Augmentative and alternative communication (AAC)

For someone with limited or no speech, including people with autistic spectrum disorders, AAC is a means of getting their message across to others. AAC is also useful for people with difficulty understanding language, with specific language disorders, and as a bridge to literacy.

AAC systems include facial expression, body posture, gesture, eye pointing, and vocalizations as well as more formalized systems of signing and graphic symbols (low-tech), or voice output communication aids – VOCAs – and computer based speech and text producing systems (high-tech). Both low and high-tech systems can be used by people who are unable to spell or read, as well as by people who are highly literate.

Specific educational approaches like the Picture Exchange Communication System (PECS) actually embody a specialized form of AAC, rather than being separate or different from AAC. PECS is primarily low tech. High-tech devices range from simple aids (e.g. single message VOCAs, pointer boards, toys or books which speak when touched, etc.) to very sophisticated systems such as that used by Professor Stephen Hawking.

In general, AAC users typically use not just one but a combination of different forms of communication, such as a symbol communication book and a VOCA, signing with close family and friends and using a VOCA with strangers. Whether ICT is used in a simple or elaborate way it is usually only one component of the person’s communication system.

Pupils will commonly use both VOCAs and classroom computers. VOCAs go with pupils all the time, enabling them to participate and interact, ask and answer questions, comment, direct, explain and report, and practise their use of language in a natural and immediate way. Computers are used more for teaching and curriculum support.

Scenario 1

Rosie has quadriplegic cerebral palsy. She seems to understand others but has slow processing and needs structured prompting. Rosie currently communicates using facial expression and eye pointing – PCS symbols in a communication book arranged by topic accessed through manual scanning by a partner with Rosie indicating ‘yes’ at the desired item – and PCS symbols on an eight-location AlphaTalker (Digitized VOCA, see below) set in topic themes, using auditory prompts and single switch access. Rosie also uses the classroom computer, with a single switch, and is practising scanning and choice making with basic concepts / vocabulary, using ChooseIt! Maker.

Key skills and equipment

The key skills for the above example are the ability to:

• use and accept any ‘prop’ which will facilitate Rosie’s communication – facial expression, eye pointing, PCS symbol book, listener scanning, digitized VOCA
• make a communication book
• program a VOCA
• set up ChooseIt! Maker with appropriate options and switch access

The key equipment is:

• Computer running PCS symbol software (Boardmaker, Writing with Symbols 2000, Clicker 4) to create a communication book
• ChooseIt! Maker software
• AlphaTalker

High-tech communication equipment

Within this Unit the term ‘equipment’ includes VOCAs as well as computers, software and specialist access devices. VOCAs have been divided into three categories. Specific VOCAs within each category are briefly described in Appendix 2.

Digitized VOCAs

All VOCAs in this category use digitized (recorded) speech. The user of a digitized device can only say what someone has already recorded into it on their behalf. On the whole, digitized VOCAs are easier to program than synthesized ones.

This category covers a wide range of VOCAs from those offering single messages to those with multiple messages that can be organized in ‘themes’ or ‘levels’. VOCAs in this category can also be used as a classroom aid or dedicated to a single user.

Synthesized VOCAs

VOCAs in the Synthesized and Computer-Based Communication Applications categories use synthesized speech, which the computer generates by combining phonemes according to rules laid down within the speech synthesizer used by the device. The use of synthetic speech results in a far more flexible device since the synthesizer can generate any combination of words and / or syllables that the user chooses. These are the most expensive of the dedicated communication aids. Such VOCAs are usually provided for a single user and should not normally be purchased without specialist assessment advice.

Computer-based communication applications

Some communication programs have been written to run on ordinary computers, providing access to curriculum applications as well as providing vocabulary structures to support communication. These can be used as dedicated communication aids for a single user. They can also be used, however, on a classroom computer to explore the child’s and staff’s ability to manage the system, before funding is requested for a dedicated system.

Key factors for success with AAC and ICT

Whose responsibility?

Ideally an interdisciplinary team will be involved in supporting pupils who need communication aids. While the initial introduction of a communication aid may be led by the speech and language therapist (SALT), integrating the use of communication aids into classroom learning is the responsibility of the teacher.

Choosing effective teaching and learning approaches

Medical or speech and language therapy diagnostic ‘labelling’ of pupils may not help much. Teachers still have to identify the most effective teaching and learning approaches for each child. Principal approaches (not mutually exclusive) are:

• Remedial approach
  Levels of developmental speech, language and communication disorders vary. In some cases delays can eventually be overcome, while in others difficulties may be long lasting. The overall educational approach will generally be remedial / rehabilitative and supportive – filling in gaps through the provision of structured language learning opportunities, building on the skills the pupil does have, providing a language-aware environment with plenty of repetition, and modelling.
• Compensatory approach
  Where aspects of the language and communication disorder are very severe, the most effective educational approach will be to bypass defective channels and try to use the pupil’s areas of relative strength. Concentrate first on establishing basic functional communication through AAC use, and then use this as the medium for social interaction and the teaching and learning of new skills.
• Specialized approaches
  Structured approaches for pupils with autistic spectrum disorders such as the Treatment and Education of Autistic and related Communication Handicapped Children (TEACCH) and PECS, which is based in behaviourism, are really examples of highly specific implementations of a compensatory model of AAC, but as they tend to be 'packaged' and taught as stand-alone approaches, they might usefully be given their own heading.
  In TEACCH, the use of visual and nonverbal skills are used to build up understanding, confidence and success. As one example, it is recommended that locations in the classroom are specially organized and colour coded, to help the child learn to be independent in following a highly consistent and structured routine, eg. in following the list of activities on his colour-coded visual schedule, he moves activities from left to right across a set of trays or desks depending on whether they are waiting, being carried out, or completed.
  In PECS, children are taught to give a picture to an adult, in exchange for the food, toy or activity that they especially like. If each of the six highly detailed Phases is taught and carried out correctly, some children will move gradually from exchanging any square of card (ie picture recognition not required) to spontaneously initiated requesting and commenting, in short sentences, using a wide range of meaningful pictures/symbols.
  ICT can certainly be used within these approaches but only by trained staff who see how it fits into the overall programme.

AAC Targets

For AAC users, there are communication targets as well as curriculum targets, ultimately leading to communicative competence. Light (in MacDonald and Rendle, 1988) defines the components of this:

• Operational – how to operate the AAC system – motor and cognitive skills required to access and send / signal a message (knowing the sign or locating the desired message, pointing, scanning, operating switches, controlling cursors, editing, etc).
• Linguistic – adequate receptive and expressive mastery of the native language (vocabulary and grammar) plus mastery of the AAC code (signs and symbols).
• Social – competence in the social rules of communication; for example making appropriate eye contact, sharing the balance of talking and listening, responding to non-verbal clues like turning gaze away, giving feedback.
• Strategic – ability to adapt communicative style to suit the listener (knowing who can understand signs and who will need other clues, changing vocabulary to suit pals, older persons or authority figures), or learning how to repair and extend the conversation (being able to signal “I don’t understand” or “What do you think”).

It is standard practice for teachers and therapists to concentrate on operational and linguistic competencies, but once these are established it is the social and strategic competencies which are crucial to the person becoming an efficient and effective communicator who can cope in all situations and environments. Social and strategic competencies need to be addressed from an early age with cognitively able pupils: they need to be able to make mistakes, be rude and then be corrected in just the same way as a normally speaking child. Above all, they need communication opportunities to practise their skills.

Using support from external specialists

There is a national network of specialist services in ICT for communication in education, and for AAC. There are also specialist communication aids centres within the Health service. Discuss referral of particular pupils to one of these services with your Head Teacher and speech and language therapist.

Choosing and setting up hardware

• Remember that simple AAC devices can be used as ordinary classroom resources for use by groups – they do not always have to be allocated exclusively to an individual pupil.
• For pupils for whom literacy is a realistic goal, choose AAC systems that offer printout (or connection to computer) facilities, if possible.
• For early learners, choose AAC devices that are simple and quick to manage in the classroom – or else they will not be used (some AAC users will use more than one system – simple for class group work and more complex for personal use).

Choosing software

• So much is available and some of it is very costly (up to £1000). Therefore try to see a demonstration, borrow for a trial, or negotiate ‘sale or return’ before you buy.
• Always try software out yourself (using the special input method the pupil will use) before trying it out with a pupil.
• Choose software which matches the developmental level of the child, as well as being topic relevant

But also

• Think about where the pupil is now and the many steps they need to negotiate to become an efficient communicator. Choose software or VOCAs with ‘room for growth’, but easily usable by the pupil as they are now.
• Keep to a small set of software. Don’t ‘drown’ the pupil (or yourself) in too many different packages at the same time.
• Try to stick to software from the same ‘stable’, so that presentation and the mode of operation are consistent (especially for scan and switch users), so that the pupil is not distracted from the content of the package by having to master lots of different user interfaces.
• Look out for the teaching and learning style embodied within different software (cf. Blamires, 1999, p11-14). Structured ‘drills and skills’ type software with fixed content may be good for reinforcing language sub-skills, such as matching and sorting, but ineffective for developing connected language and higher level skills. Creative and exploratory software, such as open-ended frameworks and word / symbol processors that allow you to use your own content, are good for developing understanding of word meanings, discovering new concepts and for sequencing words into sentences and stories. These programs may take longer for the teacher to get to grips with initially, but repay the investment of time and effort later on, in their flexibility of use.
• Be aware of software suites such as Bio-Bytes, Earobics and Making Tracks to Literacy, which provide complete ‘packages’ of graded activities within a consistent presentation style – with pupil progress management, and record keeping, along the lines of Integrated Learning Systems (ILS).

Introducing ICT and AAC use

• Start from where the pupil is, or even slightly below, so that they achieve success that can be built on, rather than imposing external notions of what they ought to be doing.
• Phase in technology use gradually, in well-supported steps, with lots of time for reinforcement and consolidation of each stage for both the pupil and all the staff.
• Introduce VOCA use in the natural environments in which specific language and communication needs arise. Teach and practise specific new vocabulary items, language structures or types of interaction in familiar social contexts linked in a meaningful way to the curriculum.

AAC and technology use takes time and work

Pupils who require AAC have a large set of special extra skills to master, and will always use language and communication in slightly different ways to natural speakers. This requires some specialist input (including ICT elements) and the allocation of plenty of time and human resources, which has implications for school policies.

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