Wikipedia:School and university projects/AAC/Sandbox

This is a sandbox page for the Mcgill AAC project; This is where you can store information, drafts etc, until you are ready to move it into the article proper

Organization of symbols

Within an AAC system, symbols must be organized in such a way as to promote and facilitate efficient and effective communication. This is especially important when the individual has an extensive number of symbols in his or her AAC system [Beukelman reference]. Vocabulary organization refers to the way pictures, words, phrases, and sentences are displayed. (Blackstone, 1993). There are two main categories of organizational strategies: grid displays and visual scene displays. Grid displays are made up of individual symbols, words, phrases, or pictures. There are three types of grid displays: semantic-syntactic, taxonomic, and activity [Beukelman reference]. Semantic-syntactic grid displays have vocabulary items organized in terms of spoken word order or usage (Brandenberg & Vanderheiden, 1988). A common example of this type of grid display is a Fitzgerald key. The Fitzgerald key organizes symbols on a display from left to right into categories labelled who, doing, what, where, and when, with frequently used phrases and letters clustered along the top or bottom of the display.(McDonald & Schultz, 1973). Overall, semantic-syntactic displays have been cited as facilitating language and literacy skills in children.

Taxonomic grid displays group symbols according to categories such as people, places, feelings, foods, drinks, and action words [Beukelman reference]. The third and final type of grid display, the activity display, involves organizing vocabulary items according to specific situations. These can include items that are related to an activity (i.e. going grocery shopping) or routines within that activity (i.e. making a list, going to the grocery store, picking up items, paying for items at the cash register) (Drager, Light, Speltz, Fallon, & Jeffries, 2003). As such, each display contains symbols for the people, places, objects, feelings, actions, and other relevant vocabulary items for an activity or routine. These vocabulary items are then usually grouped in terms of semantic categories (i.e. all of the actions are in one area).

Visual scene displays are depictions of events, people, objects, and related actions that are parts of a particular scene [Beukelman reference]. These types of displays resemble activity displays, as they contain vocabulary that is associated with specific activities or routines. For example, a picture may be taken of a child’s room and included in the AAC system. Objects and events within the photograph can then be used as symbols for communication. The concept of play could be accessed by selecting the toy box, whereas selecting an individual toy could generate the name of the toy (e.g. blocks) (Drager, Light, Speltz, Fallon, & Jeffries, 2003). Research suggests that visual scene displays are easier for young, typically developing children to learn and use, when compared to taxonomic and activity grid displays (Drager, Light, Carlson, 2004; Fallon et al., 2003).

Symbols can also be arranged in a hybrid display, in which both the grid and visual scene dispays appear together [Beukelman reference].

Vocabulary can also be organized based on the frequency of the words and messages used by the individual. This frequency-based organization divides vocabulary into two main types: core and fringe. Core vocabulary refers to words and messages that occur frequently and show a high degree of commonality across users [Beukelman reference]. This type of vocabulary carries little information, but provides a framework for language(Yorkston et al., 1988). Conversely, fringe vocabulary refers to words and messages that are specific to a particular individual. These might include names of family members, friends or other significant people, locations, activities, and preferred expressions [Beukelman reference]. This type of vocabulary is large, constantly updated with new words, consists almost exclusively of content words (i.e., nouns, verbs, and adjectives), and has a low degree of commonality across users (Blackstone, 1988). Research has shown that both children and adults use a small core vocabulary and a large fringe vocabulary (Beukelman, Jones, & Rowan, 1989; Beukelman et al., 1984; Marvin, Beukelman, & Bilyeu,1994).

Specific groups of AAC users

Intellectual impairment

Intellectual impairment (also known as mental retardation) is described by the American Association on Mental Retardation (AAMR) as a condition that is characterized by:

Significant limitations both in intellectual functioning and in adaptive behaviour as expressed in conceptual, social, and practical adaptive skills. This disability originates before age 18.”

This description emphasizes the degree of support that an individual needs, rather than their ability level, thus recognizing the effect that appropriate supports can have on an individual’s day to day functional skills. Even though AAC and communication services is currently more widely accepted for individuals with II, prior to the mid 1980s, these individuals were often excluded due to a failure to demonstrate prerequisite skills (most of which were cognitive in nature) thought necessary to succeed with AAC or due to existing or potential speech skills because of the notion that AAC will interfere with speech development. However, in a recent comprehensive literature review, substantial evidence from research studies found that AAC users did not decrease in the development of speech production. In fact, the majority of cases demonstrated significant gains in speech skills.

Although most individuals with intellectual disabilities do not have concomitant behavioural problems, behavioural problems are typically more prevalent in this population than in others. In the past, strategies to “manage” the behavioural problems of those with intellectual impairments included incarceration, medication and aversive behaviour modification techniques. However, since the mid 1980s, greater emphasis has been placed on proactive strategies to prevent situations that may trigger behavioural problems before they arise. These strategies include teaching functional communication skills to individuals as an alternative to “acting out” in order to exert independence, claim control, inform preferences, etc. This paradigm shift in the management of behavioural problems for this population has placed new emphasis on AAC because many of these individuals do not have functional speech for communication.

Still individuals with intellectual impairments are face with a challenging predicament in their efforts to develop communication skills. Generalization (the transfer of learned skills into daily activities) is a common difficulty in individuals with intellectual impairments; however, AAC training is often conducted in highly structured settings rather than natural situations where skills are required. They often lack naturally occurring communication opportunities and frequently live and work in segregated environments where social interactions involve other individuals with communication impairments or staff workers who are hired to accommodate to their needs. One of the greatest needs in this population is responsive communicators with whom they can interact in the home, school and community environments. As such, AAC intervention for this population takes in account opportunities for integrated, natural communication opportunities, and vocabulary selection and instructional techniques are a reflection of each individual’s access to particular types of communicative opportunities.

Autism

Autism is a disorder distinguished by qualitative impairments in communication and social interactions. Children with autism may exhibit both receptive and expressive language difficulties, yet it is more challenging to acquire expressive communication than receptive communication . Children with autism may have no spoken language or may exhibit a delay in use of spoken language or gestures. The role of AAC for this population is to improve and enhance the child’s current functional communication, not to replace what already exists .

It has been found that some children with autism will express protests and requests, while joint attention or social communicative intentions are usually lacking. A child may be motorically capable, yet lack the prerequisites to language or the social communicative base on which language is built . Therefore, if a child presents with an uneven developmental profile, it is important to first begin intervention by targeting the prerequisites for language (joint attention, verbal and motor imitation, turn-taking, etc) and begin to establish some form of functional communication . It is vital to steer AAC intervention towards the linguistic and social abilities of the child . If an AAC approach has begun before the child has established the precursor language skills, it will most likely result in stereotypical, non-functional behaviors and inappropriate use of the AAC device. Therefore, it is important that some functional communication exist to set the groundwork for communication and to make the best use out of the AAC device. It has been found that children with autism who have established joint attention and can point are able to deal with at least 50 symbols on a communication board. If joint attention has yet to be established, they can handle 2 to 6 symbols on a communication board . Some goals of the AAC device include providing the child with a concrete means of communication, as well as facilitating the development of interaction skills .

An AAC device is recommended for any nonverbal child, since all individuals needs to be able to communicate. It has also been shown that speech acquisition by the time children enter school is one of the most significant predictors of outcome for children with autism . Thus, early intervention with an AAC system is key, and it is important to keep it simple and easy . Children with autism have also been found to have strong visual-processing skills, making them ideal candidates for an AAC device.

AAC systems for this population will generally begin with object or picture exchanges (for instance, Picture Exchange Communication Systems(PECS)), and also communication boards. AAC methods can be used in conjunction with other methods, such as direct speech therapy. There currently exists little empirical evidence related directly to speech treatment.

Debate on Which AAC System to Use
There has been much debate in the field about which AAC device is most appropriate for this specific population. Son, Sigafoos, O’Reilly, and Lancioni (2006) compared the use of a voice-output communication aid (VOCA) board to a picture-exchange system and found that each were plausible options for children with autism, as the ease and speed of acquisition of both systems was similar among all participants. It is important to consider the child’s preference when AAC intervention is to begin.

Parkinson's Disease

Parkinson’s disease is a progressive neurological condition ; thus, AAC interventions must plan for future speech, motor, and cognitive decline . Initially, there may be no speech disorder present . Later, hypokinetic dysarthria may result with symptoms including reduced loudness, monopitch, decreased speaking rate with some rapid bursts of articulation, harsh and breathy voice quality, and imprecise articulation . Some individuals with Parkinson’s disease will eventually loose all functional speech . Other communication problems may include reduced use of gestures and facial expression, micrographia, word finding difficulties, and reduced self-monitoring of intelligibility . Motor problems may be present including a resting tremor, bradykinesia (slowed movements), paucity (reduction in movement), muscular rigidity, and disturbed postural reflexes. Cognitive changes may include dementia, slowed problem solving skills, visual-spatial processing difficulties, and depression.

Most individuals with Parkinson’s disease will be able to communicate using natural speech to some degree for most of their disease progression; thus, interventions are often multimodal communication approaches with natural speech and an AAC device . Some individuals with Parkinson’s disease might be resistant to AAC intervention because they can still communicate using speech and they may be unaware of their communication difficulties ; hence, counselling and supportive communication partners are necessary.

Early AAC intervention is suggested to introduce people with Parkinson’s disease to the progressive nature of speech loss and the supports that are available . AAC intervention for people with Parkinson’s disease could include increasing overall loudness, decreasing speech rate, and/or improving intelligibility . A portable amplifier could be used to increase the volume of a person’s voice . To increase intelligibility, people with Parkinson’s disease could be taught to use an alphabet board supplementation technique where they point to the first letter of each word. This helps to decrease a person’s speech rate and to provide more visual information to the listener to help compensate for impaired articulation . A person could also spell out whole words or provide the topic of conversation if communication breakdown occurs . If a person with Parkinson’s disease suffers from muscular rigidity with reduced range and speed of movement, the organization of the alphabet board may need to include a smaller selection display . Furthermore, their hands may need to be stabilized on the communication board to help compensate for a resting tremor . People with Parkinson’s disease who are no longer able to communicate using speech or write due to micrographia, may be assigned a high-tech AAC keyboard device; however, adjustments such as a keyguard to prevent miskeying caused by a resting tremor . Due to speech, motor, and cognitive decline, success with AAC devices in this population is variable . Overall, amplifiers and alphabet boards are the most common low-tech AAC devices and the Lightwriter is the most common high-tech AAC device assigned to people with Parkinson’s disease .

Literacy

Many children who use AAC devices have difficulties learning to read and write due to severe speech, cognitive, or physical impairments. These barriers and their effects on emergent literacy vary across AAC users. Users with motor impairments, such as Cerebral Palsy or spinal chord injuries tend not to experience significant cognitive or learning delays that contribute to communication difficulty. AAC users who have an additional language delay are at risk for poor literacy because they do not have the necessary knowledge of language to act as a foundation for emergent literacy. Young AAC users who enter school with limited language knowledge are at risk for falling behind their typically developing peers. It has been well established that children become more successful in literacy learning when they have engaged in rich language and literacy experiences before entering school. These experiences help foster vocabulary development, discourse skills, and phonological awareness. Many children who use AAC experience difficulty across language domains, including vocabulary delays, short utterance length, poor syntax, and impaired pragmatic skills. Another significant barrier to literacy is that individuals with these limitations are often given fewer opportunities to engage in reading and writing activities. For AAC users, the the amount of time, range, and quality of experiences devoted to teaching reading and writing tends to be restricted in the classrom setting. Moreover, many people have false beliefs that individuals with these impairments are not capable of learning to read or write.

Most children who use AAC do not become functionally literate. Those who do often to dot achieve literacy skills beyond the second grade level. The individuals who use AAC who do become functionally literate into adulthood often report abundant access to reading and writing material at home and in school during childhood. Current research suggests that with direct and explicit reading instruction, AAC users can better develop their reading skills to participate in academic, vocational, and community activities. For AAC users, literacy skills facilitate self-expression and social interaction in face-to-face conversation and provide opportunities to participate in home, work, school, and social settings. Furthermore, literacy provides access to educational and vocational opportunities and can help foster independence.

History of AAC

Although AAC can trace it roots back to the early days of Ancient Rome, with the first use of augmentative strategies for the Deaf, its modern inception began in the 1950’s. At this time, AAC devices were mainly implemented for those with disrupted laryngeal anatomy due to surgical procedures such as laryngectomies and glossectomies. There was little thought given to the use of AAC strategies for those with severe communications impairments resulting from other origins. Despite this, manual languages proliferated naturally with the Deaf community. Members of the community began to actively pursue their right to be taught using American Sign Language (ASL) during the 1960’s, coinciding with the United States Civil Rights Movement. This activism help increase public and governmental awareness of the issues related to AAC. At this time, the first academic text to discuss ASL as a true language, Sign Language Structure, was released and Total Communication, an educational approach for the Deaf, was developed.

During the late 1960’s, it became acceptable to use manual sign languages with individuals who suffered from hearing impairments alongside cognitive impairments. The use of AAC devices was also prevalent among those for whom it seemed that intelligible speech would likely never be possible, including those with severe dysarthrias, cerebral palsy and amyotrophic lateral sclerosis. In most cases however, it was still common practice to employ AAC strategies only after traditional speech therapy practices had failed, as many felt hesitant to provide intervention to those who might be able to learn to communicate verbally.

This view continued to dominate the field until the 1970’s, when several governmental acts helped expand the application of AAC strategies. In 1975, the Education for All Handicapped Children Act (P.L. 94-142) (later renamed the Individuals with Disabilities Education Act (IDEA)) sanctioned the provision of educational services for all school-aged children with disabilities. As a result, many children with disabilities entered the public school systems, compelling classroom teachers to find ways in which to assist communicative exchanges. The 1986 Education of Handicapped Act Amendments (P.L. 97-457) promoted the use of technological devices to help accomplish the aforementioned goal.

During the beginning of the 1980’s, AAC became an area of professional specialization and articles, newsletters and textbooks on the matter were published as well as the first international conferences. The American Speech-Language-Hearing Association published a position paper regarding AAC as a field of practice for speech-language pathologists in 1981, and in 1983, the International Society for Alternative and Augmentative Communication (ISAAC) was founded.

The Technology-Related Assistance for Individuals with Disabilities Act (P.L. 100-407) was announced in 1989 and declared that all states make every possible effort to provide access to assistive devices and technologies to citizens, regardless of age, disability or location of residence. A variety of other acts at the time sought to highlight the importance of disseminating information regarding assistive technologies and the right to their access to the general public. In 1992, the Communication Bill of Rights, set forth by the National Joint Committee for the Communication Needs of Persons with Severe Disabilities, stated that all individuals with severe communication disabilities have a right to use AAC devices at all times as well as a right to information and the opportunity to have and make choices.

Since the 1990’s there has been an increase in in-class and natural education techniques (as opposed to traditional pull out methods), which has led professionals to seek ways for children with disabilities to participate more comprehensively and successfully in classroom activities. This inclusion model promotes the enrichment of functional skills taught within a natural context. The 1997 amendments to the Individuals with Disabilities Education Act (previously the Education for Handicapped Children Act) mandated individual assessment of children’s assistive technology needs, including augmentative communication as well as consideration of these needs in student’s Individualized Education Program. The field of AAC now follows a participation, or universal model, believing that anyone can communicate and benefit through the use of AAC devices and methods.

Outcomes

Coinciding with a move towards Evidence Based Practice within Speech-Language Pathology and health care in general, Speech-Language Pathologists have increasingly been interested or even required to demonstrate the effectiveness of their interventions. Within the field of AAC, this effectiveness can be measured according to a number of parameters related to the client and his or her family including participation, functional communication, consumer satisfaction and quality of life. A number of tools, both general and more specific to AAC, exist to measure outcomes of intervention. The QUEST (Quebec User Evaluation of Satisfaction with Assistive Technology) is a standardized interview or questionnaire designed to assess an AAC user's satisfaction level. Another measurement tool developed by the American Speech-Language-Hearing Association (ASHA), is the FCM (Functional Communication Measure). The FCM for Augmentative and Alternative Communication is a seven-point rating scale, ranging from least functional (Level 1) to most functional (Level 7). It is one of fifteen such scales that represent a continuum along which to describe the different aspects of a patient’s functional communication abilities over the course of intervention. Research projects and Data bases have also been established to advance the area of outcomes measurement within the broader field of assistive technology by improving the field’s ability to measure the impact of Assistive Technology on the lives of people with disabilities while determining the effectiveness and usefulness of devices and services.