An Introduction to Augmentative and Alternative Communication

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Introduction

Communication skills are the vital component in every child development. They are a key part of every child's participation in social activities like playing with friends, talking at lunch or texting friends. Communication is made up of several different aspects which include producing sounds that can be heard by others, using symbols to communicate, and verbal and non-verbal movements, actions, or behaviours. Children with cerebral palsy may experience difficulties in speech intelligibility and/or in language and pragmatic abilities which affect their abilities to express their needs and wants, building relationships and learning language. This article provide an overview of communication, speech and language assessment, and intervention for children with cerebral palsy.

Three Aspects of Communication

Speech

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

• A speech disorder is a delay or difficulty in the way people produce sounds, words, phrases, or sentences and includes:
  • Speech Sound Disorders (articulation disorder or phonological disorder) are characterised by the child substituting one sound for another, leaving sounds out, adding sounds, or changing a sound.
  • Ankyloglossia or tongue-tie is a condition in which the tongue’s movement is restricted affecting speech clarity
  • Orofacial Apraxia is inability to carry out learned purposeful movement of the mouth or tongue muscles despite the presence of a good motor, sensory, or coordination function.
  • Dysarthria is poor speech intelligibility affecting child's communicative participation

Speech Assessment

A speech and language therapist completes the speech disorder assessment with input from the interdisciplinary team of parents, caregivers, teachers, psychologists, and physicians, and after the hearing problem is ruled out. The assessment should include the following:

• Speech errors and irregularities
• Anatomy and function of the oral mechanism
• Developmental and health history
• Cognitive function

Therapeutic Interventions

• Instructions on how to produce the difficult sounds
• Practice the sounds 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 rules."--Sopio Nadiradze

• Language disorder is an umbrella term that covers severe and persistent difficulties in spoken, written, or other symbolic languages such as sign language, augmentative and alternative communication forms.
• It involves 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 characterised by the child's trouble learning new words and saying sentences, following directions, understanding questions, and expressing themselves.
  • Learning disabilities with problems including reading, spelling, and writing. Dyslexia describes reading problems.
  • Selective mutism categorised as difficulty speaking or communicating at certain times or in certain places.

Language Assessment

Language assessment may include:

• Examining the individual's ability to use and process the language in an age-appropriate manner.
• Assessments of the child's vocabulary, grammar, syntax, storytelling, and writing skills.
• Measures of speech-sound production, speech-motor, and fine/gross motor skill.

Hearing screening and behavioural assessment are also recommended.

Communication

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

• Includes verbal and non-verbal movements, actions, behaviours
• Provides the foundation for how we interact with other humans
• A sender, receiver, message and means of communication are necessary elements of communication

Communication Challenges in Cerebral Palsy

Table 1 presents 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 come across

Method of communication	Challenges
Speaking	Coordination of mouth and tongue muscles Problems with receivers (not being listen 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

"States 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 of the Rights of Persons with Disabilities.

• Communication systems=assistive technologies
• Include augmentative and alternative communication systems (AAC)
• Augmentative=supplementing or improving existing speech
• Alternative=alternative forms of communication other than spoken language
• Unaided-AAC does not require any physical aid or tool to facilitate communication
• Aided-AAC uses tools or materials to facilitate communication
• Text-based AAC operated via 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 impairment of articulation of speech sound, fluency, and voice.
• A person with speech disorder and language disorder with impaired comprehension, or use of spoken, written, or other symbol systems.
• An individual with complete, grammatically correct vocabulary-rich messages in their minds but unable to express through speech.

Goals and Expected Outcomes

Goals:

1. To learn new ways to self-express
2. To become more involved in academic and non-academic activities
3. To fulfil full academic and non-academic potential

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 Plan

• Chronological age and developmental stage
  • Choosing age appropriate vocabulary and instructions
• Functionality
  • Considering the functionality of stating choices and preferences
• Interaction
  • Providing opportunity to both send and receive messages
• Cognitive development
• Level of independence
  • Independent use or use for partner-interpreted communication
• Sensory profile
  • Considering the ability of an individual to indicate intentionality of actions
• Social significance
  • Enhancing the user's social identity and interaction
• Prerequisite skills
  • Requiring no prerequisite skills to enhance or increase opportunities for interaction and communication
• Pluralism
  • Designing and selecting multiple communication strategies, tools, or methodologies
• Natural environment
  • Having the means to communicate in addition to opportunities in the natural environment
• Preferences
  • The user determining the communication intervention plan and methodology
• Communication partners
  • Multidisciplinary team assessing the abilities of all communication partners

Assessment Components

The following components should become part of the communicative function assessment process 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)

Resources

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