I know it’s been forever since I posted…and I apologize. I’m currently working on a post about PROMPT and whether it’s EBP or pseudoscience and I suspect I’m avoiding delaying working on it because I’m afraid of what I’ll find.
However, I wanted to post something…and this has been laying rather heavily on my heart lately, so I thought I’d post it here. Go on…click on it, it’s not personal.
Expressive AAC App by Smarty Ears
I read an article recently from Speak for Yourself AAC on The Myth of Augmentative and Alternative Communication (AAC) Pre-Requisite Skills.
The post talks about myths: low cognitive skills, behavior problems, needs to be more verbal…etc. And it really made me think. I’ve had exactly two kids I’ve considered for AAC of any kind here in my current school (going on 7 years – yes, it is utopia, but that’s another post!).
With both of those kids, we implemented PECS. One is now completely verbal and doing great (not even on an IEP anymore). The other moved away halfway through and I’m not sure of the outcome.
Like most school-based SLPs, over the years I have had a few kids that don’t fit nicely into any particular mold…preschoolers who weren’t in a language rich environment and encouraged (okay forced) to communicate to get wants/needs met, or kids with known problems but no label, etc.
I’ve often wondered what criteria I should use before suggesting AAC…and I really hope I’m not the only one who isn’t 100% sure.
When the child comes to me and has a total of 20 words at age 3 – do I automatically consider him an AAC candidate or do I try to teach him language first? If he doesn’t have 200 words after 3 months of therapy do I do it then?
What’s the magic rule? Is there one?
I’m curious what everyone’s views are on this subject.
What things do you look for before questioning whether AAC is something to be considered? For instance, would you consider it for the 3-4 year old who is highly unintelligible or do you wait until school age in hopes of that magical language burst?
What about the kindergarten student with suspected ASD who is highly echolalic and can’t answer yes/no questions with any sort of intent, but the echolalia has some functionality…occasionally? He might be able to say he hurts – but when questioning him, he couldn’t reliably tell you if his head/tooth/ear/stomach hurt. He would benefit from AAC – but is it necessary? How do you, as a school-based SLP, make that pitch to the educational team? What if the parents or caregivers can’t afford it – won’t carry through with it – don’t want it? Then what?
Is AAC something you even consider? What would you start with? I’d really like to hear your thoughts.
Until then…Adventure on!
Mary
Speech Adventures 
When I get those 3 year olds with little language, I always ask two questions: 1. What can we do to meet their immediate communication needs (that is often AAC) and, 2. What can we do to develop language. AAC supports verbal communication and you are rarely wrong to try that avenue.
I completely agree, we need to continue to support and build verbal language and that AAC is a great way to do that.
I’d love to hear what type of AAC you do with the little ones Sharon. Do you do mainly PECS or something else?
Great post, Mary! I have little experience with AAC and even less experience being the one to decide if/when AAC should be implemented in some way. So all I can say is what I’ve seen the Kindergarten students come with from the preschool SLP program (school board SLPs only start seeing children when they start school). It seems that if the child can’t consistently get across basic needs verbally, there is a low tech system started no matter what the diagnosis or prognosis is. So, for your second example, that child would be started on low tech AAC. For your first example, it depends on what the 20 words were–is there a mix of commenting, requesting, protesting? If yes, those children don’t typically come with low tech started. If no, then low tech has usually been started.
But I find that no matter what, the SLPs are including in the discussion with parents that starting AAC is not meant to be a replacement for verbal communication, that it can have the effect of helping push verbal along, as well as decreasing frustration and negative behaviours in the meantime.
Hey Mary, so many questions in one post.
I have always been skeptical of PROMPT but I believe there was a recent RCT that was favourable. I have found from my own experience and talking to colleagues if you do a non- linear phonological analysis and an assessment based on motor hierarchy you end up with the same targets. Interesting ?
PECS – agiain was skeptical but took the training and I truly believe it is EBP as long as you are trained and diligent in application. Also based on no pre- requisites. If you know to walk through a door as opposed to the wall you deminstrate cognitive function. Our instructor was clear Don’t wait, Learn by doing and using. – (with respect),
I don’t believe that we can wait for child struggling to communicate effectively. Sign language works for some based on motor skills and trained communication partners but if visual language supports or VOCAS increase language output or interaction then I think we need to consider as young child learns to use verbal input or to scaffold children who are unintelligible.
I always think of it not as yes/no but more as as it depends based on our clinical judgement.
[Big disclaimer for those other than Mary (she knows) – I’m not an SLP, but it’s my job to support them]
I’ve learned a TON from the AAC and AT folks as I’ve worked with them for ATIA, CTG, GATE, etc. but the most important things are these:
1) When working in early childhood, choosing to implement AAC is almost never an alternative to learning spoken language. It’s a tool that is used to introduce and support the concept of language, provide a means of expression (which often improves behavior) and teach core vocabulary. It speeds, not hinders spoken language.
2) Far too few SLPs are well-versed in AAC – even the low-tech or no-tech varieties. I’ve heard many treat it like a failure: that they’re “not ready to give up on talking.” This is entirely the wrong approach. Tools like communication boards and systems like PECS or even signing allow you to teach expressive and receptive language skills, even when the child’s speech isn’t sufficient to do so. The earlier this language is cultivated, the better the long-term outcome.
3) Your AT staff is not capable of supporting you. God bless the AT team, but in almost every case when I meet with them (and I do fairly often because they evaluate LessonPix), it’s 4 wonderful ATPs (or SLP/OTs) in a frikkin’ closet full of dusty devices, trying to support 200 SLPs and 800 SPED teachers in the district. I mean, I have REPEATEDLY given demos to AT teams where there was no projector or tv and the team huddled around my laptop in their closet. Given the amazing things they can do for people, it’s kind of offensive how poorly they’re treated. Ask them for help – but realize they will take forever to get back to you and you can do a great deal on your own.
I’m going to add a quick anecdote (because I like to talk): Lori (SPED Pre-K) had a kiddo last year who had zero pragmatic language at 4yo. He could articulate (and exhibited echolalia), but had no requesting, no expression at all. His (wonderful) SLP worked on PECS and other techniques with him with no success. When we went to ATIA in January of last year, we attended the EdCamp Access International – an UnConference after the main event). We met with Karen Janowski, Mike Marrota all the folks who meet on the #ATChat.
Vicki Haddix from Boston told Lori, “Start with two little buttons – make one something he enjoys (Lori chose ‘Tickle Me’) and make the other one ‘Go Away’. Make all the teachers and staff honor both of those requests and go from there.” Joe Volp from Ablenet sent me a set of their Talking Brix (https://www.youtube.com/watch?v=4Jt8frWIgJw knowing the vendors has benefits 🙂 and we printed pictures for them from LessonPix (we have a template for them).
It was amazing. He “got it” right away, thought it was a riot to tell people to go away and that they’d do it and within weeks was using those two phrases in context verbally. It “kicked off” his language, Lori graduated him to a device with more options, and they had great success through the end of school in May. Would he have had that burst anyway? Probably, but the AAC was an effective catalyst.
In short, I think there are lots of ways AAC can help you without having to make a decision to “go the AAC route” instead of speech. But you shouldn’t trust me: trust those I have learned from. Here are my go-to AAC resources:
#1 – (MOST important) @PrAACticalAAC (Carole Zangari) at Nova Southeastern has an amazing blog with the largest collection of “known good” AAC solutions http://praacticalaac.org/
#2 – Join the #ATChat Wednesday nights on Twitter – even if the topics are not around AAC every week, the folks there ARE the experts in this space. @KarenJan runs the joint and is wonderful.
#3 – Jane Odom from PRC runs the AAC Language Lab. There is lots of stuff that is PRC-specific, but lots more that’s just good info about AAC. The blog in particular is helpful https://aaclanguagelab.com/blog
#4 – Go to the AT Conferences – Closing the Gap is near you and coming up quick! The attendees raved about the sessions there and it’s an inspiring conference overall. ATIA is not near you (it’s in Orlando in January though, and you live in the tundra—so, there’s that), but it’s also great and it hosts the EdCamp Access “unconference” which was incredibly helpful.
Anyway, sorry to spam your blog, but I thought I had something that might help! Adventure on!
Bill
Love it Bill. I completely agree, AAC is in addition to, not instead of speech for the majority of people. Yes, there are some that truly are not going to be able to verbalize, but for most pre-schoolers that’s not the issue.
For me, it’s hard to know HOW to get started. How to explain it to resistant teachers and parents that it’s a good thing to help build that bridge to language.
In this case…thanks for the spam. You had great insight and wonderful information. 🙂
You spoke for me, Mary!! My small districts don’t have AT teams. I am a lone SLP…it’s so difficult trying to muddle along with regards to AAC. I’ll take Bill up on all his advice. Another great post.
Thanks! It’s hard when you’re the lone SLP and have no one to bounce ideas off of in real time. Some days I really wish there was someone I could say – go LOOK at this kid – tell me what to do.
Bill has some great ideas – and it helps that Lori is a SPED teacher and KNOWS what the kids need to. In my district, my SPED teacher is good – but we have never used AAC for anyone so there’s no experience with the benefits that can happen with it…and therefore a natural resistance.