AAC REVISION NOTES.pdf

AAC REVISION NOTES Adult Acquired Child Life Long ● MND ● Autism ● Parkinson’s ● Intellectual disability ● Traumatic Brain Injury ● Cerebral palsy AAC & Multimodal communication Multiple ways to communicate Access methods ICF Communication assessment Communication competencies Feature...

AAC REVISION NOTES Adult Acquired Child Life Long ● MND ● Autism ● Parkinson’s ● Intellectual disability ● Traumatic Brain Injury ● Cerebral palsy AAC & Multimodal communication Multiple ways to communicate Access methods ICF Communication assessment Communication competencies Feature matching Executive Function Symbol representation Barriers and facilitators Behaviours of concern Eye gaze Literacy When in hospital MND About ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● Diagnosis (fatal neurological disease) both upper and lower motor neurons ○ mixed dysarthria of spastic and flaccid types ○ profound weakness and reduced phonation ○ (often initial complaint is phonation) AAC recommendations accepted and technology purchased Instruction provided and ongoing needs monitored and adjusted as change occurs Progressive, degenerative disease affecting the motor neurons of the brain and spinal cord, but not sensation. Weakness is the common early symptom, with upper-extremity weakness most frequently reported. Different types of weakness, including respiratory weakness, may be present in those affected. Neck weakness is a primary prognostic factor associated with loss of speech and swallowing function. Respiratory failure is typically the cause of death in MND patients. AAC support is commonly required for communication needs, as most MND patients lose the ability to speak. Dysarthria, a motor speech disorder, is prevalent in MND patients, with mixed flaccid-spastic type dysarthria being common. Bulbar involvement may lead to rapid deterioration of speech and swallowing functions Individuals with predominantly spinal involvement may have normal or mildly dysarthric speech for a longer period of time. The progression of speech symptoms in people with MND varies, but almost all experience a severe communication disorder later in life. Apathy is the most common behavioural impairment associated with MND, along with irritability, inflexibility, poor frustration tolerance, and emotional indifference. Cognitive and behavioural changes can occur in some people with MND, such as frontotemporal dementia, mild cognitive impairment, and behavioural impairment. Role of AAC in MND ● ● ● ● PHASE I – Voice preservation, voice banking and message banking; MONITOR, PREPARE, and SUPPORT ● PHASE II – Assess, Recommend, Intervention – AAC systems (compensate, decrease number of words/breath) – NDIS IMPLICATIONS ○ Need the funding ASAP as we need to get fast with requesting the equipment ○ Trialling different devices? Might need to fast-track this process, trying for a day VS 3 weeks ● PHASE III - Adapt and Accommodate ○ Changed needs – need to return to NDIS a move to eye-gaze as the disease progresses AAC is an important consideration for people with MND AAC interventionists should screen for cognitive and behavioural impairments as they can impact individuals' acceptance and ability to learn to use AAC systems. AAC interventionists typically follow a three-phase intervention model: 1. Early Phase (monitor, prepare, and support) from diagnosis to AAC assessment referral. 2. Middle Phase (assess, select, and trial) for AAC system selection and trial. 3. Late Phase (listen, enhance, and transition) for system use and support. Stages and Monitoring of Speech Performance ● Stage 1 : No detectable speech disorder ○ Speaker and listener note no changes in rate, precision, or loudness ● Stage 2: Obvious speech disorder with intelligible speech ○ Apparent changes, may be more pronounced when fatigued ○ Compensations include decreasing rate, increasing number of breaths per utterance ● Stage 3: Reduction in speech intelligibility ○ Rate, resonance, articulation are impaired but speakers can modify speech ○ Environmental/situational reductions in intelligibility and comprehensibility ● Stage 4: Natural speech supplemented with AAC ○ Natural speech must be combined with AAC for comprehensibility ○ Natural speech may be limited to highly predictable messages ● Stage 5: No useful natural speech ○ Complete loss of natural speech, may vocalize for emotion/pain with extreme effort ● ● The Early Phase is characterised by natural speech that meets daily communication needs. The Early Phase MND assessment involves monitoring speech performance on a systematic schedule to detect changes that signal the need for AAC assessment. A reduction in speaking rate is found to precede a reduction in speech intelligibility. Objective measures, such as the Speech Intelligibility Test–Sentence Version, are important for accurate assessment. Screening cognition and behavioural function is important in the early phase of MND to identify impairments that can affect communication and decision-making. The speaking rate can be monitored accurately via analog or digital telephone technology for individuals unable to travel to a clinic. The MND-CBS is an effective screening tool for assessing cognition and behaviour (Woolley et al., 2010). ● ● ● ● ● Recommendations for Early Phase Activities in MND ● ● ● ● ● ● ● ● ● AAC teams conduct assessments of cognitive, motor, speech and language, and sensory capabilities. The speaking rate decreases as MND progresses, with a significant decrease in speech intelligibility expected when speaking rate reaches around 125 words per minute. For individuals with MND with severe dysarthria that reduces speech intelligibility, an AAC assessment is recommended when sentence intelligibility drops below 90%, regardless of speaking rate (Ball et al., 2007). If individuals score below a cut-off for frontotemporal dementia, a more comprehensive neuropsychological assessment or a simplified communication system can be considered. Informing individuals with MND and their families about voice banking and message banking options early is important. Voice banking involves recording an individual's speech to create a synthetic voice for generating messages. The process of voice banking can take 4-6 hours and may need to be done in smaller increments due to fatigue. There are commercial companies that support voice banking using various methods. Message banking refers to recording personally chosen messages. AAC Supports and Activities for individuals with MND ● ● ● "Message banking" is the practice of recording one's own voice and inflection for later use in AAC technology. Some individuals with MND rely solely on synthetic voices in their AAC technology instead of message banking. An AAC team should be involved early on to complete assessments, select AAC options, purchase technology, and provide instruction. ● ● ● ● ● ● MND speakers can benefit from implementing AAC supports that reduce speech effort and fatigue while preserving natural speech. Voice amplification systems and palatal lifts may be recommended for specific individuals with MND. Some individuals with bulbar MND use AAC applications on mobile devices to support communication and reduce fatigue. Educating individuals with MND and their caregivers about arranging their environment and maximizing hearing is important for successful communication. Some individuals with MND prepare video or audio recordings using their remaining natural speech to communicate with loved ones. Educating individuals with MND and decision-makers about AAC-related decisions is an important activity in the early phase. Middle Phase of AAC Evaluation Process ● ● ● ● ● ● ● ● ● ● ● ● During the middle phase of the AAC evaluation process, the person with MND participates in an evaluation that focuses on four activities. The first activity is identifying participation patterns and associated communication needs. The second activity is assessing current and anticipated capabilities in areas such as motor skills, cognition, speech and language, vision, and hearing. The third activity is assessing potential constraints that may affect AAC decisions, as well as considering social and personal care supports. The final activity is selecting low- and high-tech AAC options to meet current and future needs. Individuals with acquired physical disabilities, like MND, often experience other significant changes in their lives. These changes can occur gradually or abruptly, and their communication needs and participation roles are determined by their physical disabilities and personal lifestyle preferences. Some individuals prefer to center their lives within their home environment. Transitioning between living situations, such as moving from a private home to assisted living or a nursing home, can impact funding and necessitate changes to AAC systems. Employment can be important to individuals with MND, and communication technology plays a crucial role in enabling them to continue working. For example, Jamie, diagnosed with bulbar MND, used multimodal technologies like a computer and cell phone for her daily communication needs. She purchased temporary mobile technology with an AAC application, knowing that she would require more advanced AAC options in the future. Assessment, High-Tech and Low-Tech Options, Technology Purchases, and Funding ● ● ● ● ● ● ● ● Some individuals are interested in AAC-related information and actively seek it out, while others rely on professionals for decision-making. Early adoption of a mobile tablet with a communication application can be helpful, but consideration should be given to the targeted AAC system if arm and hand function declines. A 55-year-old male with bulbar symptoms wanted to continue working and prepared by banking his voice. He integrated visual materials into his presentations and used handwriting for quick communication breakdowns in person. He downloaded an AAC application to his smartphone and tablet, which allowed him to upload his banked voice messages. AAC tools were also useful for managing medical care and digital communication with clients. When his speaking rate reached 125 words per minute, he participated in an AAC evaluation to explore a system that could meet more communication needs. He regained effective access to technology through AAC and continued to stay in control of his medical care and work. AAC Technology for individuals with MND ● ● ● ● ● ● ● ● ● ● Interventions for individuals with MND should include computer literacy and Internet training to provide options for continuing employment and accessing a range of supports. Expanded electronic communication options have resulted in expanded opportunities for employment, volunteering, distance learning, financial transactions, and commercial activity. Some individuals who use AAC technology may not be interested in virtual activity, while others participate regularly on the Internet. Some individuals with MND adopt a participation strategy of staying active in the community for as long as possible, continuing to work outside the home, travel, and attend social events. A case study example showcases a man named Tom who maintained an active lifestyle even after being diagnosed with MND, using AAC technology to participate in extensive social interactions. Communication needs and AAC supports should be based on an individual's patterns of participation. individuals who primarily communicate at home may require AAC technology that can easily be moved, while those who participate actively in the community need self-contained, portable communication systems. Efficient Internet access and the ability to use the telephone and email are important for individuals with MND. Consideration of an individual's opinions and preferences regarding participation and lifestyle patterns is crucial during assessment and intervention. Eye gaze technology is widely used for face-to-face communication and text entry for individuals with MND, with many utilising it for email or text communication with medical providers, caregivers, and family members. Communication Needs of individuals with MND ● ● ● ● ● ● ● ● ● ● Communication partners used partner-dependent eye gaze to communicate urgent needs when eye-gaze AAC technology was not available. Speech severity, swallowing severity, and speech usage accounted for 55% of the variance in communicative participation. Expressing certain communication purposes, such as calling for help and expressing feelings, were identified as mandatory for persons with MND. Detailed needs assessment benefits the person with the disability and their support network. Communication needs inventory helps individuals with acquired communication disorders identify specific communication needs and assign priorities. Individuals with MND experience degenerative symptoms, with some abilities gradually being lost while others remain stable. Motor capabilities greatly impact the selection of AAC systems for individuals with MND, and it is important to assess these capabilities and consider fatigue throughout the day. Bulbar and spinal symptoms affect motor capabilities differently, with bulbar symptoms initially allowing for direct selection AAC technology control, but eventually requiring head or eye-tracking access. individuals with spinal MND typically experience motor impairments before losing speech, and may require mounted systems with head or eye tracking for AAC access. Various constraints, such as family attitudes, availability of facilitators, and funding, can impact AAC decisions for individuals with acquired communication disorders. Operational Competence, Funding and Acceptance of AAC Systems ● ● ● ● ● ● Successful AAC interventions require assessing constraints and focusing on remediation. Family members and friends may have different opinions regarding communication needs and assistive technologies. Individuals with MND generally show high acceptance of AAC technology. AAC acceptance rates continue to increase with the advancement and commonality of AAC technology in society. Gutmann and Gryfe's study found that 27% of participants decided not to pursue AAC interventions. Gutmann's analysis showed that women prefer voice output systems more frequently than men. ● ● ● ● Operational competence with AAC systems requires time, instruction, ongoing support, troubleshooting, and customization. Families of individuals with MND should receive at least five hours of training. People with MND can select and learn to operate AAC systems while they can still use natural speech. Timely implementation of AAC systems is crucial for individuals with degenerative conditions like MND. AAC Options and Support for individuals with MND ● ● ● ● ● ● The decline of speech function in MND often leads to frustration, and exploration of AAC options should start when speech slows to about 125 words per minute or when intelligibility is inconsistent in adverse listening situations. individuals with MND require ongoing support from AAC facilitators, who may provide technical instruction, message selection and modification, and assistance with motor control options and system position. Late Phase of AAC implementation focuses on adapting and accommodating to changing communication needs and capabilities until the individual's death. Most individuals with MND accept AAC technology, with only a small percentage rejecting it completely. The duration of AAC use varies depending on the onset of MND and the acceptance of mechanical ventilation support. In the last few weeks of life, individuals with MND often rely on low-tech options such as eye linking, eye gaze, or partner-assisted scanning for communication. Late Phase use of AAC Technology in of MND ● ● ● ● ● ● People with MND prefer eye linking over eye-pointing boards or partner-assisted scanning for communication. Some individuals with MND still have the strength and desire to use AAC technology in the last days of their lives. 91% of participants used multiple communication supports, including eye gaze and partner-dependent eye gaze, for urgent or immediate needs. Quality of life measures may differ between individuals with MND and their caregivers, requiring individuals to self-advocate if their wishes change. Positioning adaptations and multiple communication options are important in the final stage, as individuals with MND may spend more time lying down. AAC technology positioning needs to be adjusted to ensure continued access regardless of the location in the home. Parkinson's About ● ● ● ● ● ● ● ● ● ● ● ● ● Nervous System – inability to execute learned motor plans rigidity (increase muscle tone) bradykinesia (slowness of movement) Postural Instability – can’t correct posture balance (high risk of falls) Mono-pitch, mono-loudness, reduced stress, short phrases. LSVT – Loud treatment Short rushes of speech, imprecise consonants Depression, cognitive changes, language changes Parkinson's disease is a syndrome characterised by motor symptoms including tremors at rest, rigidity, paucity, and impaired postural reflexes. It results from a loss of dopaminergic neurons in the basal ganglia and brainstem. The onset is typically insidious, with individuals initially attributing symptoms to normal aging. Tremor in a resting position is often the first symptom that leads individuals to seek medical attention. Medical treatment, particularly the introduction of levodopamine (L-dopa), has greatly impacted the natural course of the disease, improving mobility and independence. Pharmacological treatment can improve performance but may have side effects that interfere with the use of alternative and augmentative communication (AAC) approaches. Dysarthria is a common communication symptom in Parkinson's disease. Speech symptoms and intervention in Parkinson's disease ● ● ● ● ● ● ● ● Parkinson's disease often leads to worsened speech and voice, as reported by 70% of surveyed individuals. Speech symptoms in Parkinson's disease include reduced pitch variability, overall loudness, and use of vocal parameters for stress and emphasis. Imprecise articulation and harsh, sometimes breathy voice quality are common. Speech disorders vary among individuals, with some speaking too fast, others speaking with reduced intensity or loudness, and others having limited articulator movement. Gradually, speech becomes increasingly difficult to understand as the disease progresses. AAC techniques, when used, become part of a multimodal communication system that includes natural speech. AAC intervention options are available in the early, middle, and late phases of speech progression. Early: Not usually requiring AAC, Speech interventions (loudness, pacing), computer access, normally retain speech capacity ● Mid: Voice – amplifiers ● Late – Rate control, partner support, alphabet supplementation, text-to-speech, pacing board, alphabet supplementation, typing system, partner support ● Alphabet supplementation means speaker points to first letter of the word as a cue. ● AGE – middle age onset impacts roles – communication supports need to address this for employment, family responsibilities etc Progression and Interventions for Parkinson's Disease ● ● ● ● ● ● Parkinson's disease progresses and motor speech disorders are common. Middle Phase: Assistive technology and AAC supports are used to supplement natural speech. Delayed auditory feedback can be effective in slowing down speaking rate for some individuals with hypokinetic dysarthria. Background noise played into the ears can help some individuals speak more loudly. Portable speech amplifiers can benefit individuals with consistent voicing but reduced speech loudness. Late Phase: AAC technology is implemented for those unable to meet communication needs through ● ● natural speech. Communication needs of individuals with Parkinson's disease are influenced by social environment, physical impairments, and the effectiveness of spoken communication. Assessment of cognitive/linguistic, sensory/perceptual, and motor capabilities is necessary prior to AAC intervention. Considerations for AAC Interventions in Parkinson's ● ● ● ● ● ● ● ● individuals with Parkinson's disease typically have developed language abilities, which support AAC interventions. Controversy exists regarding whether dementia is a feature of Parkinson's disease. Memory impairments and problem-solving slowness may be observed in some individuals. Cognitive limitations may interfere with AAC interventions, requiring additional instruction and practice. Sensory disturbances typically do not interfere with AAC interventions in Parkinson's disease. Motor control problems, such as reduced range and speed of movement, tremors, and hyperkinesia, may affect AAC interventions. Parkinson's disease symptoms, like micrographia, can impact fine motor control. Resistance towards AAC intervention and hearing limitations of communication partners may pose constraints in Parkinson's disease. TBI About ● Traumatic brain injury often occurs as a result of a severe sports injury or car accident. Immediate or delayed symptoms may include confusion, blurry vision and difficulty concentrating. Infants may cry persistently or be irritable. Treatment may involve rest, medication and surgery. ● Assessment, observe, read progress notes, interact ● Person centered communication in health settings ● Ensure access to commmunication tools ● Access to personlly held written health information ● Increase communicative competence of hospital staff ● Collaborate effectivley with carers, spouses and parents. FUNCTIONAL COMMUNICATION PACT: ● Prepare ● Ask questions ● Create a plan ● Take-away information from appointment. SPEACS (train ICU nurses on communication strategies with non-verbal people) AAC in USE – Results of the SPEACS trial ● “The SPEACS intervention showed positive effects, specifically, significant increases in length of communication exchanges, AAC use, and in success of communication about pain and other symptoms. Communication difficulty was reduced by the addition of SLP individualised assessment and AAC intervention. ● This study provides support for the feasibility and utility of a multi-level communication intervention consisting of communication skills training, materials and SLP consultation in the ICU. The findings provide preliminary evidence for efficacy of a training intervention.” Early Stage Intervention AAC ● ● ● ● ● ● ● ● ● ● ● People with TBI in the early stages of recovery cannot speak functionally due to cognitive impairments. Language and motor control impairments further contribute to their communication disorder. AAC goals during this stage are to increase consistency of responses and shape them into meaningful communication. AAC techniques used vary depending on the individual's neurologic involvement. individuals with cognitive and motor control impairments might require alternative access modes, such as a single switch. Communication facilitators can encourage contingency awareness by engaging the individual in purposeful activities like operating electronics with a single switch. As individuals become more purposeful, they can use multiple switches to make choices among different audio devices. Limited symbols (1-4) may represent choices, and should be brightly coloured or exaggerated. Visual capabilities of individuals following TBI should be understood as they can range from double vision to cortical blindness. Stimuli (music, voices, video, pictures) should be motivating and personally relevant. individuals with cognitive or hemiplegic impairments developed yes/no responses earlier than those with high or low muscle tone. Middle stage of recovery and assessment ● ● ● ● In the middle stage of recovery (Rancho Levels of Cognitive Functioning IV and V), the individual can respond consistently to stimuli. People with TBI in the middle stage of recovery can often indicate their basic needs, such as being hot, cold, hurt, or hungry, as well as communicate information about their location, time of day, and other personal details. Early in the middle stage, individuals with TBI may experience agitation and poor awareness of their communication deficits, which can make it challenging to accept AAC interventions. Assessment in the middle stage aims to identify residual capabilities for achieving specific communication goals. Assessment ● AAC teams should choose one or two major communication goals for the middle stage of recovery, depending on the nature of the brain injury. ● The first goal may be to help the person compensate for attention and memory impairments, by using communication techniques to aid in remembering names and schedules. ● The second goal of intervention is to provide individuals with techniques that support conversational interaction, particularly for those who have sustained damage to language or motor control areas of the brain. ● Most AAC interventions in this stage use non electronic means or a limited number of simple AAC technology displays that generate speech. ● Context-specific activity displays may be used to facilitate participation in cognitive rehabilitation activities, recreational events, or daily living routines. ● Depending on linguistic capabilities, photographs, line drawings, or printed words and phrases may be used on activity displays. ● Some individuals with TBI may navigate AAC technology more efficiently with icon-only displays. ● individuals in this stage may have difficulty visually discriminating similar symbols or symbols with multiple elements. ● Alphabetic displays are usually too difficult for encoding at this stage of recovery. ● Small activity displays with specific content are preferred to large, complex communication boards to control complexity. Communication and Assessment Strategies for individuals with TBI ● individuals without specific language impairments or severe motor control impairments usually start ● ● ● ● ● ● speaking functionally during the middle stage of recovery, although their messages may be somewhat confused. AAC materials or strategies can help support communication by establishing topics, representing episodic experiences, and identifying specific names for people, locations, or events. Family members and friends can assist by selecting topics that are important to individuals in this stage. Seating and postural issues should be coordinated with AAC concerns to minimize interference with speech or AAC usage. Assessment of motor control capability is important for determining direct selection or scanning options. AAC specialists should work closely with the medical team to coordinate communication interventions with any orthopedic surgical procedures that may affect motor access sites. Assessment should also focus on memory and attention capabilities, with consideration given to the complexity of scanning patterns. Visual Impairments and AAC Assessment and Intervention ● ● ● ● ● ● ● ● People with TBI often have visual-perceptual and visual acuity disturbances that should be considered in AAC assessment. Visual functioning can be observed at lower cognitive levels through ocular response, focus movements, and ability to follow objects or faces. At higher cognitive levels, visual disturbances can be noted during AAC triMND with input from team members trained in vision assessment. TBI can result in varying visual impairments, including cortical blindness where auditory and tactile feedback are needed for AAC use. AAC intervention for an adolescent with cortical blindness and TBI involved auditory scanning and cuing and support from communication partners. Vision impairments can also include field cuts, visual neglect, and diplopia. Communication technology for someone with a field cut and double vision was arranged on the left side of the screen and included a visual anchor. Neuro-optometrist examination can detect the type and severity of visual impairment, with a member of the AAC team accompanying to assist in communication during the assessment. Communication interventions for individuals with traumatic brain injury (TBI) ● For individuals with severe injury, their patterns of organisation can be inconsistent, necessitating assessment (Brown, Hux, Kenny, & Funk, 2014). ● individuals with attention and memory limitations could benefit from written-choice strategies during intervention. ● In the middle stage, single switches can be used to activate call buzzers, appliances, CD/DVD players, or mp3 players, serving as training for long-term environmental control technology. ● Communication partners are important in structuring interactions and should introduce topics, suggest augmentative modes, assist with breakdowns, and create motivating opportunities. ● Partners should be patient, avoid rushing, excessive encouragement, and distracting suggestions for message formulation. ● Partners should provide systematic cuing but eventually phase out cuing. ● In the late stage, individuals regain cognitive capability for natural speech, while those who cannot speak may have severe specific language or motor control issues. The Role of Mobile Technologies in Communication Support for individuals with TBI ● ● ● Using a smart phone for communication support is a desirable option for individuals with TBI, such as Jeremy. Jeremy used text-to-speech communication technology with a large keyboard to accommodate his limited access capabilities. As Jeremy's ability to use his left hand improved, he transitioned to a large smart phone using a ● ● ● ● ● text-to-speech app and a stylus. Mobile devices may also assist in supporting cognitive challenges for individuals with TBI, such as using reminder apps with tactile or auditory cues. The Participation Model can guide effective assessment and intervention planning in the late stage of recovery for individuals with TBI. Analysis of participation patterns and expectations for participation is important in assessing communication needs. Late stage AAC intervention focuses on individuals with TBI who are already oriented and able to demonstrate goal-directed behaviour. However, even individuals who regain speech may still require AAC for writing support for an extended period. Interaction Needs and AAC Techniques for individuals with TBI ● ● ● ● ● ● ● ● individuals with TBI have various interaction needs, such as communication, information sharing, social closeness, and social etiquette routines. During the late stage of cognitive recovery, traditional AAC techniques similar to those used for other motor and cognitive impairments are appropriate. Approximately 78% of individuals with TBI who cannot speak can successfully use direct-selection AAC techniques. Most individuals operated their technology with their fingers or hands, while others used eye pointing, headlight pointing, or chin pointing. Some individuals with TBI can utilise AAC supports with orthography, including letters, words, and sentences, as they retain reading and spelling abilities. Concrete coding strategies should be used for individuals with cognitive limitations. Long-term communication support for TBI survivors should consider that new learning may be difficult and require extensive training. Complex AAC techniques that require learning a large number of messages should be introduced cautiously and changes should be avoided once the individual has learned the system. Autism About ● ● ● ● ● ● ● ● ● Autism Spectrum Disorder (ASD) is a developmental disability with two key components: deficits in social communication and social interaction, and restricted, repetitive patterns of behaviour. ASD encompasses conditions previously diagnosed as autistic disorder, pervasive developmental disorder not otherwise specified (PDD-NOS), and Asperger syndrome. ASD is a spectrum disorder with a wide range of symptoms and severity. The DSM-5 introduced a severity scale for ASD, with Level 1, 2, and 3 indicating the extent of support required by individuals. AAC interventions are necessary for individuals with ASD who have complex communication needs and limited speech. The exact causes of ASD are unknown, but genetics and environmental factors are believed to play a role. Although there is no cure for ASD, early educational and intervention programs can make a significant difference in outcomes. individuals with ASD experience difficulties with social interaction, and various social impairments can be observed early in life. Temple Grandin, an author with autism, describes her experience with sensory overload and the challenges of social interactions. Overcoming Communication Challenges in Autism Spectrum Disorder (ASD) ● ● ● ● ● ● ● Autistic children are over-responsive to some stimuli and under-sensitive to others, causing overwhelming experiences in crowded and sensory-rich environments. Many individuals with ASD have receptive and/or expressive language impairments, including difficulties in understanding spoken language. ASD affects various domains, such as vocal and speech development, nonverbal communication, vocabulary, syntax, pragmatics, symbolic play, literacy learning, and executive function. Functional communication skills are crucial for educational, vocational, and social participation outcomes in individuals with ASD. Augmentative and Alternative Communication (AAC) interventions are essential to enhance communication and improve outcomes for individuals with ASD and complex communication needs. Intellectual impairments, genetic conditions, hearing and vision impairments, unusual sensory processing, motor difficulties, sleep disorders, and emotional and behavior regulation challenges are commonly associated with ASD. AAC interventions can help individuals with autism overcome these challenges and improve their quality of life. Key Considerations for AAC Intervention for Individuals with Autism Spectrum Disorder (ASD) ● Six Steps in Assessing Language & Communication Skills ○ Step 1. Observe and interview supporters ○ Step 2. Assess: Cause & Effect ○ Step 3. Assess: Can the child match? ○ Step 5. Assess Visual Expressive Mode ○ A non-standard (play, pictures, objects) Communication Needs Assessment ○ Step 4. Assess Visual Instruction Mode (Receptive) ○ Step 6. Assessing Visual Organisation Mode ● Communication needs in ASD can be addressed with the help of two recommended books: "Interventions for individuals with Autism Spectrum Disorder and Complex Communication Needs" edited by Ganz and Simpson (2019), and "Autism Spectrum Disorders and AAC" edited by Mirenda and Iacono (2008). Effective intervention for ASD requires the collaboration of a multidisciplinary team, including speech-language pathology, applied behavioural analysis, psychology, psychiatry, and occupational therapy. Social interaction, intervention across the lifespan, and effective intervention techniques are key considerations for AAC intervention in individuals with ASD. AAC interventions should focus on promoting social interactions, not just expressing needs and wants. Many interventions for individuals with ASD primarily focus on teaching requests for preferred objects, neglecting goals to promote social interaction and information exchange. Intervention should focus on learning to engage in sustained social interactions and address the core deficit of ASD in social communication and interaction. Pragmatic aspects of communication should also be addressed in AAC intervention, including vocabulary, syntax, morphology, and meaningful activities in daily life. ● ● ● ● ● ● Visual supports ● ● ● ● ● Development of symbol understanding Development of ‘pictorial’ understanding develops gradually over the first few years of life and for all symbols might be 3+ years for typically developing children Some concepts may be easier than others to ‘picture’ Children’s drawings vary considerably from those in commercially available symbol sets Think about the ‘iconicity’ (how clear the picture has meaning) for understanding what a symbol means Four types of symbols are vital for children as they develop symbolic language ● Speech ● Gesture and signs ● Graphics ● Video Importance of Early AAC Intervention for individuals with ASD ● ● ● ● ● ● ● ● ● ● ● ● Providing intervention for individuals with ASD involves repeated triMND to promote skill acquisition and generalise skills to real-world interactions Research has shown that early intervention for children with ASD is critical for optimising outcomes. Children with ASD are typically not diagnosed until preschool age, but parents express concerns before formal diagnosis. Entry into intervention programs should begin as soon as a diagnosis is seriously considered. AAC intervention should be considered for infants and toddlers at risk for ASD or other developmental disabilities to enhance communication and language development. AAC intervention is important for jump-starting communication and language skills. While early intervention is important, ASD is a lifelong disability and there is a lack of services for adolescents and adults with ASD, particularly those requiring AAC. There is a need for more research on AAC interventions to build social interaction skills with adolescents and adults with ASD. There is no agreed-upon list of evidence-based practices for individuals with ASD, but several organisations have conducted systematic reviews to identify interventions supported by research evidence. Intervention approaches for individuals with ASD vary from highly structured behavioural approaches to naturalistic developmental behavioural interventions. Most of these approaches have been adapted to include AAC supports for individuals with ASD and complex communication needs. Individualised programs that meet the needs of individuals with ASD and their families are crucial, as emphasised by the National Research Council. Intellectual Disability About ● ● ● ● ● ● ● ● Intellectual disability is characterised by significant limitations in intellectual functioning and adaptive behaviour. Adaptive behaviour includes conceptual, social, and practical skills. IDD originates during the developmental period and impacts individuals' functioning. The degree and types of support needed vary, and the Supports Intensity Scale can be used to assess needs and plan interventions. The Supports Intensity Scale–Adult Version evaluates support needs across various life domains. IDD can be caused by genetic conditions, problems during pregnancy, health issues, and exposure to environmental toxins. individuals with IDD may have associated motor, vision, or hearing impairments and may have multiple diagnoses. Communication challenges are common among individuals with IDD and affect their quality of life and participation. Intervention for individuals with Intellectual and Developmental Disabilities ● Personalising intervention is key, as the nature of communication interventions can vary greatly depending on the specific disability involved. ● ● ● ● The AAC team should consider the overall developmental patterns, strengths, and communication characteristics of individuals with specific intellectual disabilities. Each individual with IDD presents with unique communication needs, skills, psychosocial factors, and environmental supports and barriers. The AAC team must conduct a careful assessment to design appropriate AAC intervention Low expectations and negative social attitudes are significant challenges for individuals with intellectual disabilities, often resulting in exclusion from services and society participation. Meaningful Communication and Inclusion for Individuals with Intellectual Disabilities ● ● ● ● ● ● ● ● ● ● Meaningful communication opportunities are crucial for individuals with intellectual disabilities in various settings such as home, school, work, and the community. The goal is to eliminate barriers and ensure the inclusion of individuals requiring AAC (Augmentative and Alternative Communication) in society. The focus should be on building generalisation of communication skills to real-world interactions instead of only using structured settings for intervention. Challenging behaviour may occur in individuals with intellectual disabilities due to a lack of preferred and functional opportunities. Importance of Positive Behavior Supports and Effective Communication for individuals with IDDs Intervention should focus on the proactive use of positive behaviour supports and teaching socially appropriate, functional communication skills as alternatives to challenging behaviours. Visual schedules can be used to support transitions and prevent challenging behaviours. These approaches have been proven to be effective in reducing challenging behaviours. AAC teams providing services to individuals with IDDs should have competencies in these interventions to support effective communication and increase positive participation. It is important for AAC teams to respect the autonomy of individuals with IDDs and consider the reasons behind challenging behaviours. Assessment ● ● Communication matrix (parent reporting) ○ Pre-Intentional Behaviour – Comfort, discomfort, interest in other people ○ Intentional Behaviour – Protest, continue action, obtain more, attract attention ○ Unconventional Communication - Early sounds, body movements, facial expressions, visual behaviour, simple gestures ○ Conventional Communication - Conventional gestures, specific vocalizations, Looks back and forth – ie shared attention/joint gaze ○ Concrete Symbols - Object symbols/picture symbols/Pantomime gestures/mimic sounds ○ Abstract symbols - Spoken words/manual signs/written words/Braille words ○ Language - Combination of 2 or more symbols Bayley scales Cerebral palsy About ● ● ● ● ● ● ● ● ● ● ● ● Cerebral palsy refers to a group of neurological disorders that affect muscle movement, coordination, and posture. The motor impairments appear in infancy or early childhood and are a result of damage or abnormalities in the developing brain. Cerebral palsy specifically affects the motor cortex of the brain and disrupts the ability to control movement. The damage caused by cerebral palsy is permanent, and the disabilities resulting from it are lifelong. There are various potential causes of cerebral palsy, including genetic abnormalities, congenital brain malformations, lack of oxygen, maternal infection, or fetal injury. Some cases of cerebral palsy occur after birth from brain damage in the first months of life. The specific cause of cerebral palsy often remains unknown. Individuals with cerebral palsy experience difficulty with motor control, but the severity, number of limbs involved, and type of motor difficulty can vary. Some individuals have mild difficulties and are able to walk and communicate naturally, while others have more severe challenges and require AAC intervention. Motor control difficulties can extend to all four limbs (quadriplegia) or only two limbs (hemiplegia). More than half of children with cerebral palsy are able to walk, while others use mobility aids or wheelchairs. The location and extent of the brain lesion determine the specific experiences of individuals with cerebral palsy. Types and Implications of Cerebral Palsy ● ● ● ● There are various types of cerebral palsy, including spastic, dyskinetic, ataxic, and mixed, each with different characteristics and motor control difficulties. Communication impairments, such as articulation disorders and language delays, are common in individuals with cerebral palsy due to respiratory control issues and limited access to language-learning opportunities. Intellectual disabilities, hearing and vision impairments, and seizures are often associated with cerebral palsy, with the severity of motor impairments affecting the likelihood of these problems. People with cerebral palsy may face social acceptance issues and a lack of understanding from others, desiring acceptance and understanding instead of pity. AAC intervention for individuals with cerebral palsy ● ● AAC interventions for individuals with cerebral palsy require a team approach involving professionals from multiple disciplines, such as occupational and physical therapists, orthotics specialists, and rehabilitation engineers. In addition to motor impairments, individuals with cerebral palsy may also have speech and language difficulties, intellectual disabilities, vision and hearing impairments, seizure disorder, and/or social challenges, requiring expert input from medical profession MND, speech-language pathologists, vision experts, audiologists, educators, and psychologists. ● ● ● ● ● Vision, hearing, and motor skills should be addressed early in the assessment process to establish viable channels of input and determine reliable motor responses. AAC intervention must be balanced with other interventions targeting different needs, such as mobility training, physiotherapy, access techniques, speech therapy, feeding intervention, and instruction in literacy and academic subjects. The time and effort devoted to each intervention should be determined based on the individual's needs, skills, and priorities identified by the individual and family. individuals with cerebral palsy may have limited access to learning experiences, social interactions, and community activities due to muscle impairments, architectural/transportation barriers, and attitudinal barriers. Ensuring access to AAC interventions is a key challenge for the AAC team. Adapting Play Activities and Access for Children with Cerebral Palsy ● ● ● ● ● ● Efforts to increase access for children with cerebral palsy should start at an early age by providing access to adaptive play activities. Play activities should be interactive, appealing, and accessible to foster learning and communication. Play adaptations can be implemented at home or at school to stabilise toys, keep them within reach, and enhance manipulation and functional use. AAC teams often provide children with cerebral palsy access to single-switch technology to enhance their control of the environment and support participation. It is crucial to integrate single-switch technology into meaningful activities to avoid isolating children with cerebral palsy. Robots offer the potential for children with cerebral palsy to engage in fun play activities. AAC & Multimodal Communication Multiple Ways to Communicate Unaided: (meaning is consistently assigned) ● Key word sign ● Body and head movements ● Facial expressions Low Tech: ● Communication, alphabet boards, picture books, topic displays, wallet cards..etc Ipad ● Not a dedicated speech generating device, but can be dedicated for communication. ● Poor quality speakers and battery needs charging a lot. ● Could be a useful backup for someone. Electronic Non-electronic Speech Unaided-gesture/sign Dry environments/water protection needed (cleanable) Laminated /splash protected & saliva (cleanable) Single item (can be low or high cost) Replicable / copies (paper, card) (can be low or high cost) Weight – will have battery weight Weight – can be heavy or light Effort, speed, intelligibility Working against gravity to move, co-ordination Relies on batteries –charging / battery life No batteries - freedom Speech, language, respiratory support Effort, energy, mobility, co-ordination Voicing + Able to speak up No voicing + need attention Voice – intensity, quality Knowledge of what each one means, vision Visible (face, head, body, arms, legs, proxemics) Vocalising? Main method, back-ups, and multiple methods at once Access Methods: An optical pointer, Light pointer, Head Tracker, Eye Tracker and Eye Gaze Indirect Selection: Scanning. Auditory or visual due to lack of motor control. Scanning can involve use of a Yes/No response or the use of a switch to select the desired item Types of Scanning ● Automatic Scanning: Activating a switch starts the scan and then it keeps moving automatically until the required item is selected. ● Inverse Scanning: Rather than depressing a switch to select, the person will release the switch to select. This means holding down a switch to keep it progressing and then letting go when the item is reached. ● ● ● Step Scanning: The person needs to hit the switch each time they want the scan to move to the next item. High physical demand; greater control over timing. Two-switch scanning: One switch is used to start/progress the scan, a different switch is used to select the item; Less cognitive demands Partner assisted: scanning the communication partner takes the responsibility for ‘scanning’ through the options available and looks to the individual to confirm when they have reached the desired item ICF & AAC -These health conditions impact the person’s body structures and functions. -Personal factors and environmental factors influence participation and inclusion. Current Communication Assessment ● Observe and use standard tests ○ Modify / Not use norms ● Speech samples (what speech or vocalisations do they use) ● Interviews and scales (parent reports), Play, Language sampling Potential for environmental adaptations: ● Dynamic assessment, Symbols, pictures, photos, gestures, Communication partner behaviours Assess the potential use of AAC systems and strategies (environmental factors) Assess opportunity barriers ● Policies, Practices, Communication partner skills, Communication partner knowledge, Attitudes (societal/communication partner) Assess the interventions that might be most suitable to ‘feature match’ to the capabilities and constraints ● AAC systems and devices, Environmental adaptations, Natural ability interventions, Opportunity interventions ● A SYSTEM FOR TODAY AND TOMORROW EVALUATE EFFECTIVENESS GO AROUND AGAIN 4 Communication Competencies Operational competency Linguistic competency Strategic competency Social competency Feature Matching “Feature-matching involves comparing the features (e.g., storage of vocabulary, retrieval of vocabulary, method of access, modifying voice gender accent pitch and volume, adding items) of two or more AAC systems that are best suited to the person’s needs. A systematic approach ● ● ● ● ● ● 1. 2. 3. 4. 5. 6. 7. the communication and participation needs of an individual (goals and outcomes) the environmental factors that act as barriers or facilitators of participation the current communication abilities of an individual the communication potential of an individual ○ Specifically, capabilities and constraints of an individual the features of communication modalities and methods, systems and strategies Plan and adapt AAC systems to the needs, capability, and constraints of an individual and their environment Operational Requirements Profile Constraints Profile Individual and Family Preferences Communication Partner Attitudes Communication Partner Skills and Abilities Funding Capability Profile Motor Assessment ● Seating and positioning ● Access methods ○ Direct = Using fingers, hand, arm, head, orofacial structures, foot, leg, eyes to select desired target ○ Indirect = Activating a switch with a part of the body to start and stop scanning (Auditory or visual) ALSO Partner assisted scanning Cognitive Linguistic Abilities Information about their level of: Awareness, Communicative Intent, World Knowledge, Memory, Symbolic Representation, Metacognition, Expressive / Receptive language skills Literacy (formal or informal) Addresses: letter-sound correspondence; Sound-blending skills; Phoneme Segmentation; Word Decoding; Sight word recognition; Reading Comprehension; Spelling assessment Sensory Perceptual Assessment (vision/hearing) ● Sensory impairments commonly accompany many of the developmental conditions that lead to communication difficulty and are a common reason why AAC systems may be abandoned. Checklist: ● Type and number of messages, vocabulary size, coding system, symbol sets, message retrieval, Size, layout, system memory, optical indicators, auditory prompts, rate enhancement, programmability, and computer compatibility. Type of input method (e.g., switches, mouth stick, head pointer, alternative keyboard, and direct selection, scanning, encoding). Type of output (e.g., speech print, LCD, Braille). ● Mounting and portability. Executive Function: The cognitive processes required to control behaviours. Types of symbol representation Symbolic Representation (Concreteness / Abstract) Real objects – the whole thing as it is (not symbolic, towel for swimming) Parts of real objects – token/fragments/pieces (salient representation or association of that with an activity e.g., part of towel) Real mini objects (look the same but are smaller) miniatures Picture Communication ● Symbols ● Mini objects ● Emoji ● Pictograms ● Line drawings Concrete: real objects. Abstract: written words/text. Triple C (Checklist) + InterAACtions (Interventions) ● Practical ● Theoretically sound ● Respectful ● Flows into intervention ● Clinically feasible to implement ● Involves communication partners and close observation of the person with disability ● Revised Triple C stage description Communication level Description Unintentional passive Behaviours produced in response to internal and external stimuli are assigned intent Shows an awareness of sounds, particularly voices. or meaning by a Visually follows slowly moving objects or people. communication partner. Beginning attempts to act purposefully on objects, with behaviours assigned intention or meaning by a communication partner. Reaches or moves towards familiar people in familiar situations. Intentional informal Acting on the environment to create a specific effect, resulting in communication attempts through informal rather than symbolic means. Imitates novel behaviours. Uses people to get objects. Symbolic (basic) Integration of information from each of the senses, trial and error to solve simple problems and uses conventionally understood symbols within limited contexts. Gives or shows an object to a person to obtain an action. Follows a simple instruction out of routine. Symbolic (established) Solving of problems through thinking about them; the person had internal Predicts cause/effect relationships. Uses photos, pictures or signs for choice making. Unintentional active Reaches for or looks at an object to indicate preference/choice. representations and can use symbols in a range of contexts. Barriers and Facilitators Barriers (services and policies) Policies Funding Training Problems measuring, monitoring, documenting progress Conflicting advice Facilitators Family-centred Increased intensity of services All members of team collaborate Consistent advice People who know (experts available) AAC System Tool: As a Barrier/Facilitator Barriers (AAC TOOLS) Technical competence, training, time needed to learn tools Battery span, usability, narrow application, limited portability of low tech AAC system not available within and across settings Facilitators Tools/devices available in all natural environments Easy for child and communication partner to use Device has a variety of functions – photo, video, electronic recording of progress, adaptation of Vocabulary needing to be prepared ahead of time Difficult to co-ordinate visuals for use in story-book reading time vocabulary as needs change iPad & mobile devices reduced stigma, more portable A range of AAC tools can be used Communication Partners: Barrier or Facilitator Barriers (communication partners) No prior training in AAC interventions Not always present to facilitate the use of AAC Lack of modelling, children not receiving models of AAC from their peers Facilitators Children’s communication partners interested in and see the benefits of AAC Trained in AAC Using modelling and prompting to support engagement in AAC Communication partners being present increased likelihood of AAC being used Parents: Barrier or Facilitator Barriers (parents) Parents thinking that AAC hinders or replaces speech. Parents finding it difficult to fulfil the many tasks that using AAC involves (e.g., vocab selection, programming, design and implementation) Facilitators Parents thinking that AAC supports natural speech development, behaviour, and attention Parents being a link between different environments and can promote consistent use Parents directing their own learning about AAC on internet and other parent chat Parents learning from other parents Child with ASD: Barrier or Facilitator Barriers (children with ASD) Lack of attention, interest or motivation to engage in AAC Difficulty initiating or engaging in spontaneous communication using the AAC Children’s anxiety, inflexible or challenging behaviour Fine motor skills (eg for signing) Facilitators Child interested and motivated to use the AAC. Showing positive outcomes, stimulating communication partners to continue trying to use Using the system independently for spontaneous comms Introduced early in child’s early language development Any preference for the screen modality/motivating Behaviours of Concern Behaviour Support and Restrictive Practices Definition Causes Refers to behaviours of such intensity, frequency or duration that the safety of the person or others is Health conditions and co-occurring mental illness Intellectual and developmental disability, acquired brain injury, syndromes likely to be placed in serious jeopardy, or the behaviour is likely to seriously limit the use of, or result in, the person being denied access to ordinary community facilities. Developmental and life events Environmental of concern or maladaptive environment Eye Gaze Literacy Factors affecting literacy learning: Orthographic processing (processing and identification of letters and letter patterns); Phonological processing (detection and manipulation of the sound structure of speech and mapping of letters to sounds and sounds to letters); Context processing (use of vocabulary knowledge, syntactic/grammatical knowledge, and world knowledge to derive meaning from text or encode meaning into text); and Meaning processing (integration of orthographic, phonological, and contextual processing to build a coherent understanding of the meaning of the text) Intrinsic (in the person) factors – affected by environment ● Visual, hearing, motor, cognitive, language and speech impairments. Assessment Letter-sound knowledge, phonemic awareness, phonics ● Assess reading and writing skills (e.g., word reading accuracy) ● Assess skills typically associated with literacy development ● Adapted curriculum- and criterion-based assessments most appropriate ● Plan how you are going to adapt your assessment ● Provide ‘alternative pencils’ for writing ● Provide a ‘response method’ using pictures/symbols/letters/words Assessment of Phonics ● Decoding during shared book reading using read, pause, wait process (reader to fill in the blank) ● Combine phonological awareness, decoding, and sight word instruction ● Strategies – i) provide explanations of correct responses, ii) lead st