The Changing World of Augmentative and Alternative Communication (AAC)

September 6, 2012





Each time I prepare to teach a graduate student class, train a group of therapists or provide therapy for a client, I spend time making sure my information is up to date. I recently taught a symposium at George Washington University titled,“AAC Devices and Implementation Strategies to Promote Success: An Update on Cutting-Edge Technologies for Augmentative and Alternative Communication”. Although I have been immersed in this world of AAC for quite a while and use many iPad apps as well as more traditional devices, as I gathered information and prepared for the presentation, I became even more aware of how much the entire world of AAC including its purpose, products and delivery model have changed.

Back in the mid-1980s when I attended Northwestern University, I took an elective AAC class. I remember it well. I learned about devices produced by well-known companies such as Prentke Romich and Dynavox. We learned a formal very lengthy AAC protocol to help us decide which device would be best for individuals with significant communication needs from congenital challenges such as Cerebral Palsy or degenerative diseases such as MS or ALS. We wrote comprehensive reports which included measurable goals to use in therapy. There was a long process to go through to obtain funding of the machines that were many thousands of dollars. I recall spending hours reading manuals so that I could try to customize the vocabulary content to meet the user’s needs.

Fast forward to now. AAC has existed for about 40 years. The types of technologies that provide augmentative and alternative communication functions have grown exponentially. The way our society communicates is changing. Texting, email, video calls, text to speech and speech to text technologies are becoming mainstream. There are now many technology tools available that can help people express themselves. Cell phones, tablets, SmartPhones, Skype, Facebook, and technology devices with vocal output, have worked their way into mainstream society and are readily available to all. Speech-language pathologists are no longer the gatekeepers to the AAC world. It is now more affordable and easy to access AAC solutions.

There are pros and cons to this situation. On the positive side, more individuals who have difficulty expressing themselves now have easier access to potential solutions to improve the quality of their lives. Affordable technologies are finding their way into the lives of individuals who in the past might have spent their lives unable to effectively communicate. There are now more than 200 AAC apps in iTunes alone and more and more are becoming available in the Android marketplace.

The problem is that very often individuals who have complex communication needs (CCN) are frequently not provided with the most appropriate tools and training to develop and maximize their communication skills. It is critical to consider the strengths, communication needs, goals, interests, and characteristics of each person as well as typical language development. There should also be an effort made to appropriately reinforce communication attempts, model the use of the device, and expand newly learned skills into the home and daily routines. I strongly encourage individuals to seek professional guidance from a qualified speech-language pathologist when choosing and using AAC apps. In my practice, families are coming to me with a number of AAC apps that they found already on their iPads- but they don’t know how to go about configuring them or using them to help their loved ones. This often leads to frustration and abandonment.

When I work with individuals who have limited communication abilities, I have found that I often have to work with other apps and toward goals such as first establishing joint attention, promoting the concept of cause/effect and working on ways to motivate individuals to initiate communication and interact with the iPad or other device. I have found the built-in features of the iPad and many free and low cost apps make therapy more engaging and efficient in reaching these initial goals as well as helping people advance to more involved communication tasks.

Tablets with AAC apps are not necessarily the best solutions for individuals with difficulty using their hands to touch pictures and words to be said aloud by a device. Not all consumer products- even those with many accessibility options such as the iPad – meet the needs of every person. When working with adults who have aphasia or individuals with severe autism spectrum disorder the task of learning to use AAC apps to communicate is complex. It is a bit less complex when the lack of communication is due to speech or voice disorder as opposed to a language or cognitive disorder. There are also individuals with significant physical disabilities who may need to use eye gaze or scanning to access the technology. A multidisciplinary team including a physical therapist, occupational therapist, speech-language pathologist and an assistive technology expert is ideal in this situation. It is important that if an iPad is to be used with a person with significant physical limitations, the person selecting the apps and training the individual be familiar with issues relating to seating, positioning, and the apps that are switch accessible as well as recent products using alternate ways to access the iPad..
Many of the products that have been around for a long time have had years of research to support the many features they offer in terms of teaching language and facilitating verbal expression. An increasing number of products are becoming available for tablets- but the products are new. The research on their efficacy has just begun. In addition, if a tablet computer is indeed the product of choice, there is a great deal of planning that needs to go into configuring the device and teaching the individual how to most effectively use it. Careful consideration needs to be given to :
• Language representation- What is the best way to present words and concepts? Photos of people and items in a person’s environment, abstract images, and printed words can be used.
• Visual display- How many images or words should be presented at one time? Should a person have a finite group from which to select or should the person be able to scroll for more choices and produce novel messages?
• Word selection- What needs to be communicated? There is much more to life than just naming objects. Comments, requests and questions are an integral part of communication.
• Communicative Intent- Does the individual need to be externally motivated to communicate? How are the person currently communicating and what further skills need to be developed?
• Communication Abilities- What are the language, speech, cognitive and social skills of the person?
• Implementation Plan- How will the device be configured and what are the strategies for successful implementation of the device into daily routines? How much support is available? Who will continue to update the device as the needs of the individual change?
Even if families do turn to communication professionals for comprehensive assessments- the speech-language pathologists are confronted with a number of dilemmas. How should the availability of these new products change the traditional AAC assessment and intervention process? Should professionals wait for research to take place as new products become available prior to using them in their professional practices?
The following online resources may be helpful for individuals trying to learn more about this exciting but complicated field of AAC during this transformation:
The SETT framework – Joy Zabala’s model to be used in the collaborative decision-making process in all phases of assistive technology and AAC selection and implementation.
AAC TechConnect – A site filled with great suggestions and resources re AAC
Children’s Hospital Boston– An AAC feature matching resource
Spectronics AAC Apps – A wonderful blog by Jane Farrall- a SLP and special educator in Australia who is passionate about literacy, assistive technology and AAC
AAC Institute– A compilation of helpful AAC resources
AAC Language Lab– Great information on language stages and helpful teaching resources provided by Prentke Romich Company
Learning Paths – Many wonderful resources provided by Dynavox

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