Cue Dependent Communicator
Transitional Communicator
Independent Communicator
Adapted from Garrett (1992) and Beukelman (1998)
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Communication Ability Levels
 Respects the fact that individuals with complex
communication needs fall on a broad spectrum.
 Uses characteristics of individuals with complex
communication needs to determine placement on
the continuum.
 The InterAACT Framework (P. Dowden): DynaVox
http://depts.washington.edu/augcomm/03_cimodel
/commind1_intro.htm
Emergent
Context-Dependent
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Independent
Emerging Communicator
• Does not reliably use symbolic communication
• Relies primarily on nonsymbolic
communication (gestures, vocalizations, etc.)
• Emerging does not always = beginner
• May also display
– Minimal turn-taking (object)
– Limited or no joint attention
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Wants/Needs Communicator
• Identifies basic symbols
• Do not have a wide range of vocabulary
• Uses symbols to make choices and meaningful
requests objects
• Primarily uses 1 symbol at a time
• Does not use symbols to interact socially only
for wants/needs
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Context Cue Communicator
• Vocabulary includes nouns, pronouns, verbs,
some descriptors
• Combines symbols to produce phrases
• Produces socially appropriate comments
• Participates in structured conversations with
familiar partners
• Appropriately answers routine questions with
prompts
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Transitional Communicator
– Initiates conversations and social interactions with
familiar partners
– Answers questions of unfamiliar partners without
prompts
– Not comfortable initiating interactions with unfamiliar
partners and using AAC in unfamiliar settings
– Creates novel utterances
– Recognizes conversational breakdowns and uses
repair strategies with mod cues
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Independent Communicator
• Understands communication the same as same-aged
peers
• Appropriately uses AAC system to communicate across
all environments independently the same as peers
• Generates novel utterances
• Effectively uses repair strategies to fix communication
breakdowns
• Independent in operational competence (as much as
physical ability will allow)
Becker, T. 3/1/13
Levels of Communication
Children with Dev. Disabilities
• Follows typical hierarchy
– Emerging Communicator
– Wants/Needs Communicator
– Context-Cue Dependent Communicator
– Transitional Communicator
– Independent Communicator
Adapted from Garrett (1992) and Beukelman (1998)
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Technology
Access
Display
AAC
System
Language
Representation
Output
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Technology
No tech
Low tech
Mid tech
High tech
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No Tech Systems
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Low Tech Systems
Mid Tech Systems
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High Tech Devices
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Technology
Access
Display
AAC
System
Language
Representation
Output
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Language through Symbols
• Symbol – “something that stands for
something else” ( Anderheiden & Yoder, 1986, pg. 15)
–Single meaning
–Icon – based
–orthographic
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Single meaning
DynaSyms – DynaVox
PCS – Boardmaker
Proloquo2Go – iPad
Symbolstix – Tobii - ATI
Icon
• Unity Language – Prentke Romich
Orthographic
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Levels of Communicators & Levels of AAC
NOTE:
High tech
devices can be
adjusted to
meet any
communication
ability level
No to Low
Tech
Emerging
communicators
Low Tech to
High Tech
Wants/needs
communicator
Base decision on
individual
Trials, Trials,
Trials!
Mid tech to High Tech
Context-Cue Dependent Communicator
Transitional Communicator
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Independent Communicator
Continuum of
Intervention
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Intervention goals
• Goals should be chosen to build
communication skills to the next level of the
AAC continuum
Emergent
Wants/needs
Context Cue
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Transitional
Independent
Communicative Competence
“the ability to communicate functionally in natural
environments to meet daily communication needs” (Light,
1989)
Linguistic
Social
Operational
Strategic
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Ultimate Goal
Whatever
Whomever
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Wherever
What’s your ultimate goal?
• How are you going to get your client to be able to tell
you what they are thinking?
• How are you going to get them competent
communicating in a variety of situations with a
variety of communication partners?
• Consider functional vs developmental
• Consider communication skills vs discrete language
skills
Becker, T. 3/1/13
LEVEL ONE COMMUNICATOR
Emerging Communicator
– Develop symbolic Communication
– Understand Cause and Effect
– Make meaningful choices
– Make meaningful requests
– Develop turn-taking (object)
– Increase initiation
– Use greetings hi/bye
– Build receptive knowledge of picture symbols
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LEVEL TWO COMMUNICATOR
Wants/needs Communicator
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–
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Begin to combine symbols to make 2 word utterances
Expand types of requests
Make socially approp. comments with prompts
Answer routine questions with prompts
Expand vocabulary/symbols – verbs/nouns/adjectives
Increase spontaneous use of greetings (hi/bye)
Effectively and efficiently locate symbols on AAC system
Demonstrate ownership of device
Gain attention of communication partner
Becker, T. 3/1/13
LEVEL THREE COMMUNICATOR
Beginning of Context-Cue Communicator
– Combine symbols to make phrases with minimal cues
– Use comments with minimal cues in routine activities
– Engage in short social interactions/conversations with
familiar partners with mod - max cues
– Expand vocabulary (questions, adjectives, verbs)
– Use function symbols on AAC system (clear, delete, etc)
– Navigate through communication system (dynamic) with
prompts
– Learn to adjust volume based on environment
– Recognize communication breakdowns with prompts
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LEVEL FOUR COMMUNICATOR
Middle to end of Context Cue Communicator
–
–
–
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–
–
–
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Initiate conv/social interactions with familiar partners
Produce novel utterances
Expand utterance length
Develop morphology
Continue to expand vocabulary
Answer questions and participate in conversations
without prompts
Recognize conversational breakdowns
Use strategies to repair breakdowns with prompts
Navigate through communication system with prompts
Introduce programming (if appropriate)
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LEVEL FIVE COMMUNICATOR
Transitional Communicator
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–
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Encourage use of AAC across all environments
Increase comfort level in unfamiliar situations
If appropriate, continue to develop morphology
Increase independence in using repair strategies
Encourage programming to increase independence
Encourage independence in operational functions (volume
control, maintenance of system)
Becker, T. 3/1/13
Resources for Goal Selection
• Dynamic AAC Goals Planning Guide
– DynaVox: Implementation Toolkit
• Prentke Romich
– AAC Language Lab
– http://www.aaclanguagelab.com/
• AAC Communication Profile (Tracy M. Kovach)
– http://www.linguisystems.com/products/product/
display?itemid=10547
Dynamic AAC
Goals Grid
Choosing and Writing Appropriate
Goals
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Increasing Complexity of Goals
• Do you have clients who seem to work on the
same goal forever?
• How we can we increase complexity?
– Level of prompting
– Different activities
– Different environment
– Different communication partners
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Prompting Hierarchy
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•
•
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Physical assistance (PA)
Direct Pointer Cue (DPC)
Direct Verbal Cue (DVC)
Indirect Cue (IC)
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• Chain of cues
Hierarchy of Activities
Defined structured activity
Various structured activities
Unstructured activities
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Hierarchy of Activities
• Routine structured activity (activity used to
teach the skill)
– Requesting – snack activity
• Various structured activities
– Want client to be able to use skill in a variety of
structured activities
– Requesting – Mr. Potato head,
puzzle pieces, blocks
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Levels of Communication Partners
Hierarchy of Communication Partners
• Teacher/therapist (individual teaching skill)
• Familiar adult or peer
– Start with partner client is most comfortable with
• Unfamiliar
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Hierarchy of Environments
Community
Home
Classroom
Therapy
room
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Hierarchy of Environments
• Environment in which skill is taught
– Therapy room
– Classroom
• Environment client is highly familiar with
– Classroom
– Home
– May even move around different areas in familiar
environment
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Hierarchy of Environments Cont’d
• Unfamiliar Environments (not a part of daily
routine)
– Places in the community
•
•
•
•
Grocery store
Movie theater
Doctor’s office
Restaurant
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Dynamic Goal Includes…
• ALL 4 COMPLEXITY LEVELS
Client will __(skill)__ during __(activity)__
in __(environment)__with __(partner__
with ___(prompting)__with ___%
accuracy.
Becker, T. 3/1/13
Writing Dynamic Goals…
• Allows for easier tracking of progress
• Provides justification for targeting “same goal”
over time
• Develops communicative competence and
independent communication
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Intervention Strategies
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Basic Communicative Functions
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Attention seeking
Acceptance/rejection
Choice making
Requesting
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Teaching Offered Choice Making
•
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Opportunities
Objects
Symbols
Choice making formats – natural env.
Choice making Arrays
– 2 preferred
– 1 preferred, 1 nonpreferred
– Preferred, blank/distractor
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Teaching Offered Choice Making
• Must always follow through with choice!
• Present objects followed by symbols
• Present symbols followed by objects
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Strategies to Teach Requesting
• Mileau teaching interventions
– Incidental – unstructured, initiation
– Mand-Model - adult initiated, prompted
– Time-Delay – behav established, initiation
•
•
•
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Interrupted behavior chains
Missing/out of reach item
Verbal prompt-free
PECS
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Why does intervention stop with
requesting?
Need to be able to say more than…
How do typically developing
children learn language?
WHERE?
WHEN?
WHAT?
WHO?
Intervention Strategies
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Aided AAC modeling
Expectant delay
Open-ended questions
Recasting
Sentence Strips
Structured practice
Social Stories
Becker, T. 3/1/13
Aided Language Modeling
• Aided Language Stimulation
– A teaching strategy in which the facilitator highlights
symbols on the user’s communication display as he
interacts and communicates verbally with the user.
(Goossens, Crain & Elder, 1992)
• Mimics the way typically developing children learn
language
• Also referred to as…
– Aided language modeling
– Augmented input
– System for Augmenting Language (VOCA)
Becker, T. 3/1/13
Knowing the device
– Learning to use AAC device is like learning another
language
– Any successful teacher needs to be
knowledgeable and fluent in what they are
teaching
Becker, T. 3/1/13
Other Benefits of ALM
 Helps establish and build joint attention between device
and communication partner, and device and stimulus
(Video)
 Takes pressure off the AAC user to always “perform”
 Educates the communication partners regarding location
of symbols and appropriate
 Teaching reciprocal interactions – more like a natural
conversation.
 A most to least cueing hierarchy for increased success.
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Expectant Delay
• Increased pause time during interaction to
prompt child to communicate while
maintaining eye contact and expectant facial
expression
Wait for it….
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Open Ended Questions
• Asking open ended questions will …
– Facilitate use of symbols
– Prompt higher-content communication
– Allow user to demonstrate knowledge
– Facilitate turn taking
• Don’t ask so many yes/no questions!
Becker, T. 3/1/13
Recasting
• Expand child’s utterance to add new
information (model more advanced
language)
– Expand utterance
– Use more specific vocabulary
– Add word endings (-s, -ing, -ed)
Car! → Go Car! → Go racecar! → Go faster racecar!
Flower → Pretty flower → Pretty rose →
You smelled the pretty rose.
Sentence Strips/Visual cues
• Allows AAC user to see what they are
expected to produce.
– Helps make expectations clear
• Can be used for both low tech and high tech
• Important to fade so client develops
independence
Becker, T. 3/1/13
Structured Practice
• Linguistic competency
– higher level language skills (syntax, morphology)
• Social competency
– conversational skills (role play)
Becker, T. 3/1/13
Social Stories
• Typically used to teach skills such as
pragmatics, problem solving, etc.
• Can be used with AAC to teach appropriate
interactions and symbol selection
• Video Modeling
Becker, T. 3/1/13
Tri-Focused Framework
(Siegel-Causey & Bashinski, 1997)
AAC User
Environment
Communication
Partner
Becker, T. 3/1/13
What would make a child a successful
communicator?
• Use of a device across environments and
across communication partners.
• Ability for your child to engage in variety of
interactions and activities of their choice.
• Interventionists who are considering building
those skills across all environments and
partners.
Becker, T. 3/1/13
Traditional AAC therapy
• Traditionally, AAC intervention has focused on improving only
AAC user’s skills
• Because of this “traditional model” we are seeing a lack of
success in carryover and even AAC abandonment for some
children.
• AAC abandonment occurs when there is a lack of carryover
across partners and environments.
• It is just not functional to use with 1 partner in 1 place.
Becker, T. 3/1/13
Factors of AAC Abandonment
• Negative impact on life and family stress
• Lack of opportunities and support
• Lack of training
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Survey says….
• Parents want a partnership with professionals
working with their children
• Parents want us to consider their family a unique
case regarding training and goal selection
• Parents want us to face the reality of parenting a
individual with special needs when providing
recommendations
• Parents want information!!!
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We can’t forget!
• Parents know their child better than we ever could
• Parents are with child in more environments than
we are
• Carry over outside of any therapy setting is a must!
CONSIDER THIS….
 Teaching a skill for ONLY 45 minutes, twice a
week will take over 40 years to master
Becker, T. 3/1/13
Importance of family involvement
• Family is the essential context for
language learning and communication
development
• Primary communication partners for
AAC users
• Provide essential social experiences and
practice opportunities for developing
social and communication competence
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Family-Centered Intervention
• Priorities and choices of family drive
intervention
– Family focus of services
– Families decide what is important
– Provide services to families
• The process of actively involving the
entire family in treatment of a child with
a disability (Rainforth & York-Barr, 1997)
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AAC Boot Camp:
Research on impact of involving
parents in intervention process
Stephanie Fanale, B.S. – graduate student
Trina Becker, M.S., CCC/SLP – faculty mentor
Beth Bergstrom, CCC/SLP – faculty mentor
Eastern Illinois University, Summer 2012
Becker, T. 3/1/13
Independent Variable
•
Informational meeting
– General AAC training—1.5 hours
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The benefits of AAC
The necessity for AAC use in all environments
A general overview of the strategies that will be taught during the program
– Operational skills training—1.5 hours
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Conducted by representatives of AAC device companies (i.e., Prentke Romich, DynaVox)
Communication partners were divided into groups based on the AAC device used by their AAC users.
Training included:
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•
Trouble shooting, programming, and basic operational features of the AAC devices
Two weeks of training sessions
– Week one:
•
3 training sessions targeting aided language modeling and recasting—2 hours each session
– Week two:
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3 training sessions targeting asking open-ended questions and expectant delay—2 hours each session
– Each training session included:
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Time for the communication partners to share their experiences
Discussion of why and how to implement the targeted strategies
Observation of the SLPs on how to implement the strategies
Supported practice
Independent implementation of the strategies during play (15 minutes)
Fanale, 2012
Dependent Variables
• Data collection for communication facilitating strategies:
– 3 home observations were videotaped and reviewed for each participant
prior to initiation of the communication partner training program
– During training—1 observation was videotaped each session
– Six weeks post-training—3 home observations were videotaped
– Each observation was 15 minutes and used the same toy set across
participants
• Survey included questions regarding:
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Demographic information
Previous AAC training
Views of AAC
Use of AAC in the home
A rating of the saliency, frequency, and feasibility of incorporating AAC in
everyday home activities using a 5-point scale (1= never; 5 = always).
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– The survey was completed priorecker,
to the
training and six-weeks post training
Strategies taught at boot camp
• Aided Language Modeling
• Recasting
• Asking Open-ended Questions
• Expectant Delay
Results
Results
Results
Results
Data from 2 of the students
# of Communication Symbols
# of Independent Initiations & Responses
Column1
Column2
45
40
35
30
25
20
15
10
5
0
Baseline
Treatment
Maintenance
Conclusion
• Overall, participants increased their use of
communication facilitating strategies with their children
• ALM was the easiest strategy for the participants to learn
and retain
• Expectant delay and recasting were the most difficult
strategies for the participants to use consistently
• Individual differences and skill levels of the AAC users
contributed to the participants’ performances
– E.g., Participants 1, 3, and 4 had AAC users who initiated use
of their AAC devices, therefore providing opportunities for
the participants to use recasting, while participants 2 and 5
had limited opportunities
Fanale, 2012
Participant Quotes from Boot Camp
• “Thanks for making me realize the disservice I have been
doing to my child all these years” (participant 1)
• “When playing with my child, I now think about and see
sequences that I can use on the device” (Participant 2)
• “I didn’t realize how important it was that I used her talker
until I started doing this boot camp and saw how much this
helps her”(Participant 3)
• “I am surprised at how much he has changed” (Participant 4)
• “He has changed more in two weeks of boot camp than he
did in a year of traditional therapy” (Participant 4)
• “I am going to do my own boot camp at my house with the
teachers and educators at his school” (Participant 5)
Fanale, 2012
Conclusion
Conclusion!
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Conclusion
Trial lots of devices!
-consider preferences
-find language system that best fits
-think about functional vs developmental
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Choose goals to build
Communicative competence!
- 4 areas of competency
- Consider a continuum
- Increase complexity
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Choose intervention
strategies that work!
ALM
Use language
intervention you
are familiar with
and incorporate
AAC!
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Involve Communication Partners!!
Most want to
be involved!
I want specific,
individualized
assistance.
Help me!
Becker, T. 3/1/13
Websites
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http://www.dynavoxtech.com/
http://www.prentrom.com/
http://www.assistivetech.com/
http://www.aacinstitute.org/
http://aac.unl.edu:16080/yaack/toc.html
(AAC Connecting Young Kids)
• http://www.aacintervention.com/
• http://www.gatewaytolanguageandlearning.com/
• http://aac.unl.edu/vocabulary.html
(vocabulary lists)
• http://www.lburkhart.com/
• www.creativecommunicating.com
• www.mayer-johnson.com
Becker, T. 3/1/13
EBP for Aided Language Modeling
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•
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Colgan, (2008). Aided language modeling and requesting behavior in two
preschool children with autism. Unpublished undergraduate thesis, Eastern Illinois
University.
Drager, K.D.R., Postal, V.J., Carrolus, L., Castellano, M., Gagliano, C., & Glynn, J.
(2006). The effect of aided language modeling on symbol comprehension and
production in 2 preschoolers with autism. American Journal of Speech-Language
Pathology, 15, 112-125.
Harris, M.D. & Reichle, J. (2004). The impact of aided language stimulation on
symbol comprehension and production in children with moderate cognitive
disabilities. American Journal of Speech-Language Pathology, 13, 155-167.
Light, J. (1989). Toward a definition of communicative competence for individuals
using augmentative and alternative communication systems. Augmentative and
Alternative Communication, 5, 137-143.
Becker, T. 3/1/13
Other Resources
• Beukelman, D. & Mirenda, P. (2005) Augmentative and alternative
communication supporting children and adults with complex
communication needs. Brookes Publishing Co., Baltimore, MD.
• Light, J., Beukelman, D. & Reichle, J. ( 2003) Communicative competence
for individuals how use AAC. Brookes Publishing Co., Baltimore, MD.
• Light, J. & Drager, K. (2007) Evidence-based AAC interventions for Infants,
Toddlers, and Preschoolers. Presentation at ASHA, Boston.
• Clarke, V. & Schneider, H. Beyond Eat, Drink & Potty (2007) Presentation at
Closing the Gap, Minneapolis.
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References from Boot Camp Study
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•
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Bruno, J., & Dribbon, M. (1998). Outcomes in AAC: Evaluating the effectiveness of a
parent training program. AAC: Augmentative and Alternative Communication, 14(2), 5970. doi:10.1080/07434619812331278216
Carter, M., & Maxwell, K. (1998). Promoting interaction with children using
augmentative communication through a peer-directed intervention. International
Journal of Disability, Development And Education, 45(1), 75-96.
Kent-Walsh, J., & McNaughton, D. (2005). Communication partner instruction in AAC:
Present practices and future directions. AAC: Augmentative and Alternative
Communication, 21(3), 195-204. doi:10.1080/07434610400006646
Light, J. (1989). Toward a definition of communicative competence for individuals using
augmentative and alternative communication systems. AAC: Augmentative and
Alternative Communication, 5(2), 137-144. doi:10.1080/07434618912331275126
Siegel-Causey, E., & Bashinski, S. M. (1997). Enhancing initial communication and
responsiveness of learners with multiple disabilities: A tri-focus framework for partners.
Focus on Autism and Other Developmental Disabilities, 12(2), 105-20.
Starble, A., Hutchins, T., Favro, M., Prelock, P., & Bitner, B. (2005). Family-centered
intervention and satisfaction with AAC device training. Communication Disorders
Quarterly, 27(1), 47-54. doi:10.1177/15257401050270010501
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