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But Wait, There's More! AAC Edition

Updated: Jan 4

Let's imagine all the multitude of ways we can communicate. You might remember our blogpost from earlier in the year about using AAC to expand the communication toolbox (check it out here). In this blogpost, we'll explore different aspects of AAC.


First, let’s set the scene:


  • Jane is a second grader with a neuro-muscular disorder that impacts her ability to make purposeful movements. Her family often has to guess at what she wants. When they get it right, she smiles. But, they can tell she is frustrated when they don’t understand, which happens more than they would like.


  • Lizzie is in kindergarten, and it appears that she doesn’t like the visual input from screens, but she is engaged with printouts of the same picture symbols that are used in her classroom. Her support network has also observed that she has a hard time navigating her current system that is organized around different vocabulary groups. 


  • Fitz is in his teens and has cerebral palsy. Using eye-gaze is tiring for him, but he wants to still use his high tech communication system without the assistance of a communication partner. 


For each of these children, oral speech is unreliable to meet their needs. They can all benefit from access to augmentative and alternative communication (AAC), but what is the best fit for them? This is where SLPs can assist. Most parents when they think of AAC think of high technology devices like Stephen Hawking’s - a large computer and a robotic voice that he used with his eyes. But, that isn’t the only form of AAC, the only way it can sound, or the only access method.


Not every communication system is the right fit for each child, but finding the right fit - what SLPs call feature matching - is crucial for children beginning their AAC journey. Let’s explore some of the ways that SLPs can customize AAC you may not have heard of including:


  • Access Method


  • System Organization


  • Amount of Technology


  • Voice Output


ACCESS METHOD

When SLPs talk about access, we're talking about how the AAC user makes their selection on the device. AAC users can utilize direct or indirect selection to dictate their message. Let’s circle back to Stephen Hawking - he used direct selection with his device as an eye-gaze user. Other forms of direct selection include touch, using a stylus, or a head pointer. With direct selection, there is no intermediary between the user and their device like a communication partner or a switch. Most times when people think of AAC, they are thinking of direct selection. But, direct selection is not the only option! Indirect selection is another valuable way users can access their AAC. Some examples of indirect selection include:


Partner Assisted Scanning

Example of partner assisted scanning. An adult woman sits across from a girl in a wheelchair while pointing to different pictures of the senses while stating, "I see something... I hear something... I feel something... I smell something... Oh, I saw you smile! You smell something!"
Offering choices with partner assisted scanning

Many children and adults who need AAC to communicate have complex bodies with motor and sensory disabilities that make direct selection AAC inaccessible. For these users, partner assisted scanning (PAS) can help them access communication. When users communicate through PAS, a communication partner systematically offers sequential choices to the communicator - this is the scanning. The communicator signals their choice, and the communication partner moves to the next choice.


PAS can be a part of an AAC learning journey as a bridge to another method or it can be the main way a user communicates. Using PAS is also a great backup for if another system is out of battery or otherwise unavailable. 


Thinking back on our three children, PAS could be Jane’s way to access a communication system. She indicates acceptance through smiling, and with SLP support and caregiver training, she and her family could benefit from exploring partner assisted scanning in therapy sessions.



Switch Scanning

9 button phone keypad with speech bubbles. "Something to eat, press one." "Somewhere to go, press two.", "Something to feel, press three." Something you don't like, press 6"
Auditory Scanning with a Phone Menu

Switch scanning is another indirect access method for AAC. It combines a device with a switch placed so that the user can activate it by moving a part of their body to hit it. Their device might highlight buttons sequentially (visual switch scanning) or read the message (auditory switch scanning) then the user makes their selection using a switch. Think about the phone menu when you call a doctor’s office. The digital voice reads a series of choices. When you hear what you need, you hit your ‘switch’ (aka the number) to be taken to the next menu. Switch scanning works the same way!


Back to Fitz, he has communicated to his team that direct selection through eye gaze isn’t a good fit for him because he finds it too fatiguing. Partner assisted scanning is also not a good fit because he doesn’t want a communication partner involved. With an SLP, Fitz can explore different switches and switch placement to use switch scanning as his indirect selection method. His preferences are an important part of the feature-matching process.


ORGANIZATION

There are many different ways a language system can be organized. Common systems are organized around language use (e.g., grouping of related words or phrases, grouping different word classes together) or around motor planning (e.g., using unique motor patterns to reach different words). A third way language systems can be organized is pragmatically. Pragmatically organized systems, like Pragmatic Organization Dynamic Display (PODD), are organized around the communication function. From a home page, users navigate to different pages based on their message. Pages will be organized around things like making a request, conveying that something is wrong, or making a comment as examples. Some children and adults who use PODD use it through partner assisted scanning - but PODD can also be used independently without a communication partner.

Page display with communication options.
Example of a first page in PODD Source: Boardmaker

Dynamic PODD Display
Example of a high tech device with PODD Source: Tobii Dynavox
Example of a second page in PODD Source: Boardmaker

Thinking about Lizzie, a pragmatically organized system might be a better fit for her based on her team’s observations. Through collaborating with an SLP, she and her team could trial a pragmatically organized system like PODD. But, Lizzie also doesn’t seem to like screens, which leads to a third aspect that SLPs can help customize.


TECHNOLOGY

AAC exists along a continuum ranging from no tech to high tech. When most people think of AAC, they imagine a high tech device like the one used by our example AAC user Stephen Hawking. Now, parents might be wondering, isn’t high-tech always better? The answer is definitely "No!"




Different AAC options are displayed ranging from No Tech (communication binders, boards, and eye gaze board), mid tech (single and multiple message voice outputs), and high tech (tablet based devices)
Technology Continuum

Some learners, like Lizzie, may dislike screens and prefer paper-based communication. Others might need more tactile feedback from pressing a button and will be most successful with methods that provide more sensory input. For Lizzie, it is likely that she will be more comfortable using a communication binder organized pragmatically.


VOICE

Lastly, let’s circle back to Stephen Hawking one last time, another feature that SLPs can customize while trialing AAC is the voice itself. This is another feature where user preferences can guide selection. When Stephen Hawking became an AAC user, digitized speech was in its early days. While digital speech improved, he maintained the same voice because it was his. When trialing AAC, we can explore different voices to find one that resonates with the user. As children grow, we can also ‘grow’ their voice through adjusting the settings so that their voice matches them. 


What about...

You might have noticed that I mentioned high and no tech communication systems, but the Picture Exchange Communication System (PECS) didn’t make the cut. This is because PECS, as an out of the box protocol, isn’t a robust communication system. The implementation is rigid, focuses on compliance and requires hand-over-hand prompting, and also  doesn’t lend itself to the natural modeling needed for children to learn language. An important sidenote, sometimes people use the term “PECS” to refer to all no-tech, symbol-based communication like communication boards. While PAS and PODD require a lot of communication partner involvement, communication partners can model naturally using these access methods to help their children become more proficient and autonomous users.


AAC at Talk Time

Finding the right match for these (and more) AAC features is why trialing is such an important step in the AAC process. At Talk Time, we do this during language therapy sessions when exploring AAC options for children through trialing different language systems, displays, voices, displays, access, and technology to find the best AAC system for a child that matches their needs.  


I want to know more!

If you’re wondering about AAC for your child, ask a speech language pathologist! If you have questions or concerns, or just want to talk out your thoughts, an SLP is the perfect person to talk to. If you’re curious and want to learn more, there are some great resources shared below that focus on these aspects of AAC.


 If you want to reach out to us at Talk Time, please email us at info@talktimeboston.com.


Resources:

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