Author: Katie Kocar, MA, CCC-SLP Edited by: Ainsley Martin, MS, CCC-SLP
Of the many different areas of expertise we are expected to have as speech-language pathologists, Augmentative and Alternative Communication (AAC) is one not often taught in depth by many graduate programs. Picture this scenario: a four-year-old nonverbal patient with Autism walks in your door after receiving many years of intensive traditional language therapy and you know he needs AAC. But how do you know if your patient is “ready?” How do you establish buy-in from the parents? Where do you even start? These are just some of the many questions asked by fellow SLPs. In addition to these questions, major “myths” regarding AAC have also been propagated within and outside of the field of speech pathology, further contributing to the confusion. In this article, three of the top myths regarding AAC will be debunked in an effort to provide a better understanding of the skills required to successfully utilize AAC, appropriate candidates for AAC, and the interaction between AAC and the development of oral language skills.
Myth 1: There are prerequisite skills a child must have to use AAC
When considering the implementation of AAC, a patient does not necessarily need to have a certain cognitive level or fine motor ability to be able to learn to utilize AAC. While there is a link between cognitive and linguistic skills, there is no direct causal link. Additionally, the development of language skills may also have a positive impact on cognitive function. First and foremost, it is important to start where the child is with their current abilities! For example, one child might need to be deliberately taught how to communicate using an evidence-based technique such as Picture Exchange Communication System (PECS), teaching the child the intention behind communication. Another child might need to be taught cause and effect using a Big Mac switch or Sounding Board application on an iPad. Some children might be ready for high-tech speech-generating devices without any previous exposure to the aforementioned methods. There is such a great variety of AAC interventions that can be used for the dual purpose of teaching cognitive or communicative skills others might consider as “prerequisite” to AAC while also teaching functional communication. In my experience, when people think of implementing AAC, they automatically think of introducing a high tech speech-generating device, which may not be appropriate at that time in the child’s language development.
The “…ultimate goal of an AAC intervention is not to find a technological solution to the communication problem, but to enable the individual to efficiently and effectively engage in a variety of interactions (Beukelman and Mirenda, 1992)."
Not all AAC users require a high tech speech-generating device. They may simply require a functional communication system that allows them to be effective communicators throughout their day. Having said that there are no prerequisite skills for AAC, this does not mean that AAC is the answer for everyone. The idea is that every person deserves a chance to learn and use AAC and we should not limit their access based on limitations we set for our patients.
Myth #2: Only nonverbal individuals can benefit from AAC
A patient does not need to be completely nonverbal to benefit from AAC. Any individual that does not have a functional communication system that can be used effectively with a variety of communication partners is a potential candidate for AAC. In my current setting, I see many children who are verbal but do not have a functional communication system. For example, some children may be able to talk clearly and intelligibly, however, the majority of their spoken language consists of scripted language or immediate and delayed echolalia. This is not a functional communication system. Picture this scenario: a child goes to McDonald’s. When the cashier asks “What can I get you?” the child immediately responds "What can I get you?” This is an example of immediate echolalia and the child is not effectively using speech to communicate. In this situation, AAC intervention should be considered. In another example, a child that suffers from severe apraxia of speech may have many intentional communication attempts using speech, however, they often cannot be understood across environments. Familiar communication partners may understand these communicative attempts, however, an unfamiliar communication partner (e.g., the cashier at McDonald’s) most likely will not. If speech is not used effectively as a functional communication system across all environments, AAC should be considered. Note, this does not mean that AAC interventions will replace speech or be required for life-long use, but it serves to augment speech and repair communication breakdowns when they occur.
Myth #3: Using AAC will inhibit the development of speech
Research has shown that a lack of language development occurred when a child did not have access to a speech-generating device, while targeted language skills increased when access to a speech-generating device and direct instruction from a speech-pathologist were implemented (Neeley, Pulliam, Catt, & McDaniel, 2015).
This case study concluded that both natural verbalizations by the child and synthesized language produced on the device increased as a result of access to a speech-generating device. Parents and family members are often cautious about implementing AAC because of the fear that any interest in speech will be replaced or lost. However, family member education regarding this research is a sound way to ease those fears and strengthen family buy-in with implementing AAC. It is also important to educate other disciplines on this research to ensure that all team members have a unified understanding of AAC intervention and facilitate carryover. I have worked on multi-disciplinary teams where physicians questioned the implementation of AAC because the child was verbal and they feared that AAC would be the 'easy way' out of learning to communicate using speech. However, when taking a language sample of what the child could say verbally and comparing it to the utterances produced on a speech-generating device, it was clear that AAC enhanced the child’s expressive language skills. After obtaining data that showed increased utterance length and a greater variety in the vocabulary used with the speech-generating device, we then wanted to explore which method of communication, verbal or speech-generating device, offered clearer communicative intentions. For example, the child could say “cracker” verbally, however with the speech-generating device he could say “want cracker”, “more cracker” and “no want cracker.” It soon became clear that access to AAC allowed for the child to have a larger variety of communicative attempts and in turn, decrease frustrations as he was clearly understood by all communication partners when using AAC.
In conclusion, I feel strongly that more education for future professionals in the field of speech-language pathology requires a greater focus on AAC. While it is time-consuming to create visuals for a PECS communication system or write up a funding report to obtain a speech-generating device through insurance, it is well worth the time to increase a patient's access to functional communication.
Every person deserves a chance to communicate and shouldn’t be denied that right because of the limitations we create. We serve in the field of speech-language pathology because we know the importance of communication to quality of life, so it’s our job to advocate for all people, even those with complex communication needs, to find their voice.
References:
Beukelman DR, Mirenda P. (1992). Augmentative and Alternative Communication : Management of Severe Communication Disorders in Children and Adults. P.H. Brookes Pub. Co.; http://search.ebscohost.com/login.aspx?direct=true&db=cat01905a&AN=ohiolink.b10788177&site=eds-live&scope=site. Accessed October 18, 2019.
Neeley RA, Pulliam MH, Catt M, McDaniel DM. (2015). The Impact of Interrupted Use of a Speech Generating Device on the Communication Acts of a Child with Autism Spectrum Disorder: A Case Study, Education135(3):371-379. http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=101708139&site=eds-live&scope=site. Accessed October 18, 2019.
About the Author: Katie Kocar, M.A., CCC-SLP graduated from the University of Cincinnati in 2015 and has worked with the pediatric population in both the school and medical settings. Her clinical interests include Augmentative and Alternative Communication (AAC) and Autism. Her passion for working with the nonverbal pediatric population has led her to complete training in Picture Exchange Communication System (PECS) and Language Acquisition through Motor Planning (LAMP). Katie also serves as a member of ASHA’s SIG 12. Outside of being an SLP, Katie enjoys working out, spending time with family and friends, and hiking with her dog Wrangler.