Augmentative-alternative communication (AAC) is a quickly growing field. Speech-language pathologists (SLPs) across all settings are finding themselves helping more and more clients who would benefit from AAC. How and where does an SLP start when there is a student on their caseload who may benefit from an AAC device? This article will provide a foundation for evaluating a student for AAC, incorporating AAC into therapy sessions, and providing training to caregivers and school staff.
Evaluation and Assessment for AAC with School-Aged Children
Depending on the school system or district, SLPs may have access to an assistive technology (AT) specialist or team who can help out with AAC assessments. Even with this resource, it is helpful for SLPs to have an idea of where to start and what communication systems to trial. This can speed up the process of getting a student a dedicated communication system.
Do they need a communication system for augmentative or alternative reasons?
Some students have some verbal speech, but it may be unintelligible to some communication partners. Some students have some verbal speech, but it is echolalic and scripted, or it is difficult to produce spontaneously. These students may benefit from AAC as an augmentative system, or to support the speech they already have.
Some students are unable to produce verbal speech or have a limited repertoire of speech sounds. These students may benefit from AAC as an alternative system, or something to use in place of verbal speech. Some students use AAC for both augmentative and alternative reasons! This is important information to explain to caregivers and to note in your referral or evaluation. You will need to explain that the student’s current speech and language abilities are not developed enough to communicate their wants and needs or to participate in the classroom.
How and what can they communicate now?
The first thing to consider is how the student is presently communicating. Are they using unconventional communication behaviors, such as body movements or early sounds? Are they beginning to use abstract symbols, such as word approximations or picture symbols? The Communication Matrix is an excellent resource for identifying emerging and mastered skills at a variety of communication levels. You can use this as a starting point because it serves as evidence that the student needs an augmentative and/or alternative communication modality. It also allows you to identify what behaviors need to be shaped into communication that is functional and recognizable to all communication partners.
Consider access and motor skills
Many students are able to use touch access, but some may need to use alternative access methods, such as step scanning or eye gaze. Collaborating with an occupational therapist and physical therapist can help identify fine or gross motor strengths that can be shaped into a movement pattern for communication. OTs and PTs are great at analyzing what movements are voluntary and controlled and can give recommendations about positioning that can help a student access a communication system better.
It is important to have an idea about what access methods you want to try, especially if an AT team or company representative is visiting you to help with trials. You want to make sure that they are aware that an alternative access point may be necessary, so that they bring systems that can be used with those access methods and the appropriate equipment.
In a guest post at PrAACtical AAC, SLP Vicki Clarke from Dynamic Therapy Associates, Inc shared some assessment considerations for student who use eye gaze. These are great starting points for clinicians new to AAC assessments and trials. When considering access, I often find it helpful to ask caregivers what they think looks easier for a student, especially if they are able to use two different access methods. It’s also a good idea to trial systems that allow for different access methods, so that if a student’s medical status or motor abilities change drastically, they are able to use the same vocabulary, but can access it differently.
For example, I work with a student who previously used a dynamic display speech-generating device with touch access. Due to a seizure disorder, she began to demonstrate a regression in motor abilities and had difficulties reaching out to touch the device. The school team did an AAC re-evaluation and found that the student was able to use eye gaze to access the same vocabulary.
Try feature matching
All communicators are unique, so not every AAC system is appropriate for every communicator. When assessing for an AAC system, feature matching can be a great start to the journey. Feature matching was coined in the 1990s by Shane and Costello; it's a process where you identify the student’s strengths, skills, and needs, and match them to available systems, tools, and strategies.
When matching features, consider access needs and abilities, vocabulary organization, symbol set, display settings, and the like. For example, a student may be non-ambulatory and unable to produce any vocalizations. You would want to match to a communication system that has speech output, so they’d be able to gain a person’s attention from across the room. You might observe that a student has difficulty selecting icons when the background is white, so you’d want to match to a system that allows you to change the keys’ background colors.
Another student may be able to attend to a large field size of icons and is able to navigate between pages. You’d want to match to a device where you could trial dynamic and static displays. You may work with a student who can read, and a communication system with word prediction could be a good fit for them. Feature matching is a jump-off point for selecting potential systems to trial, and from there you can see what settings (such as display size, dwell time, speech rate, etc.) make it easier or more difficult for the student to use a communication system.
Consider a system that can grow with the student
The research supporting core vocabulary is everywhere nowadays, and many AAC systems now use a core vocabulary approach. This eases the burden of programming and also allows a user to learn words that can be used throughout different communicative environments. It can be helpful to choose an AAC system that uses a robust vocabulary that grows as you increase display size.
Sometimes students have difficulty with a large vocabulary or a dynamic display when they are first learning to use a communication system. As they develop skilled use of their device, they may be able to switch to a larger vocabulary or a dynamic display. If you are able to recommend a system that can grow with a student, you can change to a higher level of vocabulary that includes the words previously learned in the same location or motor plan. Prentke Romich’s Unity, Saltillo’s WordPower and Dynavox’s Snap + Core First are examples of language systems that can grow with a student.
Trial, trial, trial
After you have some ideas of AAC systems that might work for a student, start trialing! Similar to trying on clothes at the mall, you have to observe the student using different communication systems to determine what works and what does not. I like to trial a low-tech manual communication board, a mid-tech speech-generating device, and a high-tech speech-generating device (keep in mind, some of these systems might not be appropriate depending on access methods).
When considering a high-tech speech-generating device, I trial one-hit and sequenced displays, as well as unmasked and masked displays. During device trials, I think about what strategies or prompts helped the student to be successful. For example, did they attend to aided language stimulation and imitate target words on a masked 60-icon sequenced display, but needed maximum prompting to use a display with 84 icons? You may have to switch up displays or icons on the fly during a trial session.
If I notice that a student is having trouble attending to models and locating icons, I may change the display to a high-contrast to see if that improves things. I like to compare how the student was communicating before I and how many times they initiated communication before I introduced a communication system, and with the communication system at the beginning and end of trials.
Keep in mind that it could take anywhere from two to ten to twenty trials before you figure out a system that meets a student where they are but that they can also learn and grow with! I have a student who I tried six different systems with over almost a year-long period before I figured out what was successful for her. It can also take some time for the student to understand what is expected of them. Aided language stimulation (also known as modeling) is an important learning strategy for all AAC users, so make sure that you are showing the student how and what they can communicate before you expect them to try it too.
Provide necessary documentation
This varies depending on whether you submit the documentation to your school system or through insurance, or if an AT team completes the documentation. Ask the school district or company you are working with what their protocol is. You can also explain the pros and cons to families of getting a school-owned dedicated SGD or an insurance-funded one.
If you are going through your school system, there is probably district-specific paperwork to complete. If you are recommending a high-tech SGD and submitting through insurance, you can go on the company’s website and find their funding documents and learn more about the process.
Companies like Prentke Romich and Dynavox provide overviews of the funding process, and company representatives can assist you if you have questions. The more AAC evaluations you complete the easier it will be to compile the paperwork needed for your school system or insurance.
Completing AAC trials and assessments doesn’t have to be hard. You have to examine the student’s abilities and needs from a few different angles and collaborate with other professionals. Whether you are completing the assessment independently or working with an AT team, the tips I have shared will start you off on the right foot!
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Use of AAC in Therapy Lessons and the Classroom
So, you got your student an augmentative-alternative communication (AAC) system. Hurray! But now what? Planning therapy lessons and incorporating AAC use into classroom activities does not have to be hard. This article will now focus on teaching AAC in therapy and classroom activities.
Pick your therapy targets
If you were the speech-language pathologist (SLP) who completed or assisted with the student’s AAC assessment, you probably have a good idea what communication skills or functions you want to target. If not, you’ll want to complete the Communication Matrix or look at one recently completed for the student. I swear by this assessment for identifying what communicative functions are mastered or emerging.
If you’re using the Communication Matrix, you will want to look at Level 6, Abstract Symbols, and Level 7, Language. On the completed Matrix table, early communication levels that the individual has surpassed will be colored grey, while mastered skills, such as requesting recurrence, protesting or greeting will be colored orange. Emerging pragmatic functions will be colored yellow on the completed Matrix table. These emerging functions are good starting points for your therapy.
As you continue to work with the student, you will want to expand their variety of communicative functions. Help them to know they can communicate for many different reasons in a variety of environments. Remember to highlight different parts of speech, including verbs, nouns and pronouns while teaching different communicative functions.
Model, model, model
Aided language stimulation (ALS) is an evidence-based therapeutic technique where communication partners model use of the AAC system by actually using it while they talk. This shows the AAC user where to find the words and how to use the words. We can’t expect students to use their AAC systems unless we are showing them how to use them.
You don’t have to model every single word. Aim to model one word longer than the mean length of utterance the student is typically using. Just like working with young children, you want to expand upon and recast their utterance. You can model while you read a book, you can model while you play, and you can model what the student is communicating through other behaviors.
Sometimes, you may have an entire session where the student chooses to communicate using body movements or vocalizations, and that’s ok. Keep modeling, because you never know when the student will spontaneously use their communication system to say something novel or repeat what you said. PrAACtical AAC has tons of articles and videos explaining how to model.
Remember that AAC therapy is the same as language therapy
Just because a person uses AAC doesn’t mean that they can’t learn morphology and syntax! When a student is beginning to combine two symbols into phrases, you can start focusing on grammar. You will already have been exposing them to and teaching them different parts of speech while modeling. Now, you can encourage them to start combining words while following grammatical patterns. I try to model several different forms during my sessions, such as pronoun + verb, verb + noun, verb + preposition, and adjective + noun. This allows the student to see how the different combinations affect meaning.
Keep AAC therapy fun!
Make sure you are planning activities that are motivating—nobody wants to talk when they aren’t having fun! I like to complete a reinforcer assessment. This way, when I first begin teaching AAC, the student is talking about something they really love. As they get more used to initiating communication using their system, I start to bring in other toys or activities that may highlight the same core vocabulary as their preferred reinforcer.
I try to avoid flashcard activities, but sometimes it is necessary . . . and a boring activity is a great way to target protesting! One of my favorite therapy activities is a smell test. We smell different essential oils and practice commenting (i.e., “good”, “bad”, “I like”, “I don’t like”), requesting more, and protesting. It is fun for students and staff alike!
Teach core vocabulary and fringe
While there is a ton of research supporting a core vocabulary approach, keep in mind that there are some students who are extremely motivated by fringe words. It’s important to keep fringe words (e.g., “cookie”) available for them to use, while also modeling and encouraging the use of related core (e.g., “eat”, “want”, “like”).
Make sure you teach core words in a variety of different ways. Allow the student to learn all the different ways they can use the word. For example, you’ll want to teach them that “play” could be used to request playing music or playing ball. “Go” could be used to request to leave the room or direct someone to push their wheelchair.
Ask teachers and caregivers what it is important to communicate about
What does the student need to talk about at home or in the classroom? It is important that you are teaching the student pragmatic functions and vocabulary that they can use during classroom activities and at home.
I like to talk to teachers, classroom staff and family members, especially around IEP time, to see what areas of communication need to be supported more in the classroom or home. You may learn new things from these team members. Maybe the student has difficulty initiating communication with peers. Maybe they have difficulty participating in social exchanges and asking social questions. This will help you identify some communication skills to target in your sessions!
Provide support in the classroom
Depending on your therapy schedule, you may find that you are able to co-teach or support in the classroom. This is a great way to help your student generalize the skills you have been focusing on during therapy sessions. You can talk with the classroom teacher about planning a lesson together. You can also ask them when they feel the student is struggling to use their AAC system.
Don’t reinvent the wheel
You don’t have to go crazy creating tons of different therapy activities! There are tons of different skills you can practice with the same activity. You may want to plan an arsenal of 8 to 10 different go-to activities where you can practice different communicative functions, different vocabulary, and different syntax patterns.
The smell test I mentioned before is an activity I repeat several times a year. You can always smell different things! I also like to repeat activities because it allows the student more chances to practice what they have learned. The AAC Language Lab also has great resources and lesson plans if you find yourself in a planning rut.
Speech-language therapy should be fun, and you shouldn’t stress about incorporating AAC into your sessions. Modeling vocabulary, teaching core, and keeping things fun will get you and your AAC users talking!
How to Train Caretakers and School Staff on AAC Use
Speech-language pathologists (SLPs) often lament that their students do not use their augmentative-alternative communication (AAC) systems outside of therapy sessions. However, child caregivers and school staff may complain that they simply don’t know what to do with these newfangled devices. It’s just as much of a learning process for teachers and caretakers as it is for the AAC user! Now, it's time to focus on ways to get child caregivers and school staff involved in the AAC journey.
Teach school staff about modeling
Earlier, we discussed how important aided language stimulation (ALS), or "modeling," is. Explain to the people working with your student that AAC is like learning any language, and that it requires practice and learning from other people. I like to use the example that people talk to babies for almost a year before babies begin to start using words to communicate. That whole year is essentially modeling for spoken language!
AAC users deserve the same exposure to modeling. For an AAC user to communicate effectively, all family and school staff members need to be showing them what to say and how to say it. It is important for caretakers and school staff to model communication outside of therapy sessions because we communicate about different things in different places! When AAC users see all their teachers and caretakers modeling for them, they learn that AAC is important and effective.
Show the caretakers videos of sessions
If you have permission to record sessions, film a short video showing how the student uses their AAC system and how you model. This is a great way for family members to see exactly how they should model words, wait for the AAC user to communicate something, and then respond to or recast the AAC user’s utterance.
Videos can be especially helpful for teaching how to set up equipment. For example, I like to send home a video showing how to set up a wheelchair mount and how to calibrate for eye gaze so that caretakers in the home can refer back to it when they are doing it on their own. If you can’t record with your student, you can always send them links to YouTube videos. I really like this video for explaining what aided language stimulation is. There are tons of videos showing SLPs or parents modeling with AAC users, and you can even search for a specific system.
Teach school staff about communication wait time
Providing extended response time is natural to SLPs. However, school staff and child caregivers sometimes struggle in the beginning with giving AAC-using students enough time to form a message. Many times, school staff will want to start helping the AAC user right away, when the person could have independently said something if they just had extra time to think about what to say. Sharing videos, as stated above, is a great way to show what wait time really looks like. After working with a student for a few sessions, you’ll have a better idea of how long you need to wait before they generate a message. You can tell teachers and paraprofessionals to count to ten in their heads—I do this myself! It’s also helpful to explain when to provide a prompt. For example, you can tell a school aide, “it usually takes Becky 15 seconds to think about and compose a message. If she hasn’t reached for her device in 15 seconds, you can model two different choices or repeat your utterance.”
To many SLPs, it seems easy to incorporate AAC into all activities of the day, but it can feel very overwhelming to people who are new to AAC. They might not know what words to use or they might not feel confident in modeling full sentences. Encourage caretakers to take baby steps. That can mean choosing one activity every day to model consistently during; for example, focusing on modeling words related to meals at snack time and dinner every single day for a week or two. Or it can mean focusing on modeling one word at a time. When I am first training communication partners, I like to include a list (see below) of one-word and two-word utterances to practice during different activities, such as reading, playing, and getting ready for bed. As the communication partners get more comfortable using AAC, they can expand to modeling during more activities and modeling longer utterances.
Get them involved in the therapy session
Invite families and school staff to participate in your therapy session. You can start the session by leading the activity while the parent watches, and then you can swap positions. Then the parent can lead the activity, while you provide real-time coaching-style feedback. You can jump in when they appear to be struggling with modeling or prompting, and they can ask questions as they come up.
Collaborating like this is a great way to establish good relationships between you as the SLP and other caretakers, and they will be more likely to come to you with questions about AAC instead of abandoning the communication system. Remember to give positive feedback as they practice too!
Brainstorm core and fringe vocabulary with caretakers
It is important to explain to family and staff members the differences between core vocabulary and fringe vocabulary. Explaining the difference and how core vocabulary get the “most bang for their buck” in the beginning will help you in the long run, so that you don’t have to constantly add seemingly “random” words that may only be used once or twice. Once this concept has been explained, you can work together as a team to discuss what core words can be modeled and what fringe is important to add.
For example, a paraprofessional may want the student to use the word “cookie” during snack, but you can explain that teaching the core word “eat” might be a better option, so that the student is still able to request during mealtimes, even when cookies aren’t being served. You may talk about what fringe vocabulary, such as toys, family members or preferred activities, can be considered a “personal core” and where to add those on the student’s AAC system.
When working with classroom teachers and staff, I explain descriptive teaching, which is a technique where core vocabulary is used and modeled to explain key concepts. This handout from the Independent Living Centre WA explains descriptive teaching and has a template for brainstorming what core words can be used to describe concepts. Gail Van Tatenhove also has some great videos of descriptive teaching on YouTube. Encourage teachers to reach out when they are planning an activity but don’t know how to describe it using core words.
Giving students a voice
As SLPs, it is our job to give everyone a voice, whether that is through AAC, sign language, or verbal speech. Employing the tools listed above and working as a team with other communication partners, including child caregivers and classroom staff, builds relationships and supports students who use AAC across all their environments!