Transcript AAC Basics - Becky Gohs

CSD 460
Augmentative Communication for
Non-Speaking Persons
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Intro Night
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Introduction
Syllabus
Assignments- ReggieNet
Test info
Questions for me
Let’s get started!
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AAC BASICS
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ASHA policy practice document found at:
http://www.asha.org/slp/clinical/aac/
Watch http://aacrerc.psu.edu/index.php/webcasts/show/id/17An
introduction to AAC
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Assistive Technology
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An assistive technology device: any item,
piece of equipment, or product system,
whether acquired commercially off the self,
modified, or customized, that is used to
increase, maintain, or improve functional
capabilities of individuals with disabilities.”
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What is AAC?
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AAC- an integrated group of components, including the symbols, aids,
strategies and techniques used by individuals to enhance
communication
(ASHA 1991)
“Augmentative and alternative communication techniques are used to
supplement, i.e., augment or replace speech.”
Types:
Unaided: “techniques that do not require any external equipment.”
Examples: manual sign, body language, gestures, eye contact,
pantomime
Aided: “techniques that incorporate devices that are external to the
individual”. Examples: pictures, computers, keyboards, speech
generating devices (SGD)
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History of AAC
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Emerged in the 1050s / 60s
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Until the 60s and President Kennedy’s involvement, people with
intellectual disabilities were somewhat ignored
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1975-Passage of the Education for All Handicapped Children Act (free
and appropriate education with related services in the least restrictive
environment)
At this time AAC began to be accepted
1986-Passage of the Education of the Handicapped Act Amendments
(provided technological services for school age children with
disabilities)
1989-Technology-Related Assistance for individuals with Disabilities Act
(states must make every reasonable attempt to provide AT to those
with disabilities, regardless of age, disability or location of residence)
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History cont.
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1991-The Education Act was reauthorized and
renamed the Individuals with Disabilities
Education Act (IDEA)
1997- amendments were written to target
assessment of AT and consideration of each
students needs.
This targeted AAC specifically.
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First AAC devices
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Cannon Communicator
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Handi Voice
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Definition of Population Using AAC
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Individuals with severe communication disorders those for whom gestural or natural speech, is
temporarily or permanently inadequate to meet all of
their communication needs
Hearing impairment is not the primary cause
Some may be able to produce limited amounts of
speech, inadequate to meet communication needs.
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Best Practices: ASHA
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Factors that Cause AAC Users to be Viewed
as Competent-Beukelman & Mirenda
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Portray positive self-image
Show interest in others and draw others into
interactions
Actively participate and take turns in symmetrical
fashion
Be responsive to communication partners and
negotiate shared topics
Put partners at ease with AAC system, often using
humor
Videos – Miles and DynaVox
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Important Abbreviations!
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AAC: Augmentative/Alternative Communication
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SGD:
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VOCA: Voice Output Communication Aid
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Speech Generating Device
DA: Dedicated Aid: a device that has been
programmed to be used exclusively as an AAC device
(no internet)
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General Principles/Goals of AAC
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No prerequisites to AAC intervention!
Individuals with significant developmental delays can
be very successful with AAC
In the past prerequisites were thought to be ability to
* visually track moving object,
* match pictures to objects,
* object permanence,
* cause-effect, and
* communicative intentionality
(Sigafoos et al from Schlosser, 2003)
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General Principles/Goals of AAC,
cont.
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No data to support exclusion of beginning
communicators on basis of deficits in
readiness skills or cognitive abilities
Doesn’t mean, however, that these skills
wouldn’t increase efficacy of AAC
intervention or what could be achieve
during intervention.
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General Principles/Goals of AAC,
cont.
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AAC will not interfere with development of spoken language – in
fact AAC can encourage speech and language development
Review of literature by Millar, Light, & Schlosser (2000, as cited
in Schlosser, 2003)
 24 studies with total of 58 participants most w/ Dx MR
 Majority improved natural speech after AAC, only 3 showed
no change, none decreased in use of natural speech
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YAACK website
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General Principles/Goals of AAC,
cont.
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Even very limited speech can be a major mode of
communication in combination with AAC
AAC does not replace speech, but supplements it,
therefore, should continue to promote spoken
language
Always consider language development – receptive
and expressive.
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General Principles/Goals of AAC,
cont.
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Involves at least two people
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Reduce frustration involved with communicative failure
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Promote greater participation in school and life activities
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AAC intervention must begin early in school
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Infants and toddlers can benefit from AAC intervention
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Promote vocational opportunities
 65% of people with speech impairment are unemployed
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Multimodal Systems
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Communication modes:
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Understanding (receptive): hearing, vision,
taste, feeling, touch, others???
Output (expressive): speech, writing, typing, signing,
use of pictures, devices
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Paralinguistic: tone, prosody, rate
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Nonlinguistic: body language, gestures, facial expressions
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Requirements of Multimodal
Communication Systems
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Full range of communicative functions
Compatible and work with other aspects of
individual’s life
System doesn’t restrict communication partners
(sometimes the tech is too much for the family. Ex DC)
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Usable in all environments and physical positions
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General Principles/Goals of AAC,
cont.
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Multimodal system – “AAC is NOT just technology. Too often
professionals and families focus on equipment, perhaps even on a
single device. Yet people who use AAC successfully use a
constellation of communication tools and strategies, including
high, low and no tech approaches.” http://depts. Washington.edu/
Plan for today and tomorrow
“AAC may look different, but participation in life through
communication is an immense payoff”.
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Devices: Low Tech
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Low Tech:
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Easily made and maintained
Easy to use
Inexpensive
Examples: language boards/books
Picture Exchange Communication System
(PECS)
*Regional Institute of Assistive Technology
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Devices-Elementary
Elementary:
 Costs less than $1,000
 Use store batteries
 Use static overlays and recorded speech
 Programming is easy
 No tech support
*Regional Institute of Assistive Technology
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Devices: High Tech
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Use dynamic screens (computers)
Run on rechargeable batteries
Expensive
Use synthesized voices
Good manufacturer tech support
All the bells and whistles
*Regional Institute of Assistive Technology
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Tablets and Apps
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iPad
Apps
Proloquo2Go
TouchChat
Sonoflex
Compass
Go Talk Now
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Symbols
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Symbols can be acoustic, graphic, manual and/or
tactile:
 Acoustic: digitized/synthesized speech & tones
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Graphic: icons, photographs & letters/words
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Manual: sign language & gestures
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Tactile: objects & textures (soft)
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Symbols
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Unaided: sign language, gestures, etc.
Aided
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Tangible
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Real objects: identical, similar, related
Miniature objects
Representational
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Photographs
Pictures
Line drawings
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Symbol Types
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Iconic/Symbols
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Demonstrates an association between a symbol and its
referent
3 Kinds of Symbols: (require different levels of teaching)
 Transparent
Shape, motion, or function can be readily guessed in
absence of the referent
 Translucent (background helps to guess)
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Meaning may not be obvious
 Opaque (no clues)
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No relationship to the referent
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The most opaque symbol is a written word (if not literate)
They different types of symbols will require different levels of
teaching!!
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Symbols…..
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Any symbol used should be able to
represent an individual’s communication.
(wants, needs, desires, thoughts, ideas,
opinions, or emotions.)
Must pick a symbol set that is robust.
All symbols can be used alone or in
combination with one another.
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Organization of Selection (Page) Sets
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Components of the device –
 Messages
 Symbols or codes
 Operational and interactional commands: used for
programming
Physical characteristics – based on match cognitive,
language, sensory and motor capabilities
 Number of items, size of items, spacing &
arrangement, and orientation of display
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Organization of Selection Sets
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Schematic
 Biographical or activity groupings based on
experience
Taxonomic
 Groupings based on categories
Semantic-syntactic
 Groupings based on some knowledge of grammar
Alphabetic
 Based on alphabet
Naturalistic – visual scene displays
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Organization
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Schematic: based on experience
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Another look at schematic
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Organization
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Taxonomic
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Groupings based on categories
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Organization
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Semantic-syntactic
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Groupings based on some knowledge of
grammar (Fitzgerald Key)
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Organization
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Alphabetic
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Based on alphabet
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Visual Scenebuttons are hidden within a photo/pic
of a particular activity
What hot spots could we add
to this visual scene?
The Compass had visual scenes.
Go Talk now had a visual scene.
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PODD organization-Pragmatic
Organization of Dynamic Display
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From Sarah Blackstone
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The purpose of a communication
display is to arrange language so
individuals can say what they wish to
say as quickly as possible and can do so
with a minimal amount of effort.
Many companies now include any or all
of the 6 types of organization within
their users.
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Processes- Rate Enhancement
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Rate enhancement
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Two basics types
Message prediction
Encoding – sequential coding
Typical 125 – 250
wpm
(icon, number etc)
Person who uses
Word Codes- examples
AAC
Salient letter-hmbrgr
 5-25 wpm, usually
Letter category-Fa= apple
less than 15
Alpha-numeric-13=yesterday
Morse Code
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Vocabulary Output-visual and auditory
Visual:
Pictures, icons, words, signs
(you may have one per button or you may have message buttons)
EX…
do
Don’t
Do
that
Somethings
wrong
Let’s look at Quickfires in Compass
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Vocabulary Output
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Auditory:
Digitized: primarily natural speech that is
recorded, stored and reproduced
Synthesized: speech that is produced
from computers
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Literacy Base of Individuals
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Pre-literate individuals- haven’t learned to read/write
 Coverage vocabulary: needed to express essential
messages
Look at environments to determine their needs
Pages frequently arraigned schematically (based on
activities or the environment)
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Developmental vocabulary: words unknown to user.
You do expect to be able to teach them
to increased semantics and syntax.
(pronouns, verbs, adjectives, prepositions, etc)
Never underestimate what you might need in the future!!
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Vocabulary Types-Literacy based
Literate individuals- they can read and
write
Will be creating novel sentences
Need lots of vocabulary covering all parts
of speech (articles, verb tenses, etc)
They may be using a text based system
They will need a keyboard.
Acceleration: sentences so lengthy they need to
be encoding, have prediction, etc (LOL, OMG)
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Vocabulary types-Literacy based
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Non-literate-will probably never be able to read or
write
Coverage-It’s all about teaching them functional
communication.
EX. The milk is on the table. Or I need a break.
Schematically based with more “message” buttons.
Be sure to keep age and gender appropriate!
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Where do we get developmental vocabulary?
From CORE vocabulary
Core refers to words we use… 300 words are used 80% of the time.
Diverse variety of words primarily: (very few nouns are used)
Verbs (e.g. stop, go, eat, want)
Adjectives (e.g. more, good, bad, different)
Prepositions (e.g. in, on, off, out)
Pronouns (e.g. me, I, you)
Usually 6 letters or less
Frequently used by children and adults to express a variety of
communicative functions on a daily basis
Core will change with age
Core lists- Banajee and Marvin and Stuart
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What is Core Vocabulary?
Researchers report...
•Children with and without disabilities: core vocabularies range
from 182 to 263 words with similarities between the words
among all children.
•Core vocabularies are similar across speakers of different
languages.
•Children use core vocabulary in their writing.
•Core vocabulary words make up more than 70% of the
children’s words used in their everyday language.
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Let’s look at Core
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Add screen shot 10x10
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Activity: Core in Action
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This is Dylan.
Dylan is 2 yrs 9 months
old.
Take a look at Dylan’s
language sample.
Use your core list and
see what % of his
spontaneous language
is core.
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Let’s do a core activity…how many
sentences can you make in 5 minutes?
I
Like
On
Some
You
In
Here
My/mine
Go
Out
More
What
want
it
that
help
stop
not on this board
all done
am/is/are
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Core can’t cover it all.
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Fringe vocabulary: extras, all the other words
Words and messages that are specific/
unique to the learner.
Compiled by parents, teachers, SLPs, and
siblings
A cautionary word about Fringe
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Let’s look at Prentke-Romich’s
langage system- Unity
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Semantic compaction
foods, eat, hungry, bite,
delicious, chew, feed
In Most language systems
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A Quick look at Unity
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Static screen, pics never change, premise is on motor planning, pics mean different
things, uses more opaque icons
http://prc.articulateonline.com/p/0771788060/DocumentViewRouter.ashx?Cust=07717&Docu
mentID=2b097732-fdb0-4013-a5e866152d2f918a&Popped=True&v=19&InitialPage=story.html
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Unity
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FYI
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Today’s research says to error on the side of teaching
Core vocabulary for your preliterate and literate
individuals.
Without CORE vocabulary, we are imposing a ceiling
on language development
Without CORE, we are limiting our clients to
requesting and labeling
We have to be good at teaching the use of CORE
vocabulary
It is more difficult to teach abstract concepts
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Selection Techniques-2 types
1.
Direct Selection-select a symbol directly from a set
Selection options
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Physical pressure or depression (devices)
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Physical contact (pictures or objects)
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Pointing no contact (with comm. partner)
Examples of direct select options:
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Index finger (most common, head pointer, eye gaze, etc.)
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AAC Eye Point Training with Partner Assisted
Scanning
https://www.youtube.com/watch?v=xatHPazOXw0&list=FL8v
6Snh4YKvkX3Skfsk_PzA&index=18
Meet Elle
https://www.youtube.com/watch?v=g95TO20hnmo&list=FL8
v6Snh4YKvkX3Skfsk_PzA&index=23
Alyssa Tobii
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Direct Selection Considerations
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Do they have the needed motor skills to access all
buttons on a display? (size of button, spacing and
size of display)
Do they have enough pressure?
Do they need touch enter or touch exit?
Do they need to hold for a particular amount of time?
Do they have a drag?
With eye gaze can they dwell?
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Second Selection Technique
Scanning
Partner Assisted Scanning- a person
scans the choices – low tech
Response can be a body movement or switch
activation
Yes Switch or Yes/No Switch
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Emma's PODD with Linda Burkhart
Ryan “yes” switch
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Second Selection TechniqueScanning
Device scans until the user makes a selection
Switch scanning (6 min)
Hi-lites each button, can hit anywhere on
screen when button is hi-lited
Two Switch Step Scanning Demo (2 min)
Row and column scanning, left side scans or starts
and right side selects or picks
Stephen Hawking (2 min)
You can set an iPad to scan with head movement!
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Scanning Patterns
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Circular (simplest), 8-12 items
Linear-names each item in each row
This is a very slow communication
Group-item: this enhances efficiency
Row/ column
Quadrant
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Scanning
Control Techniques
One switchDirected Inverse Scanning-hold down switch-device
scans until switch is released
Automatic Scanning- Device moves on it own.
User activates a switch to select a choice.
Step Scanning- frequently with 2 switches
One switch starts the scan and one hand picks
Ryan
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Issues with Scanning
Not a lot of research but…..
Slower
More taxing on memory
More taxing on attention
Cognitively harder
YOU MUST DETERMINE THE
APPROPRIATE SCANNING SPEED.
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Feedback-info sent back to AAC user
when a device is activated.
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Message feedback
 What the device/communication partner communicates
 Single words or full sentences
Activation feedback
 Auditory/visual feedback from the device
 Examples: beeps, spelling the word out loud, visual displays
on the device.
Let’s look at Trevor Switch Scanning
Visual Feedback on Cheap Talk 8
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AAC Issues for People with
Developmental Disabilities
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Cerebral Palsy:
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Characteristics & Associated Conditions
Unique AAC issues
Intellectual Disability
AAMR’s definition of abilities
Problem behavior
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Developmental Disability
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Present at birth
Affects one or more areas:
physical
sensory
cognitive
In public schools you can have an eligibility of DD up until the age
of nine.
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Cerebral Palsy
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Definition:
CP is typically used to refer to a
developmental neuromotor condition that is the result
of a nonprogressive abnormality of the developing
brain.
 Incident usually occurs right before, during, or
right after birth.
 Non progressive
 Live to adulthood but shorter life epectancy
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Characteristics and Associated Conditions
of CP
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One half to 2/3 have cognitive impairments
Motor skills deficits- depends on sight of
lesion
Types: spastic, dystonic, flaccid, ataxic, etc.
Communication and speech deficits
Vision problems
Hearing problems
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AAC Issues
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Must use a team approach:
 SLP’s: language development: both
receptive & expressive and AAC
 OTs: fine motor (access methods)
 PTs: positioning, seating adaptions
 Classroom teacher: cognitive development
and literacy skills
 Vision specialists- display parameters,
figure ground, symbol size
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Team Approach:
Balanced Intervention
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Use multimodal communication systems
You may find that the individual is able to
communicate with family members very
effectively, whereas he may need to rely on AAC
with unfamiliar partners.
If they have motor issues, what type of selection
method might they need?
Scanning
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American Association of Mental
Retardation’s Definition
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The AAMR definition deemphasized ability-level (or
IQ-based) classifications (mild, moderate, severe,
profound) in favor of a focus on the level(s) of
support a person needs
We currently use the eligibility of ID (intellectual
disability)
1-7% of population in U.S.
Largest population unable to speak
AAC candidates only since the 1980s
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MR: Levels of Severity:
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New term:
Old term:
Intermittent
mild
Limited
moderate
Extensive
severe
Pervasive
profound
The new term describes the amount of
support the child needs, instead of the
severity of the mental retardation.
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Intervention
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Most beneficial to learn skills in the
natural setting that it will occur
ex: snack time
Teach skills in therapy but generalize to
other environments
ex: “here it is” and “I can’t find it.”
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What about syndromes?
A diagnosis can give you an abundance of
information.
 Individuals within the same syndrome may
exhibit the same patterns of development,
cognition, motor patterns, etc. (example
Down’s Syndrome)
 BUT their may be variances
(Tuberous Sclerosis (KC &SA), rare genetic
disorders, NW)
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What about medications?
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Certain medications can inhibit
communication!
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Problem Behaviors
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“Behavior problems, however, do occur in
these (Cog.Imp/DI) individuals more often
than in people without disabilities (Batshaw
& Shapiro, ’02), for reasons that should be
quite obvious- a lack of preferred and
functional places to go, people to be with,
things to do, and ways to communicate.”
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Developmental Apraxia of Speech
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Description: “developmental apraxia of speech (DAS;
also known as childhood apraxia of speech, childhood
verbal apraxia, and childhood dyspraxia) has been
used to refer to children with articulation errors who
also have difficulty with volitional or imitative
production of speech sounds and sequences.”
Unique AAC issues: need intense work to improve
natural speech production, plus a multimodal
communication system.
What do you do when they have lots of oral language
but are unintelligible?
(ex. Melissa B, RR)
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Autism and
Pervasive Developmental Disorders
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Prevelance 1 in 88
Definition
Characteristics
Unique AAC issues
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Definition
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“All of the diagnostic systems commonly
used to describe autism agree that there
are three main diagnostic features:
1) impairments in social interactions;
2) impairments in communication; and
3)restricted, repetitive, and stereotypical
patterns of behaviors, interest, and
activities.”
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Characteristics
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“75% of people with autism also have
intellectual disabilities.” (might be 50%)
Social/ communication impairments
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Predictors noted before age 12 months: failure to
look at people, decreased eye contact, failure to
orient to name, reduced social smiling, lack of
social interest, & difficulty with imitation.
Language impairments: may be masked
Processing impairments: details rather than
gestalt (see things as a whole, not parts) processors.
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Unique AAC Issues
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Early intervention:
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Communication in a social & developmental
context:
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Start early!!!!!
Is critical
Teach generalization
Speech output:
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The use of a speech generated device (SGD) can
increase natural speech production….research!
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Adults with Acquired Conditions
Amyotrophic Lateral Sclerosis (ALS) - Progressive and
degenerative
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Attacks nerve cells controlling voluntary muscles but not
sensations
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80% unable to speak at time of death
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Survival rates…32 mons from time symptoms appear
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50% will show some degree of dementia
3 Phases of InterventionEarly Phase-educate patient and family about future speech
performance (respiratory, etc)
Middle Phase-Assessment (needs for now and future)and purchase;
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good phase for sound/voice banking/voice recording
Late Phase-Modify AAC strategies as needed
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Multiple Sclerosis (MS)
Cause is unknown- hits young and
middle aged adults
 Lesions on the central nervous system
 Disease varies greatly in individuals
 Dysarthria is most common
 Many will not need AAC in the end
Intervention- mimics that of ALS
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Parkinson’s Disease
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Loss of neurons in the basal ganglia and brain stem
Motor symptoms- tremors, rigidity impaired postural
reflexes
Dysarthria is common
Some speak to fast, some with restricted oral
movements and some with reduced intensity
Most continue to use speech
If AAC is used it is part of a multimodal system
3 phases of intervention
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Stroke and Aphasia
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Steps required to communicate may be interrupted at any
point(comprehending, creating ideas, retrieving words,
executing motor movements
These areas can improve over days, months, and years (rehab)
If natural speech and comprehension are slow to recover then
AAC can be beneficial.
AAC can enhance comprehension (it’s visual and concrete)
Means of expressing basic needs and wants
Word as a word or phrase bank
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Aphasia Interventions
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Keep them multimodal
There are 2 interventions
1.Teaching independent communication- these
individuals understand context and are
transitioning
2. Partner supported contexts- for your
profound cognitive-linguistically disordered
individual
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Dementia
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AAC can be used to reduce memory
demands
(personal info, daily schedules,
problem solving info)
AAC makes language concrete
When they hear language and see it
then it is redundant- reducing
information processing
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Teaming
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Unidisciplinary – work alone
Multidisciplinary – evaluate and plan on
own, but acknowledge that teammates are
there
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Interdisciplinary – all part of the
program, all function together, but
boundaries exist
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Transdisciplinary – all work together
without boundaries
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Teaming
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Is most important aspects of AAC
evaluation and intervention.
Involves everyone who is working/has
contact with the child or adult
Is a continuous dynamic process.
The result will be a more holistic program
for the child/adult using AAC.
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Team Members and Their Jobs.

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
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Classroom Teacher and LBS1
AT Specialist
Paraprofessional
Physical Therapist
Occupational Therapist
Vision and Hearing Specialist
Other school personnel
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Team Members and Their Jobs
as Compared to a Football Team

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Mom/student = like the general manager, has
the most invested in the child
SLP/AAC Specialist = the quarterback
AT Specialist = Equipment manager, good to use
the STEP model (framework for collaborative
thinking)
OT (fine motor/sensory) = line backer
PT, Vision and Hearing Specialist, Classroom
Teachers, AdPE Specialist, all other service
providers = running backs and wide receivers
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Classroom Teacher


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Assesses: reading levels
Consult with SLP on attention skills, listening skills,
memory within the classroom situation.
In therapy, will consult with the SLP on vocabulary
needed for the device, reading & spelling
activities, and community outings.
Most importantly- will carryout/help teach your
objectives when you are not present
91
Para Professional/Teaching Assistant


Can consult with the SLP on daily living skills
(feeding, bathroom, etc.), temperament,
ability to stay involved in an activity,
motivation, and many other things the child
goes through within his daily school schedule.
Most importantly- will carryout/help teach
your objectives when you are not present
92
Parents too!

Parents must be a part of the teaming
process:


Is device used at home
What vocab is needed at home
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Physical Therapist: PT

Assesses: muscle tone, primitive reflexes,
and movement disorders
Muscle tone: high, low or combination
Primitive reflexes: tonic neck, startle, etc.
Movement disorders; spastic = high tone,
Flaccid = low tone, and Athetosis = involuntary
motor movements, timing difficulties.
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Physical Therapist: PT

Stable base of support: elements of an optimal
seated position:
 Pelvis, hips & thighs: bear equal weight and are
centered in the wheelchair.
 Trunk: symmetrical, leaning slightly forward
 Shoulders, arms & hands: supported in a neutral
position.
 Legs, feet, & ankles: flexed at 90 degree angle,
and bearing weight
 Head & neck: in mid-line
95
Physical Therapist: PT

Will consult with the SLP on:



Optimum positioning in the wheelchair
Choice of mounting to be used for the
switch
Need for special equipment such as
butterfly harness, headrest, etc.
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Occupational Therapist: OT


Assesses: visual motor capabilities,
sensory integration problems, eye-hand
coordination, fine motor control (pointing,
writing)
Will consult with the SLP on the ability to
use direct select method or scanning,
placement of the switch, placement of the
device on the tray, therapy ideas for hand
control, type of scanning pattern to use,
or type of switch needed.
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School Psychologist


Assesses: cognitive abilities: (I.Q.),
Consults with the SLP usually through
school files as to when testing was done
and the results of that cognitive testing.
Classroom teacher’s input can also be used
in reports to explain what the child can do,
if no testing has been done by the
Psychologist.
98