An Introduction to Augmentative and Alternative Communication

Original Editor - Ewa Jaraczewska based on the course by Sopio Nadiradze
Top Contributors - Ewa Jaraczewska, Jess Bell and Kim Jackson

Introduction

Communication is a fundamental skill that impacts a child's cognitive, social, and emotional development. Without effective communication strategies, children may struggle to express their needs or engage in important social activities, such as playing with friends or interacting with peers.

For individuals who experience communication challenges, specialised support may be necessary. Augmentative and alternative communication (AAC) is designed to support individuals who have complex communication needs. AAC can be aided or unaided and includes both high-tech options, like speech-generating devices, and low-tech options, such as picture boards.

This article provides a general overview of speech, language and communication, before introducing AAC for rehabilitation professionals, including assessment considerations and types of AAC.

Three Aspects of Communication

Speech

"Speech is the physical act of speaking by producing sounds others can hear." -- Sopio Nadiradze

A speech disorder is a delay or difficulty in the way a person produces sounds, words, phrases, or sentences. Types of speech disorders include:

• articulation
• voice
• flow (fluency)

Speech Assessment

A speech-language therapist (pathologist) completes a speech assessment with input from the interdisciplinary team, which can include parents, caregivers, teachers, psychologists, and physicians. This assessment takes place after hearing problems are ruled out.

The assessment should include the following:

• checking for speech errors and irregularities
• anatomy and function of the oral mechanism
• developmental and health history
• cognitive function

Therapeutic Interventions for Speech

Therapeutic interventions include:

• education on how to produce difficult sounds
• practising sound production in different contexts, such as syllables, words, phrases, sentences, and reading
• addressing groups of sounds with similar error patterns
• teaching when and where to use specific sounds after explaining the meaningful differences between them

Language

"Language describes how we use symbols to communicate according to shared common linguistic rules." -- Sopio Nadiradze

"Language disorder" is an umbrella term that refers to severe and persistent difficulties in spoken, written, or other symbolic languages, such as sign language, and augmentative and alternative communication forms:

• it affects the form of language, the content of language, and the function of the language, or any combination of these
• language disorders include:
  • childhood spoken language disorder: a child has trouble learning new words, saying sentences, following directions, understanding questions, and expressing themselves
  • learning disabilities: associated with problems related to reading, spelling, and writing
  • selective mutism: difficulty speaking or communicating at certain times or places

Language Assessment

The language assessment may include:

• examining an individual's ability to use and process language at an age-appropriate level
• assessing the child's vocabulary, grammar, syntax, storytelling, and writing skills
• measuring speech-sound production, speech-motor, and fine/gross motor skills

Hearing screening and behavioural assessments are also recommended.

Communication

"Communication is a more complex process and describes how we influence others' ideas, actions, or attitudes." -- Sopio Nadiradze

Communication includes verbal and non-verbal movements, actions, and behaviours, and it provides the foundation for how we interact with other humans. Four aspects must be present for a behaviour to be considered as communication:

• sender
• receiver
• message
• means of communication

Example: Communication Challenges in Cerebral Palsy

Table 1 identifies various challenges children with cerebral palsy may face when using different means of communication.

Table 1. Methods of communication and challenges that a child with cerebral palsy may encounter

Method of Communication	Challenges
Speaking	Coordination of mouth and tongue muscles Problems with receivers (not being listened to)
Listening	Concentration
Writing	Fine motor skills
Pointing	Fine motor skills Hand-eye coordination
Making gestures / sign language	Fine motor skills Motor planning
Body language / facial expression	Muscle control of the body / face

Communication Systems

"Parties shall take all appropriate measures to ensure that persons with disabilities can exercise the right to freedom of expression and opinion, including the freedom to seek, receive and impart information and ideas on an equal basis with others and through all forms of communication of their choice." -- Article 21, Convention on the Rights of Persons with Disabilities

• Communication systems = assistive technologies
• Communication systems include augmentative and alternative communication systems (AAC):
  • augmentative = supplementing or improving existing speech
  • alternative = alternative forms of communication other than spoken language
• AAC can be aided or unaided:
  • unaided-AAC does not require any physical aid or tool to facilitate communication:
    • examples: gestures, facial expressions, body language, signs
    • unaided-AAC plays a crucial role in helping individuals to get their point across and facilitate understanding
  • aided-AAC uses tools or materials to facilitate communication:
    • low-tech, paper-based options, like communication boards or books
    • adapted keyboards - adaptations can include: (1) larger keys for easier targeting, (2) tactile indicator, (3) raised key borders, (4) colour-coded keys, (5) symbol-based keys for easier recognition, (6) adjustable key spacing to suit the user's reach, (7) programmable features such as macro keys for frequently used phrases or sentences, and (8) built-in word and phrase prediction to speed up typing

      

      Speech generating device

    • this sort of device is appropriate for a person with literacy skills who knows some letters, knows how to type, and can read and write
• AAC can be text-based or symbol-based:
  • text-based AAC can be operated via a keyboard; typed words are converted into sound
  • symbol-based AAC uses symbols or pictures for communication; a visual symbol may represent a word or a phrase
• AAC can be in the form of high-tech speech-generated devices:
  • speech-generating devices with one or more button switches
  • can be programmed with prerecorded messages
  • practical for people with limited motor skills as switches can be activated by any part of the body (hand, finger, neck movement, head, leg, etc.)
  • useful for the individual and their communication partner because the communication partner can record desired messages
  • examples: wearable devices, like a hand watch or necklace speech-generating device worn around the neck and activated by touch, or photo album style speech-generating devices

Who Can Use AAC?

AAC can benefit many people, including:

• individuals with an impairment that affects the articulation of speech sounds, fluency and / or voice
• individuals with a speech and language disorder and impaired comprehension or use of spoken, written, or other symbol systems
• individuals who have complete, grammatically correct, vocabulary-rich messages in their minds but are unable to express these thoughts through speech

Please watch this video if you would like an illustration of how AAC can be used to enhance communication in persons with disabilities:

AAC Implementation Guideline for Individuals with Cerebral Palsy

When implementing AAC, an appropriately trained clinician must ensure the following:

• a comprehensive assessment is completed, including individual motor skills, cognitive skills, and communication needs
• the AAC device is customised to ensure that it meets the individual's needs, including vocabulary and symbols relevant to the individual's age, developmental level, daily life, and interests
• the AAC system is available and can be used consistently across all environments, including home, school, and the community
• training for users, family members, caregivers, and educators
• the client is motivated to use the system: this can be achieved by identifying activities that motivate the client and providing opportunities for them to communicate with at least one partner per day
• learning is contextualised: the user learns how to use the AAC during daily activities
• vocabularly is modelled through a multimodal approach, which incorporates auditory, visual, and tactile channels
• access to aided AAC tools and devices so clients can get to them independently

Goals and Expected Outcomes

Goals include:

• learning new methods of self-expression
• enabling individuals with communication disorders to communicate competently and develop friendships
• helping these individuals to become more involved in academic and non-academic activities
• enabling these individuals to fulfil their potential (in academic and non-academic fields)

Expected outcomes:

• individuals with communication disorders will be able to achieve measurable gains in academic, communication, social, and functional skills
• individuals with communication disorders will be able to "say what they want to say, when they want to say it, as fast as possible, and to whom they want to say it"

Factors Influencing Assessment and Treatment

The following factors must be considered when assessing individuals with communication disorders and creating an intervention plan that incorporates AAC:

• chronological age and developmental stage
  • select age-appropriate assessment tools and intervention goals
  • choose age-appropriate vocabulary and instructions
• functionality
  • decisions are often made for individuals who are unable to communicate their preferences, which can result in a lack of personal choice or agency
  • consider when in a daily routine choices are available and if / how an individual can state their choices and preferences through AAC
• interaction
  • provide opportunities to both send and receive messages
  • provide opportunities for interaction with different peers, not just instructional staff
• cognitive development
  • enhance language and communication skills, regardless of cognitive development
  • language and communication skills are enhanced through every interaction
• level of independence
  • AAC can be used for both independent and partner-interpreted communication
• sensory profile
  • any individual who cannot reliably indicate their intentionality of actions or those whose response forms vary from person to person has a high chance of benefitting from AAC
• social significance
  • the tools and strategies selected should enhance the user's social identity and interaction
  • AAC should not escalate / should prevent stigmatisation or discrimination in the community
• prerequisite skills
  • there are NO prerequisite communication skills that need to be taught before enhancing or increasing opportunities for interaction and communication
• pluralism
  • multiple communication strategies, tools, or methodologies should be selected and designed
• natural environment
  • one-on-one instructional practice should always be in addition to opportunities for communication in the natural environment
• preferences
  • the user determines the communication intervention plan and methodology
• communication partners
  • a multidisciplinary team assesses the abilities of all communication partners

Assessment Components

The following components should be part of the communication assessment for an individual with severe disabilities:

• cognition
• motor functioning
• sensory abilities
• speech and language
• current and future communication needs
• visual tracking and scanning abilities
• hand preferences, positioning, reaching and grasping
• basic receptive language skills
• roles of parents or caregivers

Outcomes

Outcome Measures

• Pragmatic Profile
• Identifying Potential Communicative Acts in Persons with Developmental and Physical Disabilities (IPCA)
• Social Network
• Computer-Based Instrument for Low motor Language Testing (C-BiLLT)

Factors Impacting Outcomes

The following factors are important for positive outcomes:

• choosing the most appropriate device for an individual's motor abilities
• integrating the device into a daily routine that is motivating for the user
• starting with a single, functional message or task
• gradually expanding the use to other contexts
• involving family and caregivers in the implementation process

Barriers to positive outcomes include:

• lack of client motivation
• limited availability of appropriate AAC systems
• insufficient training for teachers and caregivers
• decontextualised learning
• limited vocabulary in the AAC systems

Resources

• The PRAGMATICS PROFILE of Everyday Communication Skills in Children
• Early Intervention
• Child Speech and Language