Augmentative and Alternative Communication - PDF

Unit V Augmentative and Alternative communication  What is AAC? “Augment” implies a form of supplementation and “alternative” implies a form of replacement. AAC, then, means using some form of communication that is designed to either supplement or replace more typical means of com...

Unit V Augmentative and Alternative communication  What is AAC? “Augment” implies a form of supplementation and “alternative” implies a form of replacement. AAC, then, means using some form of communication that is designed to either supplement or replace more typical means of communication Means using something other than speech to communicate Examples: line drawings to ask for something, photographs to supplement, poststroke use of gestures, photographs, pantomime etc AAC is a set of approaches that is used to improve the communication skills of a person who does not speak or whose speech is not intelligible. (Lewis, 1993)  American Speech-Language-Hearing Association (ASHA, 2005) Augmentative and alternative communication (AAC) refers to an area of research, clinical and educational practice. AAC involves attempts to study and when necessary compensate for temporary or permanent impairments, activity limitations, and participation restrictions of individuals with severe disorders of speech-language production and/or comprehension, including spoken and written modes of communication  Need for AAC/Disability conditions that may require increased reliance on Augmentative communication Congenital Acquired Cerebral palsy Stroke, TBI Mental retardation Cerebrovascular accident Severe profound HI Spinal cord injury Amyotrophic Lateral Sclerosis Deaf/blindness Laryngectomy, Glossectomy Spina bifida Brain tumour, dementia childhood AOS Guillain-Barre syndrome Developmental aphasia Multiple Sclerosis Autism spectrum disorders Parkinson’s disease Closed head injury  Progressive neurological diseases Amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease) Multiple sclerosis Muscular dystrophy (MD) Parkinson’s disease Huntington’s chorea Acquired immune deficiency syndrome (AIDS) Non-progressive Shock/ trauma/ surgery (Accidents, intubation, weakness, concussion, tracheostomy, laryngectomy, severe burns to the face etc) Guillian-Barre syndrome Temporary Permanent Laryngectomee Progressive neurological disorders TBI, Aphasia Categories of impairment 1)Cognitive impairment – Intellectual Disability 2)Sensory impairment – HI, Visual Impairment (VI), HI-VI 3)Neurological impairment –CP, dysarthria, apraxia, aphasia, TBI, progressive disorders 4)Genetic disorders 5)Structural impairment – glossectomy, laryngectomy 6)Developmental disabilities and multiple disorders – autism, ADHD etc  Some terminologies……AAC 1. Unaided vs aided Unaided AAC: use of only the body to communicate, without external equipment of any kind Eg. Gestures, manual signs, pantomime, gaze, vocalizations (which can convey emotional states or can approximate words), head nods/shakes Aided AAC: some type of external equipment (simple or complex) Eg. Photograph of a glass of juice to represent thirsty to a computerized voice output device that says THIRSTY when you press a designated button 2) No tech versus low/ mid tech versus high tech: Aided AAC: no tech, low tech and high tech  No Tech: Any type of aided AAC that is non- electronic Low/mid tech: simple electronic devices that record and play back a limited number of messages High Tech: more expensive electronic devices, many of which can be purchased as fully functional computers 3. Dedicated vs non-dedicated speech generating devices Dedicated devices or speech generating devices (SGDs) are used solely for the purpose of speech generation (low, mid and high tech) Non dedicated device: usually fully functioning computers that can run software programs that do more than generate speech. The person using this can access internet and can load any type of software onto the hard drive of the device such as word processing, email or gaming software.  Technology and aided AAC Concepts / definition Appliance – a device that benefits an individual irrespective of the individuals’ skill level, Eg. Splints, hearing aid, spectacles, artificial limb Tool – a device that requires the development of the skill for their use, Eg. Mouse, artificial larynx Hard technology – components or device that can be readily purchased or assembled in a AAC Soft technology – skills related to human such as training, use of strategy, concept, decision making etc while using a device or tool.  Components of AAC (ASHA, 1991) 1)Symbols: Refers to methods used for visual, auditory &/or tactile representation of conventional concepts Eg. Gestures, photographs, manual sign, printed words, objects, Braille etc 2) Aids: Refers to physical objects or device used to transmit or receive messages. Eg. communication charts, mechanical or electronic devices, computers etc Symbols (Visual) Braille (Tactile) Portable palmtop: communication device 3) Strategy: specific method of using aids, symbols and techniques to make effective communication or enhance communication Eg. use of prompts, modelling etc to teach a word 4) Techniques: these are methods used to transmit message. In AAC, communication process involves three factors (a) Means to represent: use of symbols to represent an idea /thought /concept (“Referent”) b) Means to select: selecting appropriate symbols to form a message. The person may choose symbols from memory (eg words, sentences etc in verbal language) or from a given symbol set. E,g: Pointing sequentially c) Means to transmit: once the symbol is selected or produced, it is transmitted through some medium to reach the receiver  Classification of AAC Two approaches: A] Super ordinate classification (Lloyd etal;1990) 1] Aided 2] Unaided Aided: involves use of some external devices or equipment (varies from simple manual devices to complex electronic devices with synthesized speech) Unaided: requires no equipment / aid. Can use individuals’ own body to communicate Aided + Unaided = Multimodal communication Gestures as symbols: use of body or parts of body to represent objects, ideas, action etc Manual sign as symbols: use of manual signs to represent a part or whole of spoken language Sign language as symbols: languages composed of different hand shapes Eg: British sign language (BSL) American sign language (ASL) Finger spelling as symbols: letters are formed by different shapes of the hand and fingers. Each word is then spelled out (adopted as a distinct part of number of sign languages)  Aided Unaided Means to represent Objects, pictures, Gestures, sign synthetic speech etc language and natural speech etc Means to select Pointers, switches etc Blinking, gestures, speech, writing etc Means to transmit Communication Direct transmission charts, boards, AAC using various body aids parts B] Subordinate classification (Fuller et al; Vanderheiden & Lloyd,1986) Aided Unaided Static/dynamic Iconic/opaque Set/system Static symbols: Symbols are permanent and enduring. They do not require any movement or change to express meaning Eg. Objects, pictures etc Dynamic symbols: They are not permanent and enduring. They require movement or change to convey meaning Eg. Symbols in sign language or gesture of bye-bye Iconic symbols: The symbols visually resemble the referents they represent E.g: picture of cat matched with a real cat (one to one relationship), i.e. a symbol that has one to one relationship or readily depicts a referent. Eg. Ο = wheel. Opaque symbols: symbols have no specific relationship to the referents they represent (can’t derive any meaning from this) Eg. Lexigrams and Premack Poor guessability of the relation between the referent and symbol Eg.red = LEXIGRAMS  Premack symbols Various plastic shapes in different colours and sizes biscuit Apple (blue triangle) Transparent symbol: the symbol can be guessed even in the absence of a referent Eg. Picture of a book for ‘book’ Translucent symbol : the guessability of the symbol with respect to referent is between ‘transparent’ and ‘opaque’ Eg. ʌ= protection (borrowed from roof of the house) Symbol set A collection of symbols where each symbol has one or more specified meanings but it is limited in terms of flexibility, expansion and generalization (no formal rules for creation of new symbols). A set of symbols are closed in nature. Eg. a set of objects or set of pictures Eg. Aided symbol sets like Picture Communication Symbols (PCS)- iconic aided symbol set and lexigrams (opaque aided symbol set) Eg. PCS Unaided symbol sets  Eg.common gestures and Amer-Ind (set of gestures based on those that the North American Indian tribes used for their intertribal communication eg. READ is a sequence of gestures book and look) Symbol system: They have formal rules and internal logic for creation of new symbols They are techniques/methods/ schools of thought which consist of set of symbols which are governed by a set of formal rules Symbol system: A set of symbols when used together helps for maximum communication Eg. of aided symbol systems are Blissymbolics Blissymbols Unaided symbol systems Eg. American Sign Language (ASL) British Sign Language (BSL) Indian Sign Language (ISL) that have their own syntactic and morphological structure American Finger spelling ASL: Words ASL ASL PICSYM: PicSyms are line drawn graphic symbols created using Boardmaker™ software PICSYM AND SIGSYM (symbol systems)  MORSE CODE Morse code is a method of transmitting textual information as a series of on-off tones, lights, or clicks that can be directly understood by a skilled listener or observer without special equipment  Tadoma is a method of communication used by deafblind individuals, in which the deafblind person places their thumb on the speaker's lips and their fingers along the jawline. The middle three fingers often fall along the speaker's cheeks with the little finger picking up the vibrations of the speaker's throat. It is sometimes referred to as 'tactile lipreading', as the deafblind person feels the movement of the lips, as well as vibrations of the vocal cords, puffing of the cheeks and the warm air produced by nasal sounds such as 'N' and 'M'.  Using these or based on these factors, the AAC symbol taxonomy (characteristics or defining features of a selected AAC symbol system) can be decided Aided Unaided Aided-static-iconic set Unaided-static-iconic set Objects, pictures, PCS (None) Aided-static-iconic system Unaided-static-iconic system Picsyms, Sigsyms etc (None) Aided-dynamic-iconic set Unaided – dynamic –iconic set Animated gestures programmed as Amer-Ind, Gestures etc software packages etc Aided-dynamic-iconic system Unaided-dynamic-iconic system (None) Natural sign languages etc  Aided Unaided Aided-static-opaque set Unaided-static-opaque set Premak (None) Aided-static-opaque system Unaided-static-opaque Finger spelling, Braille, system Morse code etc Finger spelling Aided-dynamic-opaque set Unaided-dynamic-opaque (None) set (None) Aided-dynamic-opaque Unaided-dynamic-opaque system system (synthesized speech etc) Cued speech, Tadoma etc  Aided and unaided systems have their own advantages and disadvantages Aided Unaided Advantages Flexible Convenient Uses visual recognition Potential for unlimited memory vocabulary Message can be Better speed continuosly accessed (non transient) E.g: objects Uses different sensory No cost involved modes Can augment with VOCA (voice output communication aids)  Aided Unaided Disadvantages Inconvenient Uses recall memory Increased cost Symbols are transient Lacks closeness Requires good and intimacy motor abilities Symbols can be classified based on their function Eg. Object based symbols Picture based symbols Partially picture based with linguistic characteristics Picture + VOCA (voice o/p communication aids) Manual signs and gestures Alphabet based Arbitrary logographs and shapes Electronically produced Acoustically produced  Communication devices for disabled 1) Communication board: (a) prepared from any material - shape depends on function and use (b) Vertical or horizontal mount to suit the individual users needs (c) The area in which the symbols are placed on the board depends on the handedness, motor control in the limbs and therapists position (next to or opposite to the user) ETRAN communication board  Device for “eye-transfer” (E=Eye TRAN=transfer)  Basically used for those using aided communication device who has limited motor control in the body and a good eye gaze. Person points to the required symbols through eye-gaze only  It is usually a vertically mounted device  Usually made of plexiglass with a hole in the middle Symbols face the partner (but in young users or during training, symbols are facing user) The symbols are arranged such that the communication partner holds the ETRAN up and looks through the plexiglass.  As the symbols are placed in different sections of ETRAN, in a categorised manner (based on alphabet clusters or word type), the communication partner can guess the intended word by judging the focal point of the AAC user’s gaze Used for children and adults with severe orthopedic and speech impairments (nonverbal)  Several steps may be involved in the training process, including: Learning to scan the items available on the board Learning to fixate eye gaze on the desired item Learning to look back at the communication partner to confirm the selection  Depending on the content and the capacity of the individual AAC user, many E-TRAN charts can be prepared 2) Mechanical communication devices To help individuals with little or no functional speech Eg. Devices for head position, mouth sticks, varieties of electronic switches 3) Computerized communication devices Use of computerized hardware and software to enable individuals with disabilities Mouth Sticks and Head Pointers  Communication Techniques in AAC 1. Means to represent – Aided AAC Variety of ‘symbol sets’ and ‘symbol system’ available A] Objects (Real, miniature) B] Pictures (photograph, 2 D & 3D drawings) C] Graphic representation of manual signs &/or gestures Eg. Sign writer [Sign Writer is an MS-DOS program, it coordinates with other Windows and Macintosh programs, such as Adobe Acrobat].  D] Synthetic or animated manual signs and gestures represented on computer E] Traditional orthography (TO) and modified orthography Eg: letters of alphabet or enhanced letters of alphabet Modified orthography: embellishment or enhancement of traditional orthography. Basically the letters in words, or whole words are modified to make them more visually salient or representative of their referents. Eg. The word leaf could be written by changing the letter ‘l’. Modified orthography F]Arbitrary logographs: Eg. Yerkish lexigrams and Premack symbols G] Electrolaryx generated speech H] Synthesized speech  Means to represent - Unaided AAC Many varieties available 1) Gestures – Eg pointing, Yes/No head shakes, generally used gestures etc 2) Natural sign languages etc Eg. American Sign language (ASL) British Sign language (BSL) Chinese, French, Japanese, Korean, Swedish, Taiwan, Indian sign languages  3) Manually coded English Eg SEE - I (Signing exact English)and II [SEE is a form of communication/instruction in which signs are used in exact English word order, with some additional signs for conventions such as the "ing" word ending] 4) Tadoma and other vibrotactile cues 5) Hand - cued speech Eg. Cued speech  [Cued Speech is a system of communication used with and among deaf/hard of hearing people. It is a phonemic-based system which makes traditionally spoken languages accessible by using a small number of handshapes (representing consonants) in different locations near the mouth (representing vowels), as a supplement to lipreading. It is now used with people with a variety of language, speech, communication and learning needs].  Means to select Aided- mechanical pointers, switches, prosthetic devices which can help in selection Unaided- blinking, finger pointing, body movement, eye gaze, gesturing, pointing with body parts other than fingers, speech and vocalization and writing  Means to transmit Aided-  Communication boards, charts, cards, books etc.  Dedicated AAC devices  Adapted AAC devices Unaided-  Direct transmission using various body parts (arms, face, hands, vocal tract etc.)  Selection and Transmission of symbols Access methods/ techniques in AAC aided communication systems Unaided: words are selected and retrieved mentally from a stored vocabulary in the brain Aided: An additional physical step is required to select and send messages (e.g., pressing, keyboard, or switch). There are 4 major techniques/strategies A] Direct selection B] Scanning C]Encoding D] Word prediction  A] Direct selection technique 1) pointing without physical contact Eg. eye gaze, light pointers 2) Pointing with physical contact Eg. touch screen 3) Selection with physical pressure Eg. Averaged activation keyboards, Keyguards, drool guard keyboards These are devices where only multiple activations with certain pressure will make the selection possible Eg. Athetoids, dyskinetics (they have involuntary movements i.e. sensitivity reduced i.e. low sensitivity keys) Drool guard keyboard  If motor skills are adequate or can be supported with prosthesis such as pointers, laser beam etc, direct selection should be the preferred means of access  Since it places less cognitive and perceptual demand on the user, it is often the preferred means of access in most of the disabled group  It is faster and less ambiguous compared to other methods such as scanning  Video on direct selection https://www.communicationcommunity.com/aa c-direct-selection-access/  B] Scanning  Scanning is defined as “stepping through” a set of symbols until the desired symbol is available and selected (Church & Glennen, 1992)  When the user has extensive loss of motor control, scanning selection techniques are employed rather than direct selection methods  Scanning involves the movement of an indicator/highlighter (e.g: person pointing or a cursor/light beam moving) across a display of symbols.  Low technology nonelectronic scanning can be accomplished via partner assistance. Here, an AAC partner highlights symbol choices in a logical and systematic manner until the AAC user provides some type of signaling response to indicate that the desired symbols has been reached  The speed and manner of control of highlighting choices can vary  Types of scanning 1) Step scanning / user directed scanning: Movement of the indicator (mechanical pointers, light beam etc) each time the user activates a switch. Because the movement of the indicator is directly related to the depressor or the release of the switch, the user has direct control of the speed of selection. The high number of switch activations required to get to a target, can be fatiguing to the user. For this reason, automatic scanning is used 2) Automatic scanning: One activation of the switch activates the highlighting of displays according to a preprogrammed rate and sequence. The user has to depress or release the switch at each stage to select a symbol. Automatic scanning is less fatiguing for user 3) Partner assisted scanning: The AAC user watches as another person points to each choice of symbols (visual scanning) and then the user selects the desired symbol by signaling (eg.nodding, eyeblink). If the assistant speaks the choice instead of pointing, it is called as auditory scanning Setup for scanning or approaches for scanning Simplest ways are circular and linear (time consuming) Multidimensional scanning approaches (eg. Group-item, row- column) are preferred when there is a large display 1)Circular scanning/ rotary scanning Symbols scanned in clockwise or anticlockwise direction. Device typically resembles a clock where rotating hands points to a picture symbol or word as it moves either clockwise or counterclockwise around the circle. The AAC user selects the symbol by presenting or releasing a switch to stop the hand or light movement. It is a type of linear scanning (curvi-linear scanning)  A B C Circular scanning  b) Linear scanning: It involves highlighting one symbol at a time. The indicator typically moves left to right, top to down or down to top one symbol at a time. St up according to the user’s ability or preference. Can be partner assisted scanning, or mechanically or electrically controlled.  very slow: each symbol needs to be pointed in a designated sequence before the desired symbol is chosen  -can lead to motor fatigue – especially for people with motor weakness eg. Flaccid dysarthria or other degenerative conditions Linear scanning 3) Multidimensional scanning: (higher level scanning) -enables the user to reach a desired item faster by eliminating unwanted items Two types: Group item scanning or block group scanning Row-column scanning A] Group-item or block-group scanning - user is presented choices containing large number of items to select -once the user selects the array with the desired item, items are presented in groups and /or individually until the final choice is made  This method allows the user to reject large number of items initially, thus reducing the number of switch actions needed to select a desired symbol Can be carried on only with electronic based selectors. May be difficult in manual communication systems  Rt or Lt Upper right or lower right Which column? First column target B] Row-column scanning Entire row or column is highlighted until the user selects the row or column in which the symbol/choice appears. Once the user selects the appropriate row or column, the pointer / highlighter moves across columns or symbols respectively Note: scanning helps when motor disability is severe, but it can be less efficient compared to other methods Scanning efficiency can be improved by multidimensional scanning or by arranging the most frequently occurring letters in the initial portion of the scanning device C) Encoding techniques (based on high technology devices) Encoding is a technique that allows the individual to code a smaller number of items to gain access to more extensive vocabulary. In aided AAC, encoding works in conjunction with direct selection or scanning and serves to enhance the rate of communication Requirement: good cognition Different types of encoding: 1) Memory based encoding: involves memorization of codes a) Color coding: Code groups of symbols in different colors Eg. Groups on ETRAN in different colors (red color – food; blue color- clothing etc). b) Abbreviation expansion: uses typically or idiosyncratic abbreviations to code full words. Two approaches for the same are truncation and contraction (i) Contraction method: involves omission of vowels (eg. “fr” for for, “vb” for verb) (ii) Truncation method: word shortening (eg. Coop for co-operation) usually used with literate AAC users when introduced c) Alphanumeric encoding Uses both letters and numbers for retrieving messages. ‘L’ to categorise liquids; L with no: to indicate type of liquid Eg. L = liquids; L1 =water, L2=milk d) Numeric coding 1 - greetings 2 - question 3 - alphabet 4 - function words Can be coded with different colors Can use only when limited number of messages needs to be expressed, because it is highly taxing on memory as the association between the numbers and messages are arbitrary f) Letter category encoding A category of messages are indicated with a letter and specific message in that category with additional alphabet Eg. (i) D - Drinks- DW=water; DM= milk etc (ii) E - emotion (iii) F – food g) Logical letter encoding (LOLEC) or salient letter coding The technique uses letters of keywords in a phrase to construct message Eg. If the user wants to ‘drink water’ (LOLEC=DW) If the user wants to ‘watch Television’ (LOLEC=WT) Disadvantages of memory based encoding 1) Duplication of codes can occur (for eg. DW can mean drink water or drink wine ….two different codes are needed here) 2) The user should have extraordinary memory to store and retrieve large number of messages Advantages of memory based encoding 1) Organize symbols for easy storage/retrieval 2) Meaningful associations possible 2) Semantic/conceptual encoding The limitation of memory based encoding is overcome by semantic/ conceptual encoding It involves associating multiple meanings with graphic symbols called icons If the association between the icon and the meaning is stronger, the recall is easier. Eg. ‘Red’ icon = apple, food or red ‘Study’icon = she is studying, she is writing exam, she is reading 3) Chart-based encoding - a chart is displayed throughout communication - this is used when the vocabulary items are large or codes are too complex or confusing or if the user has cognitive limitations - Usually chart is arranged in category or color code etc (dementia clients or memory problem etc) to make it easier and faster to locate items 4. Word prediction (eg. Co-writer software) -these are software programs -it presents menus of possible words each time the user types a letter -the lists are based on frequency with which the user uses the word or it is programmed according to individuals’ need Eg. When the user types “lo”- choices which appear on the screen (‘look’, ‘loop’, ‘loose’, ‘low’, ‘lone’)  user simply selects the number of choice when the frequently used words are communicated, the time and energy is saved Advantage: User need not remember the code for a word  Factors determining candidacy for AAC I. Need to communicate II.Motoric factors III.Communication factors I. Need to communicate: depends on motivation, literacy level, vocational needs, cognitive status etc II. Motoric functions: A] Sign formulation: is the ability to use signs and gestures - Depends on good motor control of upper extremity - To assess: shoulder, elbow, wrist and fingers When unaided system is chosen, look for three features: - Ability To Formulate Handshapes - Ability To Move -Ability To Make Precise Location -Good co-ordination between the above three features When a person is not a good candidate for unaided systems, then choose aided systems. For aided communication, assess the motor control and coordination required for specifying the targets B] Motor control to specify the targets Which of the remnant upper extremity movement can be used Eg. whole hand movement, head movement, foot movement, facial movement (eye blink, wrinkling of forehead, lip movement etc). C] Seating and positioning Upright / lying down or moving/static Range of motion Method of indication Manual/Unaided Aided – switch/joystick operation etc Communication factors: A] Preferences for communication: -item, place, activity, person, situation B] Signal behavior: the sign, gesture or pointing etc should be appropriate for communication Eg: least cumbersome, least amount of interpretation, Signal behavior may change over time as a result of maturation, instruction and practice  DESCRIPTION OF AIDED SYMBOL SYSTEMS Classification: I. Object communication systems: Eg Objects II.Representational symbol systems: - Pictographic Eg: photographs, 2-D and 3-D pictures and other graphics - Ideographic -Arbitrary Rebus, Picsyms, Blissymbols etc consists of all three types III. Abstract symbol systems: Eg. Yerkish, Lexigram, and Premack etc IV. Symbolic language codes: Braille, Morse code, Traditional orthography and its variations 1] PCS (Picture communication symbols) – Johnson, 1981, 1985 2] Oakland (Oakland picture dictionary)- Kirstein and Bernstein, 1981 3] Rebus: Woodcock, 1965; Clark and Woodcock, 1976 4] Sigsym (Sigsymbol dictionary picture)- Cregan, 1982; Cregan and Lioyd, 1984a 5] PIC (pictogram ideogram communication symbols )– Maharaj, 1980 6] Picsyms – Carlson and James, 1980; Carlson, 1981, 1982, 1984 7] Blissymbols – Charles Bliss, 1965  Rebus symbols (aided symbol system) - Rebus in Latin means “thing” - Consists of a set of pictographs - First developed to teach reading to normal children - It was later adopted as a AAC symbol with nonverbal individuals - Two levels of rebus: a] Simple (or basic) rebus [b] complex (or expanded) rebus - There are many varieties of Rebus. Eg: US rebus is different from one used in UK  A rebus is a kind of word puzzle that uses pictures to represent words or parts of words. For example: H+ = Hear, or Here.  Oakland picture dictionary: More than 600 simple line drawings divided into twenty major categories (body parts, food, places etc) Easily understood with little or no training Uses concrete pictures.  A pictogram is an image that represents an object. Pictograms are useful for conveying information through a common “visual language” able to be understood regardless of one's native language or degree of literacy. So that means that anyone in the world familiar with polo should recognize the pictogram below. Polo pictogram  Ideogram An ideogram is a character or symbol representing a complete idea or concept. Below is the familiar request to not smoke in a specific area. The circle and bar configuration have acquired the universal meaning of NO through use and acceptance. The cigarette and dog are examples of pictograms. The red circle and bar is an ideogram representing the idea of "no" or "not allowed." Ideographic  PIC (Pictogram ideogram communication symbols) (aided symbol system) Pictograph Ideogram Communication (PIC) symbols include pictographs in addition to ideographs. Here white symbols are represented on a black background to increase visibility. Pictogram ideogram communication symbols Logotype or Logo or logographs Technically the term logotype means a symbol comprised entirely of typography. The Coca-Cola symbol is an example of a purely typographic logotype.  Blissymbols (Aided Symbol System) -Consists of pictographs, ideographic and arbitrary symbols -Charles Bliss (1965) developed this with the idea of developing an international second language (based on Chinese scripts) -McNaughton developed and popularized this for use with nonspeaking individuals in 1970’s at Ontario Crippled Children’s Center (OCCC) -These symbols are meaning based Initially the Blissymbols communication Institute put forth 1400 symbols. But now, there are many modifications proposed -For drawing these symbols a template has to be used to maintain the appropriate size relationships of the various shapes Blissymbol  Picsyms Picsyms are a combination of pre-drawn symbols and user-drawn symbols. The idea is to provide the user an initial symbol set and allow them to draw additional ones to expand their vocabulary. They use letters and sign linked symbols.  Sigsymbols/Sigs  Sig=manual sign, symbol=graphic symbol  Sigsymbols incorporate the use of pictographs, ideographs, and manual signs.  When pictographs and ideographs cannot be used to represent an abstract idea, pictures of manual signs taken from sign language are used. Claimed to be used with Autistic, MR, deaf and aphasics Modified orthography (aided symbol system) - Traditional orthography modified in various ways -Since English follows an irregular set of rules, many modifications proposed Eg: Initial teaching alphabet (ita), International Phonetic Alphabet (IPA), UNIFON (Downing, 1963; Rohner, 1966) Types of modifications: -changing size and shape of letters -Embellishing letters with drawings, or letters or words (Jeffree, 1981; Fuchs & Fuchs, 1984) Unifon is a phonemic transcription system for the English Language. Unifon means "one sound" and implies "one sound per symbol." Enhanced Orthography [Shailashree & Manjula, 1992]  Abstract Logographs and abstract shapes (aided symbol system) - Many abstract symbol forms developed in recent years - Most of them from research originally conducted with nonhuman primates to study their ability to acquire and use abstract language - Two best known methods are PREMACK and YERKISH systems - Premack system – Premack, 1970, 1971, 1974; Carrier, 1976) - Yerkish system – Rumbaugh, 1977 - Lexigrams are used as part of the Yerkish system - There are nine basic elements in lexigrams which are combined to specify the referents LEXIGRAMS  Premack symbols Various plastic shapes in different colours and sizes biscuit apple  Traditional orthography (aided symbol system) - Consists of printed words, phrases and letters Advantages -understood by public at large -supported by simple and complex electronic devices -once learnt there is no limit to the vocabulary - They can be represented in other forms Eg Manual alphabet, braille, Morse code etc. Assessment of AAC  Interdisciplinary team in advocation of AAC Speech Language Pathologist Physical Therapist (PT) Occupational Therapist Special educators Medical professionals Audiologists Psychologists Seating and fitting specialist Engineer (For both softwares and hardwares) Social worker Vocational counsellors Manufacturers and agents Family, friends, caregivers Team leader should meet these requirements Should be a person who assesses the candidacy of a person for AAC which is generally based on oral motor performance, language competence and communication needs. Should possess the knowledge of language development and communication interaction Hence, in most cases, the Speech-language Pathologist is the team leader Role of Speech-Language pathologist in rehabilitation of severe expressive communication disorders (in a team of AAC) (Blackstone & Bruskin, 1986) 1. Assessing, describing, documenting and continually evaluating the communication/interaction behaviors and needs of individuals with severe expressive communication disorders 2. Evaluating and assisting in the selection of various communication aids and techniques to develop an effective repertoire of augmentative components 3. Developing speech and vocal communication to the fullest extent possible 4. Evaluating and selecting the symbols for use with the selected techniques 5. Developing (& evaluating effectiveness of) intervention procedures to teach the skills and strategies necessary to utilize augmentative components in an optimal manner 6. Integrating assessment and program procedures with family members and other professional team members 7. Training persons who interact with the speech/language and/or writing impaired individual.  The work of an AAC therapist Stage I: Determining candidacy for AAC Stage II: Selection of appropriate symbol system i.e. aided/unaided Stage III: Implementation features Content Access Method of Training Developing Environmental Support  Training required for a Speech Language Pathologist to work with cases adopting AAC 1] Assessment procedures for determining the candidacy for AAC and appropriate system components 2] Assessment of pre-linguistic communicative interaction (gestures, vocalization, facial expression, body language etc) 3] Knowledge of the available aided and unaided techniques 4] Knowledge of the available symbol options 5] Knowledge of the nature of augmentative communication interaction between the caregivers and Speech Language impaired persons 6] Role in the development and periodic evaluation of the usefulness of AAC system that is adapted for an individual 7] Knowledge of the effect of seating and positioning in verbal and nonverbal expression of a AAC user  AAC assessment Areas of assessment -evaluation of communicative environment -evaluation of cognitive and linguistic abilities -assessment of seating and positioning -evaluating motor accessibilities -examination of visual skills  Assessment models in AAC I candidacy model Oldest model Determines whether an individual is a candidate for AAC Based on this model, AAC was recommended only to those with expressive communication disorders with normal cognition and linguistic abilities. People who had eventually developed speech or who had developmental cognitive limitations were excluded. Not popular because it does not advocate AAC to other types of disorders. II Communication needs model (Beukelman et al, 1985) Assesses and documents communication needs of individuals Determines how the communication needs can be met through communication techniques Plans to take care of as many communication needs as possible in individual Helps in both assessment and also management III Participation model (Beukelman & Mirenda, 1988) Systematic procedure- three phases of assessment Phase I- assessing for current communication needs and different capabilities of AAC user. Phase II- assessing the communication needs and capabilities of the AAC user as required for various environments (home, school, vocation etc.) other than the current one Phase III- assessing for a comprehensive AAC system that meets the changing needs and capabilities of individual in future. IV Capability model (Yorkston & Karlan,1986) Focuses on evaluating the skills and capabilities necessary for operating an AAC system Skills are profiled in greater detail in order to determine which AAC strategy is required This assessment model was further classified into 3 groups by Beukelman and Mirenda (1992) 1.Maximal assessment models 2.Criteria based assessment 3.Predictive assessment feature matching 1. Maximal assessment models - Needs interaction with team - Evaluates individuals abilities across cognitive, academic, perceptual, linguistic and motor areas - Time consuming, needs lots of information and high degree of professional knowledge 2. Criteria based assessment model - Formalizes decision making process into a series of Yes/No questions - Information obtained through observations, records, review and evaluation - Information discussed by team.  Predictive assessment feature matching - Goal directed to find which AAC system is most beneficial for a given patient - Only those skills or behaviours which are necessary for developing AAC system is evaluated. Hence It is also called “feature” matching model/process (Swengel & vargo, 1993). - The skills of non-speaking individuals are matched to the feature of the AAC system. This is more a pragmatic model. - Team members should first know what linguistic, cognitive, perceptual and motor skills are needed to operate an AAC device and should have clinical expertise to evaluate these skills  General steps in assessment I. AAC needs assessment A] Interview: Family -other members of the communication environment -find current methods of communication and its efficiency -environment where AAC needed -Interaction partners -physical needs, mobility, wheel chair, ambulance -visual and sensory evaluation -expectations of family members and individual B] Indirect observation of AAC user’s natural environment C] Environmental barriers: Beukelman and Mirenda (1992) suggest two types of barriers Opportunity barriers: those imposed by other persons or obstacles in the user’s environment (official and nonofficial policies affecting AAC use) E.g: classroom/office, attitudes of the higher officers etc Access barriers: refers to the capabilities and needs of nonspeaking persons. These include cognitive skills, physical skills, perceptual skills, previous experience with AAC etc II Evaluation of expressive communication modalities A] Evaluation of speech intelligibility Assess intelligibility – different environments – different listeners Many standard scales available B] Identifying a motor response for assessment - inorder to check the receptive language and other cognitive skills, assess the motor access of the user using direct selection techniques. C] Assessment of receptive language, cognition and academic abilities - Appropriate standardized tests can be used D] Assessment of symbolic language abilities for aided AAC system - Inorder to use an aided AAC system, symbolic knowledge required on the part of the user. Eg. Pointing symbols, discriminating when multiple symbol choices are given, sequencing symbols, categorizing, associating words or phrases into logical semantic and syntactic groupings. When written symbols are used, should recognize letters and read basic words, spell words by rote (sight word reading) and phonetically spell new words, expand abbreviations and write grammatically ordered sentences E] Vocabulary needs assessment - Based on interview method Core vocabulary (functional words and phrases) Fringe vocabulary includes words and expressions which are content rich, related and specific to particular individuals activities or environment (developed from interviews and environmental inventories)  F] Selecting symbols for vocabulary Which symbols to use to represent the vocabulary How to organize the symbols for easy retrieval of vocabulary Selection of symbols depends on communication environment, communication partners, preference of AAC user G] Strategies-seating and positioning Most AAC users –sitting position Good sitting posture essential –to access symbols and see symbols and text on AAC device  Aim: functional sitting posture that enhances function and postural control while simultaneously reduces spasticity and involuntary movements Patients – muscle tone abnormalities, rigidity, abnormal reflexes such as ATNR, equilibrium disorders, dislocation of hips, pelvis etc. Functional sitting position is one which provides stability, mobility, head, neck and trunk control, optimum arms and hand function and comfort. H] Construction and physical layout of communication board: Communication boards on wheel chair: -rest on arms of chair -for children = 28 x18” - Made of plywood - Symbols on papers and glued on a heavy paper - Plexiglass cover to prevent dirt and moisture I] Improve communication intent Pragmatics and use J] Training the communication partners and counselling Use “WH” instead of Y-N questions Increased use of open questions Increased use of partial prompts Use reinforcement Use more pauses etc K] Visual considerations - Adequate visual acuity – for light, colour, size of symbols Visual Processing Errors Visual discrimination (use background or foreground color cues or highlight the critical part of a symbol)  Use fewer symbols on a page, separating symbols or grouping symbols in a logical way or enlarge symbols  With severe cases shift to auditory cues to locate messages L] Oculomotor considerations Nystagmus and strabismus affects visual scanning, tracking and localization, inturn affecting speed and accuracy. M] Environmental effects: Poor lighting Glare from communication boards –change position of board or use glare shields N] Evaluating motor access Many checklists and questionnaires available Check the extremities, head movements, reflex patterns etc Analyse movements required for direct selection, scanning, use of switches.  Intervention principles in AAC According to functions that AAC is assumed to achieve, the communication disorders are grouped into 3 functional groups 1) Expressive language group: Children and adults with good comprehension and poor expression eg. HI and CP 2) Supportive language group: Children and adults whose expressive speech is unintelligible or less intelligible, eg Aphasia, dysarthria 3) Alternative language group: those in whom there is little or no use of speech as a means of communication, eg PDD  AAC strategies Structured teaching: Uses specific activities for teaching, eg workbooks, curricular teaching Situational teaching: skills related to daily activity are taught in meaningful an relevant context (milieu teaching)  Instructional Procedures to be used by AAC therapist during AAC intervention 1)Mand-model: clinician asks questions or gives directions. If the AAC user fails to respond, a model of expected response is provided. Eg show me the …. (mand) 2)Modeling for imitation: Model provided by therapist is imitated by AAC user, e.g. pointing to symbols on the communication device to make a meaningful request 3) Molding/ physical guidance: physical prompts or motor assistance is provided which is gradually faded 4) Shaping: initially accept a response which is different from the desired one. Then gradually refine the response by successively accepting accurate abilities which are set as small targets 5) Enhancement: symbols are enhanced or embedded. Eg. Adding color, action etc to a symbol 6) Prompting: verbal, gestural and physical prompts can be used to elicit the desired behavior 7) Fading: Reducing the strength, frequency and duration of prompts that are used during instructional procedures in communication training  Specific considerations in AAC intervention for clients with motor speech disorders 1)Individual AAC users capabilities should be assessed thoroughly 2)Should choose AAC intervention as early as possible. That is, should not wait to see the effect of verbal/speech therapy. AAC+ speech therapy can be carried out together 3)AAC intervention should focus on current and future needs of the individual 4) AAC intervention should also include a paradigm of ongoing assessment so that progress can be monitored 5) AAC intervention should include long term and many short term goals 6) AAC therapy should be given in natural environments and in appropriate functional contexts 7) During the course of intervention, should try to minimize / eradicate barriers to communicate (social, environmental, physical etc) – more specifically physical in MSD 8) Should work with a team AAC in Developmental Disorders  Developmental motor speech disorders 1) Symbols/message to communicate- symbols that can be displayed on a communication board or monitor is selected - The selection of the symbols depends on: a) Social context of communication: - content of communication - components of AAC system that needs to be used - teach the child methods to use communication to realize one’s needs and desires b) Means to represent: select one of the following (i) Symbolic representation: one symbol stands for something Eg. Blissymbols, PCS etc (ii) Nonsymbolic representation: uses facial expression, touch and movement to convey information c) Vocabulary: selection of this depends on -Communication functions to be expressed by AAC user - Needs and preferences of AAC user - Length of vocabulary (single letter or word or sentence)  Organisation of the vocabulary on the board(depends on the physical limitation and abilities in the upper limb) Storage of the vocabulary (as children grows, additional vocabulary will be needed) d) Experience / knowledge of AAC user - More comorbid disorders in AAC user restricts the knowledge - Better/ normal cognition – AAC needs are more and sophisticated. It also depends on the context of communication (i.e. school, home etc) 2) Reason for communication/ communication needs This depends on the following: a) Internal states: such as hunger, thirst, toilet needs etc. AAC user should realize that their needs can be met b) Demand from the environment: Because of physical impairments, more care and nurturing of individuals with MSD occur. This reduces the opportunities or need to communicate, which should not happen. C) Expectations of the communication partner - communication partners should allow for active participation of AAC user - They should play adequate role in initiating, redirecting and maintaining the discourse of AAC user 3) Improving ways to communicate There are various aspects to be considered under this: a) Means to select: The ability of the AAC user and the needs of the situation helps in deciding means to select Usually ‘direct selection’ and ‘scanning’ methods are used. Pointers and other devices can be used. If only eye gaze is intact, eye gaze response (E-TRAN) can be used. b) Means to transmit message: Various options should be considered (i) Low tech (communication board) or high tech (PC with software devices) (ii) Method of selection (direct, scanning and within this the speed and accuracy of selection) 4) Communication partner Communication partner needs to be trained in (i) Teaching strategies and techniques (ii) Optimum use of communication behavior of AAC user (iii) Recognition of communicative acts of AAC user (iv) Acknowledge/receive the communicative acts and messages of AAC user (v) Contingent response to communicative acts of AAC user Intervention strategies for children with developmental disabilities  Aim- to build symbolic communication in any modality to build receptive and expressive language.  Symbolic communication includes verbal expressions, sign language, photographs, line drawings, all aided communication symbols.  Developmental Apraxia of Speech (DAS)  Children with DAS need exposure to AAC at an early age  AAC can be used to strengthen underlying expressive language and communication abilities while waiting for speech abilities to improve  - Parents can discuss issues with parents’ of other DAS children  Multimodal communication should be provided (AAC and speech)  -parental counselling: AAC is to augment speech than replace speech  -gestures, sign language, communication board  -If family members rejects implementation of AAC procedures, work on speech gestures, letter cueing etc and periodically reintroduce aided AAC approaches  pointing to picture symbols in conjunction with verbal output slows the rate of speech production in child with DAS  Unaided techniques like natural gestures and manual signs (screen for fine or gross motor apraxia)  Aided like PCS boards and VOCA  Individuals with physical disabilities (CP etc)  Gestural communication involves shared references between the nonspeaking individual and communication partner. For eg. When the individual turn his head to the side, the partner must know from past experience that this means “no more”  Eye movements, shaking one’s head, smiling, frowning/eye blink can also serve this function  Pointing a picture symbol or object – for individual who have sufficient upper extremity range of motion and dexterity. When it is absent, head points or chin points can also be used  If pointing is not an option, eye gaze can be used to signal desired item  Hand signals: Pairing left hand with one choice and right hand with another choice  Auditory scanning can be used with nonverbal and physically disabled individuals (communication partner asks a question and verbally presents 3 to 4 choices – user to indicate by pressing switch or “yes” eye movements  For individuals who are functioning at a higher level, verbal scanning of the alphabet combined with word prediction and yes/no questions to spell words and express ideas can be used.  E-TRAN Eye gaze strategies combined with encoding strategies Clock scanners Aided AAC with low or high technology  Intellectual Disability Opportunity factors: when designing AAC for individuals with MR, it is essential to take into consideration their lack of naturally occurring communication opportunities (can affect vocabulary selection) Natural gestures (iconic gestures) Symbolic communication for functional use Can be aided or unaided- PIC symbols, PECS