An estimated 25-30% of children with autism are considered minimally verbal. Communication delays can be directly related to the core characteristics of autism or the result of commonly co-occurring conditions like verbal apraxia. Difficulty communicating wants and needs can be distressing for both autistic individuals and their families, impacting social relationships, access to education, and community involvement.
Despite these ramifications, it is not uncommon for medical professionals and service providers to recommend ‘waiting it out’ to see if spoken communication will develop. Waiting for spoken communication to develop is not only unethical but unnecessary. If your client or loved one struggles with spoken communication, there are a multitude of alternative communication methods available to support language acquisition and use.
What is AAC?
Augmentative and alternative communication (AAC) is an umbrella term for communication methods that supplement or replace speech for individuals who cannot use speech to meet their communication needs. AAC systems may be unaided or aided. Unaided AAC does not require special tools. Examples of unaided AAC include gestures, sign languages, and facial expressions. Aided AAC requires the use of external tools or devices. Aided AAC can range from low-tech options like picture exchange to high-tech options like electronic speech generating devices.
Choosing the right AAC system requires consideration of many factors, including skill set, communication partners, environments, cost, and support. As such, it is important to consult with your speech-language pathologist or assistive technology specialist when selecting an AAC system.
Skill Set
Assistive technology advocates often claim there are no prerequisites to accessing a robust AAC system, but this claim discounts the relationship between an individual’s skill set and their ability to effectively use AAC. Receptive and expressive language skills, motor skills, joint attention skills, and motivation are just a few of the factors that can impact AAC use.
For example, individuals with fine motor difficulties may struggle forming signs, removing pictures from a communication book, or isolating their pointer finger to accurately select a symbol. They may benefit from larger grid sizes, key guards, or adapted picture symbols. Individuals with joint attention difficulties may attempt to communicate without gaining the attention of their communication partner, which can result in unsuccessful communication attempts. They may benefit from an AAC system like picture exchange that requires them to interact with the communication partner.
Understanding the relationship between skill set and AAC requirements can help us select the AAC system that will be easiest for the autistic individual to use. This, in turn, increases the likelihood the AAC system will be used.
Communication Partners
Successful communication is dependent upon both the communicator and the communication partner, which is why it is imperative that primary communication partners are identified and considered when selecting an AAC system.
For example, American Sign Language is cost free and easily accessible by the communicator, but it is not widely understood outside of the deaf community. LAMP Words for Life has a high-tech interface that capitalizes on motor planning, but modeling can be challenging for communication partners. PODD communication books rely heavily on the communication partner to facilitate navigation, which may make PODD most appropriate when there are highly involved stakeholders and/or limited communication partners.
By considering the communication partners, we can select an AAC system that is more likely to be widely adopted and maintained over time and across contexts.
Environments
Home, school, clinic, playground, grocery store, museum, pool…how many environments do you navigate on a regular basis? You can imagine how these environments can impact communication, particularly for autistic individuals who use aided AAC. A child is not likely to carry a bulky device or communication book around on a playground, and it is probably best to keep an expensive electronic system away from the pool. This also demonstrates the importance of continuing to teach nonverbal communication methods even when an individual primarily uses aided Augmented and Alternative Communication.
For example, a student who typically gains peer attention using an electronic device can be taught to tap a peer on the shoulder to gain attention on the playground. It can also be helpful to create low-tech supplements to support communication across environments. Rather than using an electronic device at the pool, you can create and laminate a communication board with vocabulary relevant to that environment.
Although it is important to select a consistent primary method of communication to support efficient acquisition, having back-up options can help to navigate environmental barriers and ensure consistent access to communication.
Cost
High-tech AAC devices can come with a hefty price tag. Fortunately, you can obtain funding for most devices through your insurance provider. Although each insurance provider has their own requirements, some requirements are relatively consistent across payers.
For example, most payers will require an AAC evaluation with device trial and a letter from your service provider recommending the device. If you are considering a high-tech communication device, begin by contacting your insurance provider to determine whether your policy covers speech-generating devices. Share any insurance policies or stipulations with your speech-language pathologist or service provider prior to the AAC assessment.
If insurance funding is not available, work with your speech-language pathologist to explore low- or no-cost options for communication. For example, high-tech AAC system developers may work with you to obtain funding.
Support
Ongoing support is vital to the success of any communication modality. Access to an AAC system alone is not sufficient for acquisition and maintenance of skills. Many autistic individuals receive support from a variety of professionals including educators, speech-language pathologists, occupational therapists, and behavior analysts. Families are also critical sources of support but do not always have the time, money, or knowledge necessary to support AAC use. Stakeholders will need ongoing training in order to support an autistic individual’s AAC use.
Additionally, electronic devices and communication books will need updating, and problems will inevitably arise that require troubleshooting. AAC specialists can work together with families and other service providers to select an AAC system, program vocabulary, improve accessibility, and problem solve.
However, interprofessional collaboration can be challenging due to scheduling, cost, and philosophical differences. If you are working with a team of professionals to support an AAC user, be sure to clearly communicate your preferred method(s) of decision making.
A Note on Ethics
Facilitated Communication, Rapid Prompting Method, and Spelling to Communicate are pseudoscientific communication methods that appear similar to AAC but have no supportive evidence and high risk of harm.
These methods involve the communicator pointing to a letterboard or keyboard while a facilitator or prompter holds the communicator’s arm/shoulder/back or holds the letter board/keyboard. Limited controlled studies on these practices found that spelled messages were always authored by the facilitator and never by the intended communicator. Unfortunately, these pseudoscientific practices have resulted in serious harm to vulnerable individuals and their families, including cases of abuse and false accusations of abuse.
The American Speech-Language-Hearing Association has issued position statements outlining the risk of harm associated with these discredited practices. When selecting a modality, it is important to remember the ethical responsibility to protect vulnerable individuals with diminished autonomy.
Next Steps
Ultimately, the best communication system is the one that will increase autonomy, be easy for the communicator to use, and be used effectively across environments and communication partners. Selecting an AAC system is only the beginning of the journey to effective communication, and the utilization of evidence-based teaching procedures is vital to adoption and implementation across environments.
About the Author
Jean Jarrett is a dually credentialed Speech-Language Pathologist and Board Certified Behavior Analyst. She has specialized in autism, apraxia, and AAC for more than 10 years and is currently pursuing a PhD in Speech and Hearing Sciences at UNC-Chapel Hill.
ASNC’s Clinical Department helps individuals with autism increase independence and improve communication skills. We offer Applied Behavior Analysis (ABA) services through our LifeLong Interventions program. Our ABA treatment promotes meaningful skills and behaviors in the home, school, and community, such as increased communication, improved attention at school or work, self-care, and calming strategies. Rapid Response Clinical Consultation (RRCC) is a statewide short-term telehealth service for children and adults that provides tips and strategies to address communication, behavior intervention, and other needs. We offer Behavior Consultation to help explain why behaviors are occurring, develop comprehensive behavior plans, and coach caregivers on effective strategies. We also deliver workshops and trainings to parents and professionals on a wide range of topics such as strategies to respond to behaviors, best practices in early intervention, and improving communication and social understanding in individuals with autism. You can connect with the Clinical Department by clicking here and filling out our form.
Sources
American Speech-Language-Hearing Association. (2018). Facilitated communication [Position Statement]. Retrieved from www.asha.org/policy/
Beukelman, D. & Mirenda, P. (2013). Augmentative and Alternative Communication: Supporting Children & Adults with Complex Communication Needs 4th Edition. Baltimore: Paul H. Brookes Publishing.
Montee, B. B., Miltenberger, R. G., Wittrock, D., Watkins, N., Rheinberger, A., & Stackhaus, J. (1995). An experimental analysis of facilitated communication. Journal of applied behavior analysis, 28(2), 189–200. https://doi.org/10.1901/jaba.1995.28-189
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