Early Childhood Education

Augmentative and Alternative Communication (AAC)

Augmentative and alternative communication (AAC) refers to methods, other than speech, that are used to communicate with and improve the communication of children with severe speech and language disabilities.

All human beings communicate. In fact, it might be stated that human beings are unable to not communicate. Whether it be with words, other vocalizations, gestures, facial expressions, or different types of body language, we are constantly conveying a stream of messages to others, either knowingly or unwittingly. The primary expressive method of communication used by most members of society involves natural speech. However, some children are unable to rely on speech as a primary method of oral communication either temporarily or permanently. These individuals include children with intellectual disabilities, autism, apraxia, neuromotor problems such as cerebral palsy, traumatic brain injury, and developmental verbal apraxia. Some of these children may also exhibit difficulties with written communication. In such cases, practitioners may see a need to enhance these children’s effectiveness of communication, oral or written, by introducing augmentative and alternative communication (AAC).

There are no candidacy requirements for the introduction of AAC. To the contrary, a zero exclusion policy is applied, suggesting children may benefit from these methods regardless of type or severity of disabilities. The key criterion in pursuing AAC for children is not their demonstration of specific prerequisite behaviors but rather a search for effective methods of communication for those whose speech is insufficient in addressing everyday communication needs.

The term “augmentative” suggests the goal is to supplement extant communication methods that are already proving to be effective for the child, even if only marginally. Rather than eliminate these residual skills, the child is encouraged to continue relying on them while turning to AAC as a means of expanding communication options in terms of content, effectiveness, and efficiency.

Some situations call for applying AAC as an alternative method of communication. For example, children may rely on challenging behaviors, such as screaming, hitting, and pinching, to convey basic wants and needs. An educational goal might involve replacing these behaviors with more conventional, socially appropriate messages conveyed via an AAC system. Other children rely on behaviors that are so subtle and idiosyncratic that only the most familiar listeners can guess their intended meanings. AAC may replace such behaviors, providing opportunities to communicate more conventionally and thus effectively with a broader range of conversational partners.

AAC is not merely a thing, but should be perceived of in terms of an entire “system.” While the various aided (e.g., computers, speech-generating devices, and communication books) and unaided (e.g., gestures and sign language) methods of communication are important, AAC consists of far more than the method by which communication is carried out. AAC can be depicted in relation to four primary components: symbols, aids, strategies, and techniques.

Symbols

Symbols can be graphic (e.g., photographs and line drawings), auditory (e.g., auditory scanning, where possible choices are presented aurally and the child indicates when she hears the desired message), tactile (e.g., Braille), and gestural (e.g., sign language). The level and complexity of symbols used for a particular child is determined by many factors, including the child’s sensory and cognitive skills. For example, a child with severe to profound intellectual disabilities might be found to be a candidate for symbols represented by actual objects or photographs as opposed to line drawings. Another child may be capable of using traditional orthography (e.g., spelling) as a primary symbol set. An important part of an AAC assessment involves determining a child’s capabilities to use symbols of increasing complexity and abstractness. Skills in this domain may be targeted as part of a broader effort to enhance literacy skills.

Aids

Aids, whether they are electronic or nonelectronic, are the systems used to transmit and receive messages. They may be something as simple as a page on which a choice of two photographs are affixed, to something as complex as an electronic device containing more than a hundred different symbols that can be combined to formulate an infinite number of messages.

The type of aid selected is based on a highly individualized process that typically employs some type of feature matching between the capabilities (e.g., cultural, academic, language, cognitive, motoric, behavioral, perceptual, sensory, and emotional) of the child and the operational requirements of the particular device. The process proceeds systematically and generally includes the following steps:

1. The child’s communication needs and opportunities for communication are identified.

2. Present methods by which the child communicates, and their relative effectiveness, are determined.

3. The child’s capabilities, cited above, are assessed.

4. A list of possible AAC options is generated based on the child’s capabilities as well as characteristics of people and settings in which the system will be used immediately and in the future.

5. The child field tests equipment considered for adoption.

In most cases, an AAC system will not consist of a single device or method of communication but instead be comprised of multimodal means of communication. Children must learn to recognize when any one particular means of communication is most effective based on experiential and environmental considerations. Their abilities to code switch, moving from one method of communication to another based on partner and setting variables, is viewed as an integral component of their communicative competence.

Many variables must be considered in finding the right match between a child and an aid. In the case of young AAC users, aids should be evaluated in relation to the following factors:

• Flexibility to accommodate children’s increasing linguistic abilities over time.

• Extent to which they can be used to foster language and communication development.

• The range of communicative functions (i.e., purposes for communicating such as commenting, answering, requesting information, sharing novel information, requesting objects and actions, requesting clarification, and developing and maintaining social relationships) that can be expressed.

• Ability to address present and future communication needs.

• Number of environments in which they can be used effectively.

• Variety of familiar and unfamiliar communication partners with which they can be used.

• Acceptability to children and their families.

• Cost.

• Maintenance requirements and overall durability.

• Extent to which they enhance the quality of the lives of children and their families. As indicated above, these various aid characteristics are weighed relative to children’s capabilities. Evaluation of the latter requires a multidisciplinary evaluation by an AAC team. Membership on the team can vary depending on the task at hand but often includes parents, teachers, speech-language pathologists, physical therapists, and occupational therapists. Other professionals that may be involved include rehabilitation engineers, administrators, equipment vendors, psychologists, audiologists, and pediatricians.

Strategies

Strategies refer to methods of enhancing the effectiveness or efficiency of message transmission. They include procedures such as word prediction (i.e., activation of each letter results in presentation of a menu of words with the highest probability of following that particular letter or sequence of letters), letter prediction, and dynamic display (where activation of a key opens up a page of additional vocabulary, expanding the range of meanings that can be conveyed). They also include techniques for arranging symbols such as categorizing them in relation to “who”, “what,” “what doing,” “where,” “how,” and “in what manner,” listing items alphabetically, and/or arranging letters to correspond with the typical QWERTY keyboard.

Strategies also incorporate patterns of interaction that foster children’s effective uses of their different AAC methods. For example, conversational partners are encouraged to be patient, to give children ample time to formulate and transmit their messages, to provide numerous opportunities and reasons for communication throughout the day, and to model effective uses of AAC and other communication methods.

Techniques

Techniques relate to how messages are accessed and transmitted. The two techniques for activating messages via aided communication are direct selection and scanning. Direct selection involves pointing (whether that is with a finger, head pointer, optical light indicator, or some other source) directly at the desired item. Scanning involves sequential presentations of different items until the desired item is highlighted at which point the communicator typically uses a switch to select the item or continue the scanning pattern.

While the goals of AAC are many and varied, overarching themes include maximizing effectiveness of communication while simultaneously fostering children’s participation and inclusion in their schools and communities. Interventions involving AAC are carried out most effectively in children’s homes, schools, and other natural settings. They attempt to involve as many communication partners, in as many settings, as is feasible.

Objectives are integrated into curricula, rather than constituting isolated behaviors. For example, rather than teaching choice making in a contrived setting, an SLP might analyze the various environments in which interactions typically occur and recruit natural partners in these same environments to present children with systematic opportunities to make choices using their AAC systems. Children’s self-determination can be fostered through this process of role release.

In conclusion, AAC represents a programmatic team response to an existing or projected set of challenges. Effectiveness of AAC is defined in relation to the extent to which it supports enhanced qualities of life for children and their families.

Further Readings: American Speech-Language-Hearing Association (2004). Roles and responsibilities of speech-language pathologists with respect to augmentative and alternative communication: Technical report. ASHA Supplement 24, 1-17; Beukelman, David R., and Pat Mirenda (2005). Augmentative and alternative communication: Supporting children and adults with complex communication needs. 3rd ed. Baltimore: Paul H. Brookes; International Society for Augmentative and Alternative Communication (ISAAC). Available online at http://www.isaac-online.org/selectdanguage. html.

Stephen N. Calculator