The Myth of Augmentative and Alternative Communication (AAC) Pre-Requisite Skills

MythPreReqSkillspngWe hear a lot of reasons for not beginning high-tech Augmentative and Alternative Communication (AAC) with students who have Complex Communication Needs (CCN)…A LOT of reasons.  I’ve chosen the top six and created a flow chart.  I like flow charts, but for those of you who do not, I’ve also written a narrative version, with related links.

Cognition Myth: “His/Her cognitive skills are too low to learn to use AAC. The individual has the cognitive skills of a 9 month old.  That system is for ‘higher functioning’ kids.”

I am starting with this myth because it is the one that makes the hair on the back of my neck stand up. These statements are demeaning, and I have heard people make comments like this in front of the student. If the individual is not able to communicate at the same level as peers, his/her communication difficulties may be interfering with his/her ability to accurately express intelligence. If this individual is currently using AAC, the system may be too limiting. Research shows that when you expect more from a child, his/her intelligence increases. Give the individual the benefit of a positive self-fulfilling prophecy.

Behavior Myth: “We have to get his/her behaviors under control and then we can consider communication. We don’t want the device to be thrown and damaged.”

If the individual does not have a reliable, effective way to communicate, he/she has no choice but to use behaviors. Appropriate, functional, comprehensive communication is necessary for “appropriate” behavior.

If this individual is currently using AAC, the system may be too limiting.

Proof of desire myth: “We’re waiting for him/her to develop more verbal speech so that we can tell if he/she actually wants to communicate.”

Acknowledge button presses as intentional communication, even if you don’t understand the relevance. Presume competence and give the individual your respect and attention as they learn the power and value of communication.

If the individual does not have access to a large expressive vocabulary, someone else has determined the (frequently small) vocabulary available to him/her. If the limited system insults the individual or doesn’t have what he/she wants to say, it is often ignored.

When you give individuals with complex communication needs (CCN) a system with an extensive vocabulary, you give them the opportunity to explore language and talk about what THEY want, and that can make all the difference. We all enjoy talking to people who share our interests or who are at least willing to listen. It is the foundation of relationships and socialization.

Hierarchy Myth: “He/She can’t use an AAC device unless the individual is able to combine 3 icons in the communication book.”

Get another opinion. Making individuals prove themselves before they are given access to a comprehensive communication system is archaic. If PECs or sign (for a hearing child) are being used, it should be for a brief time as a long term system is evaluated. These systems do not provide auditory feedback and are not universally understood.

Kate Ahern wrote about this and you can link to her blog here. If a professional tells you that your child has to climb a hierarchy and prove that he can use a high tech device, find a new professional.

Motor skills myth: “They need bigger buttons (less language) because their motor skills are too poor for little buttons.”

Is the individual able to purposefully move his/her hand? Is he able to access his mom’s iPhone to get into YouTube?

Use a key guard and/or limit vocabulary on the screen initially to allow for more accurate “hits.” Fine motor skills frequently improve with use of AAC as the child’s language grows. Frequently, key guards improve accuracy more successfully than increasing the button size. This is especially true if the individual is having difficulty with finger isolation. Fingers dragging in the screen will access larger buttons just as readily as the smaller ones. If someone evaluates your child and says he can only access large buttons, ask if a key guard was trialed.

If the individual has severe physical impairments that make them unable to move purposefully, contact device companies that offer eye gaze technology. This technology allows cameras to read individuals eye movements and speak the words that they look at for a certain amount if time.  Physical limitations can be challenging and require additional expertise and/or equipment, but they are not a reason to deny access to a comprehensive communication system.

Age Myth: “He/She has to be a certain age before we introduce AAC.” Or, “Wait until kindergarten (2nd grade, middle school, high school…) and then we’ll take a look at AAC.”

Are other people able to say words and use language at this age? If your answer is yes, then the individual is a candidate for AAC. If your baby is at risk for speech or language delays or there is any indication that speech may be delayed/difficult for this baby (I.e. No cooing or babbling, diagnosis, surgeries, traumatic or premature birth…), start modeling as soon as you’re concerned. Keep in mind that babies are immersed in language immediately, but it takes them two years to start putting words together.

Whether you are concerned or not, play and talk to your baby. Narrate your actions: explain what you’re doing and why. Respond when he/she vocalizes. Cherish his/her words and enjoy the beautiful phenomenon of language development that so many take for granted.

Monitor speech milestones. If your baby regresses or begins missing milestones, don’t “wait and see”… Introduce AAC as soon as you notice your child’s frustration or regression. AAC use will support – NOT inhibit- verbal speech development.

Enough Verbal Speech Myth: “He/She has enough verbal speech and can say sentences so the individual doesn’t need AAC.”

This one isn’t on the flow chart because, well, the flow chart was getting a little crowded.

Individuals with verbal speech may also be AAC candidates. If a child is only able to say the same scripted, limited sentences (“I want a cookie please.” “I want computer please.” “I watch Sponge Bob.”), he/she may be having difficulty segmenting where one word starts and another ends. In essence, he may be handling each of those sentences like one big, long word. The benefit of being able to segment words is that they can then be re-combined to form novel utterances.

Some individuals who express themselves very well verbally may have times (I.e. following seizures or when they’re exhausted or sick) when they are not able to speak verbally. AAC is appropriate and beneficial for these individuals to allow them to have a voice when they are at their most vulnerable.

Symbol representation myth: “He/She has to understand symbol representation before we can introduce AAC.”

This is also not on the flow chart, but it’s worth mentioning.  Symbols are abstract to everyone. We learn their meaning through exposure and experience. If you want a child to have symbol representation, use AAC. If she loves to play ball and every time she touches the ball and the device says “ball” and someone throws a ball to her, she’ll start to understand the representation of that symbol and use it functionally.

The bottom line is:  Individuals are candidates for high-tech AAC if they are not able to express wants, needs, ideas, thoughts, questions, fears, and pain to whoever they want, whenever they want.

High tech, comprehensive AAC provides the means to: express cognition, replace behaviors with appropriate communication, and initiate conversations about self-selected (and sometimes surprising!) topics – which then leads to an increased interest in true, meaningful communication.  There is no age requirement to start modeling and immersing a child in AAC. AAC WILL NOT HINDER A CHILD’S VERBAL SPEECH. The consistent auditory feedback provides a model and reduced pressure frequently improve verbal speech skills. Often, a “side effect” of AAC use is the improvement of fine motor skills and attention, driven by the motivation to communicate.

Communication is a basic human right, and there is no pre-requisite skill that justifies delaying access to that right. On the contrary, communication IS the pre-requisite skill to academic, social, and behavioral success. 

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13 Responses to The Myth of Augmentative and Alternative Communication (AAC) Pre-Requisite Skills

  1. Kimberli says:

    I was given most of the above reasons for why my daughter couldn’t/wouldn’t/shouldn’t use AAC. Her cognitive skills were too low, she needs to choose from a field of 4 consistently before we will even evaluate her for a device, etc. I did my research and purchased her system myself and I have learned things from her that I would never know with just using her picture system. I told the teachers and therapists that not making a choice, was a choice. If you are only offering her items that she doesn’t want and asking her to pick one, then not choosing one is a choice. It doesn’t mean she is not communicating – she is – she is communicating “I don’t like my options”. Open it up and give her unlimited choices and suddenly she is saying I am not ready for nap I want to “play more please”. Really? I didn’t teach her that sentence, she put it together based on her desire to stay up.

    Limiting her communication options to selecting which snack item she wants and saying that because she chose the “incorrect” item (the one that wasn’t food) means that she just isn’t getting it is demeaning. Or saying that because she chose two food items at the same time means that she isn’t getting it – when in reality she often prefers to eat a sweet and salty item at the same time is demeaning. She is an individual who wants to say and do her own things, she has wants, desires and needs just like anyone else and only being given the chance to say the 2-4 words that someone else has decided are an option that day is just wrong.

  2. Mary Kay says:

    We experienced all of the above. The only thing you forgot to add was the myth “your child is too old to learn”. We are so fortunate to have you help us find our voice!

  3. Pingback: There’s no such thing as too old. | You Don't Say

  4. Jennifer Ricca says:

    This showed up in my newsfeed on the perfect day. My daughter is 6 and I have heard just about everything. I asked at a speech eval. 3 months ago for a basic talk board (just 4-5 pictures on a board I can attach to our wall). She has shown therapist she will use an iPad or pictures when pushed at school or in therapy but she is VERY resistant at home. This would give her the freedom to experiment on her own and get confortable without me fighting with her to use the iPad and we spend the majority of our time in one room (very small house). She currently will grab my hand and push me out to the kitchen to communicate eat or drink so I know she is motivated to do a few basic needs at home. The idea was once she became confortable using it we would then transfer to a iPad dedicated to her (which we don’t currently have at home). The therapist told me no she needs to prove that she would be able to use it to request it from insurance. How on earth is she ever going to learn any device at home if she is not provided one to use? Needless to say the conversation did not go well after that. I have been doing things their way for 4 1/2 years and she still has no functional communication.

  5. Angela Biesecker says:

    My son is now 29 years of age, profoundly deaf-autistic and Mild IDD
    he is profoundly deaf, the world does not use sign language
    he has no Economic Value in this world according to the world of adult special needs
    back in 2009 I had Pennsylvania Office of Voc Rehab purchase proloquo2go
    and an i touch all for less than 300$ because my son must be able to communicate with the larger hearing world.
    I will repeat again how the adult delivery system, every state in this country of US regards adults with special needs They have zero economic value
    and if you cannot communicate the system cannot justify paying for communication supports because it does not equal more work because of dollars put in to the person
    I have contacted medicaid which funds waivers in most states and asked them how does this all fit within the ADA?
    According to the attorneys for ADA the “system” is supposed to pay for communication supports
    My son has not had supports for 8 years. Other than me his mother
    I have taken this to the Federal Govt I have asked the top of the system here in PA
    No response.
    If anyone knows please email me…[email protected]
    Angela Biesecker
    my celll call or text me 484-678-5000

  6. Vicki Clarke says:

    Beautifully said! Thanks for this, I’ll be sharing this very well written, easy to understand article with our families.

  7. Perfect, Heidi. Just perfect. Sharing widely.

    Lauren

  8. Pingback: September Specialty Series: Using AAC (Alternative and Augmentative Communication). A mother’s story. | Mommy of Apraxia

  9. Lisa says:

    You did not address one of the biggest “roadblocks”, which is cost. Who will bear the cost of purchase of a voice output system AND training for all communication partners involved for every individual who may benefit from a device? I don’t necessarily agree with you that every single individual with complex communication needs will best be served by a dynamic display, voice output device. In my experience there is a wide range of what is effective and appropriate. In fact I’ve had students/clients with devices that had much more success with lower tech systems. I’ve also had individuals who have really benefited from a more complex system. It’s not as absolute as you make it out.

    • Hi Lisa,
      Thank you for taking the time to share your opinion and experience. I didn’t address cost because anything that you provide has a cost. Printing icons or pages in color, cutting, and laminating them has a cost in materials, time, and training as well. Sign language requires training of the staff. If you’re providing a system that requires no training, it’s likely that the system doesn’t have adequate language to allow someone access to comprehensive, robust communication. Even the most basic low tech systems require training and basic mid tech devices (which still require training) are hundreds of dollars.

      Voice output provides auditory feedback and allows the individual the opportunity to independently explore language. If the students/clients are able to use a low tech system more successfully than a high tech system, it may have something to do with the implementation or the staff’s comfort level with the high tech system or the device itself. There are hundreds of options. If one voice output device doesn’t work, there are others to try that may be a better fit. I think it is absolute that even if a student with complex communication needs hasn’t “proven himself,” he deserves a chance to use high-tech, voice output AAC. Access to a large vocabulary increases the likelihood that he has access to the words he wants to be able to say. Having access to language may be the motivator that allows him to demonstrate the skills he’s had all along.

  10. Pingback: Questioning AAC | Speech Adventures

  11. Stephanie says:

    I don’t think it is wise to dismiss cognitive level and the difference between learning and developmental skills when determining what type of AAC system would most benefit a child. Do they have a solid understands of object permanence? Determining whether a child is presymbolic or symbolic is paramount. Do they understand one thing can symbolize another? If not their visual supports must match their level of understanding.
    Ongoing data regarding the student’s ability to use the device is important, including how much prompting is required, what vocabulary they can access on the device and whether they spontaneously initiate requests/comments.

    • Thank you for taking the time to comment! Determining cognitive skills in a child that doesn’t have language is often grossly inaccurate. Professionals spend years trying to teach symbols in isolation when the child doesn’t have access to language. So it is important to look at areas that need improvement for students or to realize that they may be having difficulty with symbols, because honestly symbols for core vocabulary are so abstract in many cases that a graduate school level adult may have difficulty identifying them, and compensate for those issues by teaching through motor planning or cause and effect. Visual scanning and supports become less important when you keep the location of words in the same place. Data should be taken and monitored and teaching strategies should change to reflect areas of need and support for the students. The end goal though is that a student should have the opportunity to communicate beyond requesting and commenting and the goal is for them to communicate across functions of language, tell stories, ask and answer questions, protest, and tease. If being able to “pass” a cognitive test is a pre-requisite to them having access to the language that gives them those abilities, they are set up to fail. So, yes, take every strength and challenge that children have into consideration, but provide a comprehensive AAC system as you teach and support their language and communication development.

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