Augmentative and Alternative Communication (AAC)
What is augmentative and alternative communication?
Some students have limited expressive communication, meaning they are not able to adequately verbally communicate to meet a variety of needs (e.g., requesting, protesting, commenting, responding to questions). These children often benefit from availability of augmentative and alternative communication (AAC) systems. The American Speech-Language-Hearing Association defines AAC as “all forms of communication (other than oral speech) that are used to express thoughts, needs, wants, and ideas. We all use AAC when we make facial expressions or gestures, use symbols of pictures, or write.” This includes unaided communication systems that utilize the communicator’s own body (e.g., sign language, eye gaze, gestures, facial expressions), and aided communication systems that utilize additional materials or equipment to augment communication. Although AAC is often thought of as service an “augmenting” or as an “alternative” to spoken language, it also can be used to support comprehension of verbal (spoken or written) directions. For example, visual schedules, first-then schedules, and graphic organizers for story grammar are all examples of AAC. In short—AAC can support both expressive and receptive language/communication. Below, we will focus primarily on the use of aided communication systems in homes and preschool classrooms. Some examples of aided communication systems, listed from low tech to high tech, include:
- Picture exchange communication systems (PECS)
- Homemade binders or books of picture symbols
- Recorded speech devices (GoTalk Communication Aid, BIGmack Communicator)
- Electronic tablet speech application (e.g., programs like ProLoQuo2Go for devices like iPads, Lenova Tabs, or Dell Venues)
- Speech generating devices, referred to as “durable medical equipment” (DME) for private and public health insurance (e.g., Dynavox, Accent™)
How do I decide which AAC device is appropriate for the child?
When deciding which AAC decide to use, consider the following:
- Child’s current cognitive, visual, and fine motor abilities. The child should be able to access the device given her current abilities and level development. For children with limited fine motor abilities, a 2×1 picture grid with large pictures may be appropriate. For children with vision impairments, icons may need to be modified (e.g., made larger, put against contrasting backgrounds). For children who are blind, you might consider tactile symbols. For children who have difficulty discriminating between multiple items, children may require explicit discrimination training, and teachers may consider starting with two icons.
- Consistent availability of the device. To be an effective means of communication, the AAC device should be available to the child at all times. For example, if a child moves from place to place or teacher to teacher frequently, you might consider AAC devices that can be attached to his person (e.g., communication bracelet). For a child who spends a large portion of his day in a wheelchair or stander, be sure to consult a physical therapist and occupational therapist to determine the most appropriate access method and possible mounting systems.
- Collaborative decision-making.Teams of adults who regularly interact with the child (i.e., teachers, parents, speech pathologists, and other professionals) should collaboratively determine how AAC might improve communication for a specific child. Because AAC devices should be used consistently across the day (e.g., during all school activities, in-home routines, and in the community), agreement among all team members is important. In much the same way that young children with typical development receive consistent help in developing verbal communication (e.g., many adults who model and respond to verbal language), AAC users need support from communication partners who understand the importance of AAC and are willing to support its use.
How should my team decide what to teach first?
Like children who communicate orally, children using AAC devices typically start by requesting highly preferred items or activities. Before they learn to use AAC devices or other communication methods, children with limited communication abilities often find other ways to communicate their needs and desires. In some cases, they may use non-verbal cues and gestures to indicate desires, including pointing, reaching toward, eye gaze, whining when preferred items are taken away, or smiling or laughing when preferred items are presented. In other cases, they may engage in challenging behavior like hitting, kicking, tantrums, or self-injury to get access to preferred items or activities.
Begin by observing the child, and identifying 2-3 items and activities that he is already requesting in non-verbal ways. These should be highly preferred by the child, such that he will be very motivated to request them with the AAC device. For example, if your child consistently reaches for more food when he finishes what’s on his plate, you might start with a “food” icon. If he whines or cries when toys fall off his wheelchair tabletop, you might start with a “toy” or “I want that back” icon. If he hits and kicks when required to sit down for circle time, you might start with a “break” icon.
If the child engages in challenging behavior, and you’re not sure what he is trying to communicate, see the Challenging Behavior as Communication section to learn how to take antecedent-behavior-consequence data. If you need help determining the child’s most highly preferred items, see the Preference Assessment section. Once you have identified 2-3 highly preferred items or activities and have created the appropriate materials for them (i.e., laminated pictures, programmed them into an iPad application), you are ready to begin systematic instruction of the AAC device.
How do I teach the child to use the AAC device?
Like most adults, young children may not initially understand how AAC devices work. Thus, adults will need to prompt correct use of the device (see Progressive Time Delay and System of Least Prompts) and reinforce correct responding (even if it is prompted) so that the child learns that the device allows them to communicate. Here are some tips to get you started:
- Model, model, model! In the video above, you’ll see that the child is making choices with a high-tech AAC device, and you’ll also notice that the teacher is modeling use of the device. When a child uses AAC, all relevant adults should also model communication on the AAC device (much the same way that we model verbal language for children learning to talk!) Even after a child becomes proficient on the AAC device, it is appropriate for adults to continue modeling new concepts and vocabulary. Always model at the same complexity as the child communicates, or slightly above. For example, if a child consistently communicates with a single icon (e.g., “cookie”), use models with 1-2 icons (“cookie” or “want cookie”).
- Respond to all AAC communication promptly, appropriately, and consistently. Whether the child communicates independently or you have prompted the child to communicate, respond to the communication right away by providing the requested item/activity or responding verbally in an appropriate manner. Even if the child requests low-preferred item/activity that you don’t think was an intended request, provide the correct consequence, such that the child can learn that certain icons lead promptly to consistent consequences.
- When the child engages in requesting behaviors, prompt her to use the AAC device. If the child uses gestures or body language to indicate that she wants an item or activity, immediately prompt the child to request the item using her AAC device, and then immediately respond to the prompted communication. For example, if the child is reaching toward a toy that is out of reach, you might prompt her to press the “toy” icon on her iPad and give her the toy. Initially, you may need to use more intrusive prompts (e.g., hand-over-hand physical prompting). As the child begins mastering use of the AAC device, you might shift to less intrusive prompts (e.g., model prompts or gestural prompts).
- When the child engages in challenging behaviors, wait for the behavior to stop, and then prompt her to use the AAC device. To prevent the child from learning that problem behavior results in access to desired items or activities, it is important to keep the child safe and wait for the challenging behavior to cease before prompting the child to use the AAC device. Once the child’s body has been calm for several seconds, you can prompt the child to request via the AAC device whatever she was trying to access. If possible, when you think a child may want a specific item or activity, you might provide a prompt or reminder to use the device before he or she engages in problem behavior.
- Make sure that the AAC device is consistently available, within and across settings. Initially, this may mean that teachers, parents, and other adults are responsible for ensuring the AAC is always near the child. Eventually, we want to teach the child to advocate for continuous access.
- Set up opportunities to teach use of the AAC device, by scheduling daily practice sessions and by embedding opportunities throughout the day. Although your team and the child should aim to use the AAC at naturally occurring instances throughout the day, it is also important to intentionally set up opportunities for the child to practice using the device with your assistance. For example, you might set a goal in free play to temporarily remove the target child’s toy five times, in order to prompt him or allow him to independently request the toy back. See below how these teachers conduct a daily practice session to teach the child how to use the AAC device, using a Progressive Time Delay prompting procedure.
7. Teach peers how to use the AAC device. If possible, give peers their own AAC devices. One of the many benefits using an AAC device is allowing children access to communicate and develop friendships with their peers. Although your child’s peers may be interested in or curious about her AAC device, it is unlikely that peers will learn to use AAC devices fluently without explicit instruction. You can use direct instruction procedures (e.g., Progressive Time Delay, Graduated Guidance) to teach peers to:
- respond to the child’s AAC communication by bringing requested items and/or responding verbally
- use the AAC device to communicate with the child
- use the AAC device to communicate with teachers and other peers, and
- help the child get or advocate for his device by bringing the AAC device to the child, helping him protest AAC removal or inaccessibility, or letting a teacher know if his AAC device is ever out of reach.
If it’s feasible, consider making AAC devices for all children in your classroom. For example, peers might use “my turn” icons during free play or exchange “more food” icons during snack or lunch time. Teaching the child’s peers to use AAC devices will not only provide the target child more opportunities to communicate with peers, but it will also provide more frequent models to show the child how to appropriate use AAC devices.
Watch the two videos below to see how an instructor used direct instruction to teach a child to respond to her peer’s AAC requests.
Where can I find additional information regarding AAC usage and devices?
- PrAACtical AAC
- Penn State AAC
- American Speech-Language-Hearing Association
- Augmentative and Alternative Communication Institute
- International Society for Augmentative and Alternative Communication
- State Assistive Technology Programs
- Binger, C., & Light, J. (2007). The effect of aided AAC modeling on the expression of multi-symbol messages by preschoolers who use AAC. Augmentative and Alternative Communication, 23(1), 30–43. http://doi.org/10.1080/07434610600807470
- Ganz, J. B., Earles-vollrath, T. L., Heath, A. K., Parker, R. I., Rispoli, M. J., & Duran, J. B. (2012). A Meta-Analysis of Single Case Research Studies on Aided Augmentative and Alternative Communication Systems with Individuals with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders, 42(1), 60–74.
- Kasari, C., Kaiser, A., Goods, K., Nietfeld, J., Mathy, P., Landa, R., … Almirall, D. (2014). Communication Interventions for Minimally Verbal Children With Autism: A Sequential Multiple Assignment Randomized Trial. Journal of the American Academy of Child & Adolescent Psychiatry, 53(6), 635–646. http://doi.org/10.1016/j.jaac.2014.01.019
- Romski, M., Sevcik, R. A., Adamson, L. B., Cheslock, M., Smith, A., Barker, R. M., & Bakeman, R. (2010). Randomized comparison of augmented and non-augmented language interventions for toddlers with developmental delays and their parents. Journal of Speech, Language, and Hearing Research, 53(2), 350–364.
- Schlosser, R. W., & Wendt, O. (2008). Effects of Augmentative and Alternative Communication Intervention on Speech Production in Children With Autism: A Systematic Review. American Journal of Speech-Language Pathology, 17(3), 212. http://doi.org/10.1044/1058-0360(2008/021)
- Wright, C. A., Kaiser, A. P., Reikowsky, D. I., & Roberts, M. Y. (2013). Effects of a Naturalistic Sign Intervention on Expressive Language of Toddlers With Down Syndrome. Journal of Speech, Language and Hearing Research (Online), 56(3), 994–1008.
- Yoder, P., & Stone, W. L. (2006). A Randomized Comparison of the Effect of Two Prelinguistic Communication Interventions on the Acquisition of Spoken Communication in Preschoolers With ASD. Journal of Speech Language and Hearing Research, 49(4), 698. http://doi.org/10.1044/1092-4388(2006/051)
To cite this page (APA 6th edition):
- Chazin, K. T., Quinn, E. D. & Ledford, J. R. (2016). Augmentative and alternative communication (AAC). In Evidence-based instructional practices for young children with autism and other disabilities. Retrieved from http://ebip.vkcsites.org/augmentative-and-alternative-communication