Augmentative and Alternative Communication: A Systematic Approach

When people think about augmentative and alternative communication (AAC), their first thought is often about a speech-generating device. What may follow is anxiety over learning how the device works and what it can do. Some can even feel an overwhelming fear over the perceived responsibility of selecting “the right device.”

I’ve had people contact me, saying that they feel like an expert should handle this. In one recent conversation, I asked, “So what do you know about this person’s communication needs? What about expressive and receptive language?”

There was a pause, and then the SLP I was speaking with repeated that they believed an expert should be involved. They were afraid of making a mistake.

SLPs Are Experts

While I understand looking for assistance in finding a good technology match, the technology shouldn’t take away from the fact that SLPs are experts in understanding people’s language and communication skills.

I can generally get people to a point where they share their clinical impressions with me. Independent of any tests, I ask them questions about who the person in question needs to talk to and what they’ll be talking about, trying to zero in on the most pressing concerns.

Planning a Systematic Approach

The needs of people who require AAC are complex, but complex doesn’t equal incomprehensible. It just means that a systematic approach is needed to unpack what’s happening and to remain organized while gathering information from those who are most involved in the person’s life and familiar with their needs.

1) Identify the person’s current communication needs.

Once you can answer the who, what, where, when, why, and how of a person’s current communication needs, you can ask about their skills. For people who are “beginning communicators,” having some kind of structured observation tool like the Communication Matrix not only helps you identify current skills, but better allows you to categorize which skills are mastered and which are emerging, guiding intervention and narrowing down the list of strategies for AAC systems.

2) Assess available systems.

You’ve identified that the person is ready to make independent selections and build language. Current decision making appears to be centered around visual scene displays leading to literacy and core word systems, emphasizing systematic teaching of frequently occurring words pre-identified on page sets.

Visual scene displays involve “just-in-time programming,” or programming during opportunities as they arise. Images representing action routines, repeating events, or turn-based conversations in context are quickly captured via digital photo or video, and then “hotspots” are created to deliver a meaningful message, allowing for participation in the depicted event. Words or symbols can be added to these displays, and in conjunction with a literacy program designed for people with complex communication needs, a person can transition to using spelling and a predictive keyboard to generate whatever they wish to say.

3) Increase the availability of frequently occurring words.

In core word approaches, clinicians gradually increase the availability of frequently occurring words in a fixed display where words are always in the same location. Core words such as “go” and “more” can be used to participate in a variety of routines, while words such as “I” and “you” can be added to extend phrases into more complex syntax.

Words that are not part of the core set can be added and accessed through other pages of activity-specific words or through system navigation. These fringe words can help personalize a message beyond “I go open” to specific objects.

Generally, a path to literacy is also emphasized for individuals using this kind of approach, but the exact integration is not always clearly stated within premade page sets. There are, however, many resources and ideas for using premade pages in activities.

4) Address the needs of individuals with aphasia.

Individuals with aphasia require a different framework. Fortunately, many existing frameworks are excellent for helping to categorize the type of communicator the person in question is and whether they are more partner-dependent, in transition, independent, or have other specific needs.

5) Accommodate physical access.

Physical access remains a challenging issue for many people with significant physical disabilities. Finding a way to make direct selection work, either through someone’s hands, eyes, head, or even feet, allows a person to directly control the display to their desire.

If no direct selection options are possible, then working with an occupational therapist is important to facilitate finding a site for a switch or other signaling device to access a system via scanning.

Finding ways to help communication partners be effective with the chosen strategies is critical, but does not require extensive technical expertise. Working with children who are moving through either visual scene displays or through core words requires updating and checking that a child is increasing vocabulary, morphology, and syntax skills through pre-made pages or in conjunction with letters and written words.

There are still other considerations for people with specific disabilities and options, including message banking, environmental control access, and integration with mobile technologies. Many resources are available to assist with these directions, including my MedBridge courses.

These are the prizes to keep your eyes on. The technology is a part of it, but you don’t have to get lost in it.