“Personal achievement in life is a function of the ability to communicate.”

A Guide to Goal Selection &

Intervention for AAC Users

Trina Becker, M.S., CCC/SLPtmbecker@eiu.edu

Becker, T. 3/1/13

What is AAC?• Refers to ways other than speech that are used to

send a message from one person to another• Includes:

– Gestures– sign language– facial expressions– picture symbol or alphabet boards– sophisticated computer systems

Becker, T. 3/1/13

Benefits of AAC

• Provides means to communicate• Increases participation & improves self-concept• Facilitates learning• Improves/restores receptive and expressive language• Reduces frustration and behaviors• Facilitates speech

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Who uses AAC?

• Anyone who has significant difficulty using speech to communicate

• Used by people of all ages and disabilities• Etiology either acquired or congenital

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Individuals who use AAC

• Developmental Disabilities– Cerebral Palsy– PDD– Mental Impairment– Developmental Apraxia of Speech

• Neurodegenerative Diseases (ALS, MS)• Acquired Disorders (TBI, Aphasia)

Becker, T. 3/1/13

Classification of

AAC UsersBecker, T. 3/1/13

Classification of AAC Users

• Emerging Communicator• Wants/Needs Communicator• Context-Cue Dependent Communicator• Transitional Communicator• Independent Communicator

Adapted from Garrett (1992) and Beukelman (1998)

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Communication Ability Levels

Respects the fact that individuals with complex communication needs fall on a broad spectrum.

Uses characteristics of individuals with complex communication needs to determine placement on the continuum.

The InterAACT Framework (P. Dowden): DynaVox

http://depts.washington.edu/augcomm/03_cimodel/commind1_intro.htm

EmergentContext-DependentIndependent

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Emerging Communicator

• Does not reliably use symbolic communication• Relies primarily on nonsymbolic

communication (gestures, vocalizations, etc.)• Emerging does not always = beginner• May also display

– Minimal turn-taking (object)– Limited or no joint attention

Becker, T. 3/1/13

Wants/Needs Communicator

• Identifies basic symbols• Do not have a wide range of vocabulary• Uses symbols to make choices and meaningful

requests objects• Primarily uses 1 symbol at a time• Does not use symbols to interact socially only

for wants/needs

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Context Cue Communicator

• Vocabulary includes nouns, pronouns, verbs, some descriptors

• Combines symbols to produce phrases• Produces socially appropriate comments• Participates in structured conversations with

familiar partners• Appropriately answers routine questions with

promptsBecker, T. 3/1/13

Transitional Communicator

– Initiates conversations and social interactions with familiar partners

– Answers questions of unfamiliar partners without prompts

– Not comfortable initiating interactions with unfamiliar partners and using AAC in unfamiliar settings

– Creates novel utterances– Recognizes conversational breakdowns and uses repair

strategies with mod cues

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Independent Communicator

• Understands communication the same as same-aged peers

• Appropriately uses AAC system to communicate across all environments independently the same as peers

• Generates novel utterances• Effectively uses repair strategies to fix communication

breakdowns• Independent in operational competence (as much as

physical ability will allow)Becker, T. 3/1/13

Levels of CommunicationChildren with Dev. Disabilities

• Follows typical hierarchy– Emerging Communicator– Wants/Needs Communicator– Context-Cue Dependent Communicator– Transitional Communicator– Independent Communicator

Adapted from Garrett (1992) and Beukelman (1998)

Becker, T. 3/1/13

AACSyste

m

Technology

Display

OutputLanguage Representation

Access

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Technology

No tech

Low tech

Mid tech

High tech

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No Tech Systems

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Low Tech Systems

Mid Tech Systems

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High Tech Devices

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AACSyste

m

Technology

Display

OutputLanguage Representation

Access

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Language through Symbols

• Symbol – “something that stands for something else” ( Anderheiden & Yoder, 1986, pg. 15)

–Single meaning–Icon – based–orthographic

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Single meaning

DynaSyms – DynaVoxPCS – BoardmakerProloquo2Go – iPadSymbolstix – Tobii - ATI

Icon

• Unity Language – Prentke Romich

Orthographic

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Levels of Communicators & Levels of AACNo to LowTech

Emerging

communicat

orsLow Tech to High Tech

Wants/needs communicator

Mid tech to High Tech

Context-Cue Dependent CommunicatorTransitional CommunicatorIndependent Communicator

NOTE:High tech

devices can be adjusted to meet

any communication

ability level

Base decision on individual

Trials, Trials, Trials!

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Continuum of

Intervention

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Intervention goals

• Goals should be chosen to build communication skills to the next level of the AAC continuum

Emergent Wants/needs Context Cue Transitional Independent

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Communicative Competence“the ability to communicate functionally in natural

environments to meet daily communication needs” (Light, 1989)

Linguistic

Operational Strategic

Social

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Ultimate GoalWhatever Whomever Wherever

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What’s your ultimate goal?

• How are you going to get your client to be able to tell you what they are thinking?

• How are you going to get them competent communicating in a variety of situations with a variety of communication partners?

• Consider functional vs developmental• Consider communication skills vs discrete language

skills

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LEVEL ONE COMMUNICATOR Emerging Communicator

– Develop symbolic Communication– Understand Cause and Effect– Make meaningful choices– Make meaningful requests– Develop turn-taking (object)– Increase initiation– Use greetings hi/bye– Build receptive knowledge of picture symbols

Becker, T. 3/1/13

LEVEL TWO COMMUNICATOR Wants/needs Communicator

– Begin to combine symbols to make 2 word utterances– Expand types of requests – Make socially approp. comments with prompts– Answer routine questions with prompts– Expand vocabulary/symbols – verbs/nouns/adjectives– Increase spontaneous use of greetings (hi/bye)– Effectively and efficiently locate symbols on AAC system– Demonstrate ownership of device– Gain attention of communication partner

Becker, T. 3/1/13

LEVEL THREE COMMUNICATOR Beginning of Context-Cue Communicator

– Combine symbols to make phrases with minimal cues– Use comments with minimal cues in routine activities– Engage in short social interactions/conversations with

familiar partners with mod - max cues– Expand vocabulary (questions, adjectives, verbs)– Use function symbols on AAC system (clear, delete, etc)– Navigate through communication system (dynamic) with

prompts– Learn to adjust volume based on environment– Recognize communication breakdowns with prompts

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LEVEL FOUR COMMUNICATOR Middle to end of Context Cue Communicator

– Initiate conv/social interactions with familiar partners– Produce novel utterances– Expand utterance length– Develop morphology– Continue to expand vocabulary– Answer questions and participate in conversations

without prompts– Recognize conversational breakdowns– Use strategies to repair breakdowns with prompts– Navigate through communication system with prompts– Introduce programming (if appropriate)

Becker, T. 3/1/13

LEVEL FIVE COMMUNICATOR Transitional Communicator

– Encourage use of AAC across all environments– Increase comfort level in unfamiliar situations– If appropriate, continue to develop morphology– Increase independence in using repair strategies– Encourage programming to increase independence– Encourage independence in operational functions (volume

control, maintenance of system)

Becker, T. 3/1/13

Resources for Goal Selection

• Dynamic AAC Goals Planning Guide– DynaVox: Implementation Toolkit

• Prentke Romich– AAC Language Lab– http://www.aaclanguagelab.com/

• AAC Communication Profile (Tracy M. Kovach)– http://www.linguisystems.com/products/product/

display?itemid=10547

Dynamic AAC Goals Grid

Choosing and Writing Appropriate Goals

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Increasing Complexity of Goals

• Do you have clients who seem to work on the same goal forever?

• How we can we increase complexity?– Level of prompting– Different activities– Different environment– Different communication partners

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Prompting Hierarchy

• Physical assistance (PA)• Direct Pointer Cue (DPC)• Direct Verbal Cue (DVC)• Indirect Cue (IC)

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• Chain of cues

Hierarchy of Activities

Defined structured activity

Various structured activities

Unstructured activities

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Hierarchy of Activities

• Routine structured activity (activity used to teach the skill)– Requesting – snack activity

• Various structured activities– Want client to be able to use skill in a variety of

structured activities– Requesting – Mr. Potato head,

puzzle pieces, blocks

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Levels of Communication Partners

Hierarchy of Communication Partners

• Teacher/therapist (individual teaching skill)• Familiar adult or peer

– Start with partner client is most comfortable with • Unfamiliar

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Hierarchy of Environments

Therapy room

Classroom

HomeCommunity

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Hierarchy of Environments

• Environment in which skill is taught– Therapy room– Classroom

• Environment client is highly familiar with – Classroom– Home– May even move around different areas in familiar

environmentBecker, T. 3/1/13

Hierarchy of Environments Cont’d

• Unfamiliar Environments (not a part of daily routine)– Places in the community

• Grocery store• Movie theater• Doctor’s office• Restaurant

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Dynamic Goal Includes…

• ALL 4 COMPLEXITY LEVELSClient will __(skill)__ during __(activity)__

in __(environment)__with __(partner__ with ___(prompting)__with ___% accuracy.

Becker, T. 3/1/13

Writing Dynamic Goals…

• Allows for easier tracking of progress• Provides justification for targeting “same goal”

over time• Develops communicative competence and

independent communication

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Intervention Strategies

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Basic Communicative Functions

• Attention seeking• Acceptance/rejection • Choice making • Requesting

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Teaching Offered Choice Making

• Opportunities• Objects Symbols• Choice making formats – natural env.• Choice making Arrays

– 2 preferred– 1 preferred, 1 nonpreferred– Preferred, blank/distractor

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Teaching Offered Choice Making

• Must always follow through with choice!• Present objects followed by symbols• Present symbols followed by objects

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Strategies to Teach Requesting

• Mileau teaching interventions– Incidental – unstructured, initiation– Mand-Model - adult initiated, prompted– Time-Delay – behav established, initiation

• Interrupted behavior chains• Missing/out of reach item• Verbal prompt-free• PECS

Becker, T. 3/1/13

Why does intervention stop with requesting?

Need to be able to say more than…

How do typically developing children learn language?

WHERE?WHEN?

WHAT?

WHO?

Intervention Strategies

• Aided AAC modeling• Expectant delay• Open-ended questions• Recasting• Sentence Strips• Structured practice• Social Stories

Becker, T. 3/1/13

Aided Language Modeling

• Aided Language Stimulation– A teaching strategy in which the facilitator highlights

symbols on the user’s communication display as he interacts and communicates verbally with the user. (Goossens, Crain & Elder, 1992)

• Mimics the way typically developing children learn language

• Also referred to as…– Aided language modeling – Augmented input– System for Augmenting Language (VOCA)

Becker, T. 3/1/13

Knowing the device

– Learning to use AAC device is like learning another language

– Any successful teacher needs to be knowledgeable and fluent in what they are teaching

Becker, T. 3/1/13

Other Benefits of ALM

Helps establish and build joint attention between device and communication partner, and device and stimulus (Video)

Takes pressure off the AAC user to always “perform” Educates the communication partners regarding

location of symbols and appropriate Teaching reciprocal interactions – more like a natural

conversation. A most to least cueing hierarchy for increased success.

Becker, T. 3/1/13

Expectant Delay

• Increased pause time during interaction to prompt child to communicate while maintaining eye contact and expectant facial expression

Wait for it….

Becker, T. 3/1/13

Open Ended Questions

• Asking open ended questions will …– Facilitate use of symbols– Prompt higher-content communication– Allow user to demonstrate knowledge– Facilitate turn taking

• Don’t ask so many yes/no questions!

Becker, T. 3/1/13

Recasting

• Expand child’s utterance to add new information (model more advanced language)– Expand utterance– Use more specific vocabulary– Add word endings (-s, -ing, -ed)

Car! → Go Car! → Go racecar! → Go faster racecar!Flower → Pretty flower → Pretty rose →

You smelled the pretty rose.

Sentence Strips/Visual cues

• Allows AAC user to see what they are expected to produce. – Helps make expectations clear

• Can be used for both low tech and high tech• Important to fade so client develops

independence

Becker, T. 3/1/13

Structured Practice

• Linguistic competency– higher level language skills (syntax, morphology)

• Social competency – conversational skills (role play)

Becker, T. 3/1/13

Social Stories• Typically used to teach skills such as

pragmatics, problem solving, etc.• Can be used with AAC to teach appropriate

interactions and symbol selection• Video Modeling

Becker, T. 3/1/13

Tri-Focused Framework(Siegel-Causey & Bashinski, 1997)

AAC User

Communication Partner

Environment

Becker, T. 3/1/13

What would make a child a successful communicator?

• Use of a device across environments and across communication partners.

• Ability for your child to engage in variety of interactions and activities of their choice.

• Interventionists who are considering building those skills across all environments and partners.

Becker, T. 3/1/13

Traditional AAC therapy

• Traditionally, AAC intervention has focused on improving only AAC user’s skills

• Because of this “traditional model” we are seeing a lack of success in carryover and even AAC abandonment for some children.

• AAC abandonment occurs when there is a lack of carryover across partners and environments.

• It is just not functional to use with 1 partner in 1 place.

Becker, T. 3/1/13

Factors of AAC Abandonment

• Negative impact on life and family stress

• Lack of opportunities and support

• Lack of training

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Survey says….

• Parents want a partnership with professionals working with their children

• Parents want us to consider their family a unique case regarding training and goal selection

• Parents want us to face the reality of parenting a individual with special needs when providing recommendations

• Parents want information!!!

Becker, T. 3/1/13

We can’t forget!

• Parents know their child better than we ever could• Parents are with child in more environments than

we are• Carry over outside of any therapy setting is a must!

CONSIDER THIS…. Teaching a skill for ONLY 45 minutes, twice a

week will take over 40 years to master

Becker, T. 3/1/13

Importance of family involvement

• Family is the essential context for language learning and communication development

• Primary communication partners for AAC users

• Provide essential social experiences and practice opportunities for developing social and communication competence

Becker, T. 3/1/13

Family-Centered Intervention

• Priorities and choices of family drive intervention– Family focus of services– Families decide what is important– Provide services to families

• The process of actively involving the entire family in treatment of a child with a disability (Rainforth & York-Barr, 1997)

Becker, T. 3/1/13

AAC Boot Camp:Research on impact of involving parents in intervention process

Stephanie Fanale, B.S. – graduate studentTrina Becker, M.S., CCC/SLP – faculty mentorBeth Bergstrom, CCC/SLP – faculty mentorEastern Illinois University, Summer 2012

Becker, T. 3/1/13

Independent Variable• Informational meeting

– General AAC training—1.5 hours• The benefits of AAC• The necessity for AAC use in all environments• A general overview of the strategies that will be taught during the program

– Operational skills training—1.5 hours• Conducted by representatives of AAC device companies (i.e., Prentke Romich, DynaVox)• Communication partners were divided into groups based on the AAC device used by their AAC users. • Training included:

– Trouble shooting, programming, and basic operational features of the AAC devices

• Two weeks of training sessions– Week one:

• 3 training sessions targeting aided language modeling and recasting—2 hours each session– Week two:

• 3 training sessions targeting asking open-ended questions and expectant delay—2 hours each session– Each training session included:

• Time for the communication partners to share their experiences• Discussion of why and how to implement the targeted strategies• Observation of the SLPs on how to implement the strategies • Supported practice • Independent implementation of the strategies during play (15 minutes) Fanale, 2012

Dependent Variables• Data collection for communication facilitating strategies:

– 3 home observations were videotaped and reviewed for each participant prior to initiation of the communication partner training program

– During training—1 observation was videotaped each session

– Six weeks post-training—3 home observations were videotaped

– Each observation was 15 minutes and used the same toy set across participants

• Survey included questions regarding:

– Demographic information– Previous AAC training– Views of AAC– Use of AAC in the home– A rating of the saliency, frequency, and feasibility of incorporating AAC in everyday home

activities using a 5-point scale (1= never; 5 = always).

– The survey was completed prior to the training and six-weeks post trainingecker, T. 3/1/13

Strategies taught at boot camp

• Aided Language Modeling

• Recasting

• Asking Open-ended Questions

• Expectant Delay

Results

Results

Results

Results

Data from 2 of the students

Baseline Treatment Maintenance05

1015202530354045

# of Communication Symbols# of Independent Initiations & ResponsesColumn1Column2

Conclusion

• Overall, participants increased their use of communication facilitating strategies with their children

• ALM was the easiest strategy for the participants to learn and retain

• Expectant delay and recasting were the most difficult strategies for the participants to use consistently

• Individual differences and skill levels of the AAC users contributed to the participants’ performances– E.g., Participants 1, 3, and 4 had AAC users who initiated use of their

AAC devices, therefore providing opportunities for the participants to use recasting, while participants 2 and 5 had limited opportunities

Fanale, 2012

Participant Quotes from Boot Camp• “Thanks for making me realize the disservice I have been doing to my

child all these years” (participant 1)• “When playing with my child, I now think about and see sequences

that I can use on the device” (Participant 2)

• “I didn’t realize how important it was that I used her talker until I started doing this boot camp and saw how much this helps her”(Participant 3)

• “I am surprised at how much he has changed” (Participant 4)

• “He has changed more in two weeks of boot camp than he did in a year of traditional therapy” (Participant 4)

• “I am going to do my own boot camp at my house with the teachers and educators at his school” (Participant 5)

Fanale, 2012

ConclusionConclusion!

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Conclusion

Trial lots of devices!-consider preferences-find language system that best fits-think about functional vs developmental

Becker, T. 3/1/13

Choose goals to build Communicative competence!

- 4 areas of competency- Consider a continuum- Increase complexity

Becker, T. 3/1/13

Choose intervention strategies that work!

ALMUse language

intervention you are familiar with and incorporate

AAC!Becker, T. 3/1/13

Involve Communication Partners!!

Most want to be involved!

I want specific, individualized

assistance. Help me!

Becker, T. 3/1/13

Websites• http://www.dynavoxtech.com/• http://www.prentrom.com/• http://www.assistivetech.com/• http://www.aacinstitute.org/• http://aac.unl.edu:16080/yaack/toc.html (AAC Connecting Young Kids)• http://www.aacintervention.com/• http://www.gatewaytolanguageandlearning.com/• http://aac.unl.edu/vocabulary.html (vocabulary lists)• http://www.lburkhart.com/• www.creativecommunicating.com• www.mayer-johnson.com

Becker, T. 3/1/13

EBP for Aided Language Modeling

• Colgan, (2008). Aided language modeling and requesting behavior in two preschool children with autism. Unpublished undergraduate thesis, Eastern Illinois University.

• Drager, K.D.R., Postal, V.J., Carrolus, L., Castellano, M., Gagliano, C., & Glynn, J. (2006). The effect of aided language modeling on symbol comprehension and production in 2 preschoolers with autism. American Journal of Speech-Language Pathology, 15, 112-125.

• Harris, M.D. & Reichle, J. (2004). The impact of aided language stimulation on symbol comprehension and production in children with moderate cognitive disabilities. American Journal of Speech-Language Pathology, 13, 155-167.

• Light, J. (1989). Toward a definition of communicative competence for individuals using augmentative and alternative communication systems. Augmentative and Alternative Communication, 5, 137-143.

Becker, T. 3/1/13

Other Resources

• Beukelman, D. & Mirenda, P. (2005) Augmentative and alternative communication supporting children and adults with complex communication needs. Brookes Publishing Co., Baltimore, MD.

• Light, J., Beukelman, D. & Reichle, J. ( 2003) Communicative competence for individuals how use AAC. Brookes Publishing Co., Baltimore, MD.

• Light, J. & Drager, K. (2007) Evidence-based AAC interventions for Infants, Toddlers, and Preschoolers. Presentation at ASHA, Boston.

• Clarke, V. & Schneider, H. Beyond Eat, Drink & Potty (2007) Presentation at Closing the Gap, Minneapolis.

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References from Boot Camp Study

• Bruno, J., & Dribbon, M. (1998). Outcomes in AAC: Evaluating the effectiveness of a parent training program. AAC: Augmentative and Alternative Communication, 14(2), 59-70. doi:10.1080/07434619812331278216

• Carter, M., & Maxwell, K. (1998). Promoting interaction with children using augmentative communication through a peer-directed intervention. International Journal of Disability, Development And Education, 45(1), 75-96.

• Kent-Walsh, J., & McNaughton, D. (2005). Communication partner instruction in AAC: Present practices and future directions. AAC: Augmentative and Alternative Communication, 21(3), 195-204. doi:10.1080/07434610400006646

• Light, J. (1989). Toward a definition of communicative competence for individuals using augmentative and alternative communication systems. AAC: Augmentative and Alternative Communication, 5(2), 137-144. doi:10.1080/07434618912331275126

• Siegel-Causey, E., & Bashinski, S. M. (1997). Enhancing initial communication and responsiveness of learners with multiple disabilities: A tri-focus framework for partners. Focus on Autism and Other Developmental Disabilities, 12(2), 105-20.

• Starble, A., Hutchins, T., Favro, M., Prelock, P., & Bitner, B. (2005). Family-centered intervention and satisfaction with AAC device training. Communication Disorders Quarterly, 27(1), 47-54. doi:10.1177/15257401050270010501 Becker, T. 3/1/13