An Introduction to Augmentative and Alternative Communication

Original Editor - Sopio Nadiradze

Top Contributors - Ewa Jaraczewska, Jess Bell and Kim Jackson  

Introduction

Communication skills are a vital part of a child's development. They play a crucial role in enabling children to participate in social activities, such as playing with friends or socialising with peers. Speech, language and communication all have different definitions. We need to understand the differences between these terms to better support individuals with difficulties in these areas. For instance, children and adults with disabilities may have difficulty with speech intelligibility, or their language and pragmatic abilities may be impaired. This can affect how they express their needs and wants, build relationships and learn language. This article provides an overview of communication, speech and language and the role of the speech language therapist in implementing augmentative and alternative communication interventions.

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 and language therapist (pathologist) completes the speech disorder 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

This video demonstrates how to teach the L sound:

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, 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 them
• 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
    

    Speech generating device
• AAC can be aided or unaided:
  • unaided-AAC does not require any physical aid or tool to facilitate communication
  • aided-AAC uses tools or materials to facilitate communication
• 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

Who Can Use ACC?

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

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

Goals and Expected Outcomes

Goals:

1. To learn new methods of self-expression
2. To allow individuals with communication disorders to communicate competently and develop friendships
3. To enable these individuals to become more involved in academic and non-academic activities
4. To allow these individuals to fulfil their potential (in academic and non-academic fields)

Expected Outcomes:

1. Individuals with communication disorders will be able to achieve measurable gains in academic, communication, social, and functional skills
2. 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 need to 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
  • consider the functionality of stating choices and preferences
  • use daily routines to highlight times when choices are available
• 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
  • a person enhances their language and communication skills 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
  • it should not escalate / should prevent stigmatisation or discrimination in the community
• Prerequisite skills
  • there are NO specific prerequisite communication skills that need to be taught prior to enhancing or increasing opportunities for interaction and communication
• Pluralism
  • design and select multiple communication strategies, tools, or methodologies
• 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 assessment process for communicative function 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

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)

ICF-CY and Communicative Competence of the AAC Users

Communicative competence "facilitates the realization of an individual’s fundamental needs, rights, and power of communication". The International Classification of Functioning, Disability, and Health for Children and Youth (ICF-CY) can be beneficial for AAC users and providers for a number of reasons:

• it reflects the multi-dimensional nature of communication and the interaction between an AAC user and their environment
• it offers a common inter-professional language and enhances communication among professionals and between professionals and parents
• it can be applied during assessment, goal setting, and outcome evaluation of AAC interventions

There are 112 codes listed in the ICF-CY for profiling communicative competence. They are categorised into four following domains:

• Body Functions: 47 codes
• Body Structures: 6 codes
• Activities and Participation: 50 codes
• Environmental Factors: 9 codes

Body Functions examples:

• b270 Sensory Functions Related to Temperature and Other Stimuli
• b310 Voice Function
• b320 Articulation Functions
• b330 Fluency and Rhythm of Speech Functions

Body Structures examples:

• s320 Structure of Mouth
• s330 Structure of Pharynx
• s340 Structure of Larynx

Activities and Participation examples:

• d160 Focusing Attention
• d163 Thinking
• d166 Reading
• d170 Writing
• d175 Solving Problems

Environmental Factors examples:

• e125 Products and Technology for Communication
• e130 Products and Technology for Education
• e310 Immediate Family
• e315 Extended Family

Resources

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