AAC With Energy—Earlier Research shows that children with communication challenges do best when introduced to augmentative and alternative communication as early as 12 months. Features
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Features  |   January 01, 2017
AAC With Energy—Earlier
Author Notes
  • Beth E. Davidoff, MS, CCC-SLP, is an instructor in the Communication Disorders and Sciences Department at William Paterson University in New Jersey and a doctoral candidate in communication sciences and disorders at Pennsylvania State University. She has worked in the area of complex communication needs for more than 20 years. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education; 10, Issues in Higher Education; 12, Augmentative and Alternative Communication; and 14, Cultural and Linguistic Diversity. beth.breakstone@gmail.com
    Beth E. Davidoff, MS, CCC-SLP, is an instructor in the Communication Disorders and Sciences Department at William Paterson University in New Jersey and a doctoral candidate in communication sciences and disorders at Pennsylvania State University. She has worked in the area of complex communication needs for more than 20 years. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education; 10, Issues in Higher Education; 12, Augmentative and Alternative Communication; and 14, Cultural and Linguistic Diversity. beth.breakstone@gmail.com×
Article Information
Augmentative & Alternative Communication / Features
Features   |   January 01, 2017
AAC With Energy—Earlier
The ASHA Leader, January 2017, Vol. 22, 48-53. doi:10.1044/leader.FTR2.22012017.48
The ASHA Leader, January 2017, Vol. 22, 48-53. doi:10.1044/leader.FTR2.22012017.48
It’s one of the most unforgettable parts of parenthood: that moment when, about a year after a baby is born, a baby’s first word is born. The babbling baby’s been practicing for months. And now suddenly the babbling takes on a form parents recognize: Joy lights up their faces as they realize they’ll soon be talking back and forth with their child.
By the time typically developing children enter preschool, they understand thousands of words and a variety of sentence types. Their sentences are well-formed and complex. What happens in these three short years is nothing short of miraculous.
In contrast, some infants and toddlers face challenges to their development because of neuromotor, cognitive, genetic, sensory, social/communicative and other disabilities. Babbling may be slow to develop, and there may be severe delays in learning to talk. If and when speech develops, it may be difficult to understand.
For these young children with complex communication needs, augmentative and alternative communication (AAC) devices and strategies can be key to their development of language, literacy, and communication and cognitive skills. The earlier AAC is incorporated into their lives, the greater the potential for improving their outcomes.
Now imagine the joy on parents’ faces when their toddler looks at a photo of bubbles on a computer, then at mommy, and—using an AAC device programmed by early interventionists—says for the very first time, “Mommy, blow bubbles.”
Reaching such a point requires a combination of AAC strategies and early intervention. Unfortunately, some research (which we will explore further) indicates that many children with complex communication needs are not introduced to AAC until after the critical 12- to 24-month window. So how do we work to introduce AAC earlier? We need to identify the characteristics of these beginning communicators more quickly and match their particular needs to the right kind of AAC technology. Let’s take a closer look at what’s involved.

We need to more quickly identify the characteristics of beginning communicators and match their particular needs to the right kind of AAC technology.

Earlier is best
Of course, early intervention is not only critical to the development of at-risk children, it is also a federal mandate for those who qualify. The Individuals With Disabilities Education Act (IDEA) Part C (2004) requires that appropriate early-intervention services are available to all eligible infants and toddlers with disabilities and their families. In 2014, for example, 350,581 infants and toddlers received early intervention services through IDEA Part C, according to the U.S. Department of Education. That figure represents an increase of more than 11,000 infants and toddlers from the previous year. Audiologists, speech-language pathologists, early interventionists, occupational therapists and physical therapists are often involved in providing such services.
IDEA Part C also mandates that, as necessary, infants and toddlers with a disability use assistive technology devices and services. Such a device is defined as “any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve the functional capacities of an infant or toddler with a disability.” AAC devices are included in this category.
AAC provides a set of tools to help infants and toddlers communicate their wants and needs, ideas, thoughts, and feelings to the most important people in their lives: their family members. AAC can be unaided (vocalizations, facial expressions, body movements including gestures, and manual signs) as well as aided (no-tech systems including objects, photos, pictures and graphic symbols, words, communication boards, and books; low- to mid-tech systems with recorded speech output; and high-tech electronic systems with speech-generation capability, such as computers, tablets and other mobile devices). People who require AAC often use multiple modalities for communication.
Determining what type of AAC device or strategy best meets the needs of an infant or toddler involves understanding the child’s motor, sensory, cognitive, linguistic and social communication abilities, and matching these to the features of a particular AAC system. There is no one-size-fits-all AAC system. To be most effective, AAC devices must be customized to the individual needs of the infant or toddler. For infants and toddlers with complex communication needs, AAC devices and strategies are tools to help develop communication, language, literacy, play and cognitive abilities.
Infants and toddlers with complex communication needs are beginning communicators: They have an expressive vocabulary of fewer than 50 words or symbols. This 50-symbol milestone is important because it marks progress across these three stages:
  • Pre-intentional, pre-symbolic communication—using the voice, physical movements and facial expressions to signal physiological states to caregivers.

  • Intentional, pre-symbolic communication—using the voice and physical movements including gestures and facial expressions.

  • Intentional, symbolic communication—using word/sign approximations, words/signs, photos, picture symbols, printed words and/or letters.

For example, when singing “Old McDonald” with the infant or toddler who is an intentional, pre-symbolic communicator, we can use a Little Step-by-Step voice output communication aid topped with a photo of a farm toy and programmed to speak the animal names and sounds: “cow…moo,” “horse…neigh,” “sheep…baa,” “pig…oink,” each time the caregiver pauses to let the child take a turn to “sing along.” A little later, to help promote development of symbolic communication, we can use the manual signs for the animal names (unaided symbols) while pointing to the plastic animals (aided symbols) to represent the words cow, horse, sheep and pig. This can then transition to photos of the farm and plastic animals that are used with a multi-message voice output communication aid.
Sign to me, baby!
Gestures are a natural part of early language acquisition for typically developing infants and toddlers. Babies reach, show and point as they transition to intentional communication. So, teaching manual signs to babies and toddlers with disabilities is a natural first AAC choice. Manual signs offer a number of advantages: They are always available and cannot be left behind or lost, they’re often iconic (resembling their referents), and they’re portable. Aided communication, conversely, can be quite cumbersome.
On the other hand (pun intended!), using manual signs alone can have disadvantages: They involve fine-motor skills, and young children with disabilities often have motor difficulties. As a result, signs may have to be modified. Also, infants and toddlers may have problems recalling the signs, particularly when they require combining symbols.
And it isn’t enough for the baby to learn how to form the signs. Communication partners also need to know how to use and understand them. If they don’t, the child’s progress in communication interactions can be impeded. So, communication partners can combine the child’s production of standard or modified manual signs with aided AAC to augment their vocalizations and speech approximations. Communication partners can use speech, manual signs and aided AAC, as well.
When designing an AAC system for an infant or toddler, it is wise to add vocabulary frequently, so that children can approach and surpass that 50-symbol mark; plan for the child to combine symbols. But how do you choose the appropriate vocabulary for infants or toddlers? One option is administering a parent vocabulary checklist such as the MacArthur-Bates Communicative Development Inventory—Words and Gesture form (MCDI-WG). Caregivers indicate which of 396 vocabulary words, signs or symbols the child understands or understands and says. Another method is the Vocabulary Selection Questionnaire (see sources) for preschoolers who use AAC, which can be adapted for use with infants and toddlers.
As part of providing services that are family-centered and culturally and linguistically responsive, always select vocabulary in collaboration with the child’s caregivers and others who know the child well, incorporating the language and cultural background of the family. Also record messages for voice output devices in the primary language of the child and family. Then get ready to actively infuse communication in the child’s natural environments, daily routines, mealtimes, caregiving, social and toy play, stories, songs, and play outdoors.
Once vocabulary is selected for a particular routine or activity, building the child’s receptive language becomes a priority for beginning communicators. Parents can model use of words in routines without expecting the child to produce the words. By hearing parents say the words and use unaided and/or aided symbols with voice output from an AAC device, the child begins to associate the spoken and visual symbols with the concepts. This crucial step of building understanding of symbols is often a missing link and is rarely targeted in intervention research, according to a recent literature review by Martha E. Snell and colleagues.

When designing an AAC system for an infant or toddler, it is wise to add vocabulary frequently, so that children can approach and surpass that 50-symbol mark.

Active AAC
Children and their caregivers benefit when early interventionists support and empower caregivers’ active use of AAC with children. This means coaching parents to use multiple communication options: talking, signing and pointing to photos or pictures on an AAC device while interacting in fun and meaningful ways with children. Siblings and grandparents can join in, too.
As a result of this aided language modeling, parents slow their rate of speech, highlight important words, model visual symbols, and make language processing easier for their children. The approach also gives the child an input model that is consistent with their expected output model, which is one of the main ways children learn language.
Some AAC intervention approaches focus on developing requesting abilities. Infants and toddlers are taught to manually sign, activate an AAC device, and/or select a symbol to express a want or a need. Although this is an important early skill, it’s only one of many reasons we communicate. Other important early communication goals highlighted in the book “Exemplary Practices for Beginning Communicators,” co-edited by Janice Light, include:
  • Developing social closeness by engaging in social interactions and routines, playing and reading books, and making friends.

  • Obtaining information from and providing information to others, commenting, and sharing attention.

  • Fulfilling social etiquette routines by greeting others, being polite and taking turns.

About those screens…
Also playing a larger role in AAC is the explosion in mobile technology. Although this technology is in many ways a positive development, children may get too “tuned in” to phones and tablets, and forego interactions with others. The American Academy of Pediatrics recently issued a policy statement urging pediatricians and families to restrict media use in children younger than 18 to 24 months. For children ages 18 to 24 months, the academy advises “high quality” media use only with parent interaction.
The danger of communication and play “apps” is focusing on the technology more than on the child and communicative interaction. The U.S. Department of Education recently published recommendations advising families of children younger than 24 months to limit media use, suggesting that “technology can be used in active ways that promote relationship development,” and that caregivers co-view technology with children older than 18 months.
These recommendations do, however, take into account that infants and toddlers with disabilities may require technology to meet their developmental outcomes. Families want guidance in selecting the most appropriate technology for these children and learning how to promote and expand communication.
Another development in AAC research and practice is the visual scene display (VSD)—a design reflecting the way young children with complex communication needs organize information (see sources). VSDs use pictures or photos of people and events that are meaningful, familiar and engaging to the young child and caregivers. Messages are embedded in pictured items using “hotspots.” For example, on a VSD showing a photograph of a child and father playing a tickling game, the message, “I’m gonna tickle you!” can be programmed in the hotspot on the father’s hands. The message “more tickles” can be programmed in the hotspot on the child’s body. When a child selects a hotspot, the device speaks the message out loud.
In an article published this year in the Journal of Developmental and Physical Disabilities, Ralf W. Schlosser and colleagues espouse capturing “teachable moments” as they naturally occur. New advances in “just-in-time” technology for tablets enable programming of VSDs and messages in real time. To illustrate using the father-child tickling scene, if the child suddenly indicates that he wants his father to tickle his feet, tummy and neck, these new messages can be programmed on the spot to capture the child’s interest as it is occurring. Because the devices are lightweight and images are clear and meaningful, the technology can be used with babies as young as 6 months old.

The danger of communication and play “apps” is focusing on the technology more than on the child and communicative interaction.

A call to action
Although research clearly shows that AAC is effective in developing functional communication for infants and toddlers with complex communication needs, studies have shown that AAC is underused in early intervention. For instance, in a study by Lauren M. Dugan and colleagues (published in 2006 in Topics in Early Childhood Special Education), early-intervention providers reported that they focused on teaching “skill development” (such as vocalizing or signing) to toddlers 12 to 24 months and would not introduce low- or high-tech AAC devices.
Even when working with toddlers older than 24 months, more than a third of providers focused on skill development, while 55 percent chose low-tech devices (Big Mack or Cheap Talk). Only 8 percent chose high-tech devices (such as Tech Speak). Similar AAC underuse was reported in 2010 and 2011 research (see sources), even though caregivers reported that their children’s communication issues hampered their participation in daily routines. The researchers believe this may be partially due to EI providers’ receiving limited training about AAC.
Similarly, Katherine C. Hustad and colleagues found in 2014 that 2-year-olds with cerebral palsy who were emerging talkers were less likely to use AAC than were children who were not yet talking. Hustad has expressed concerns about bias against providing AAC services to children who have any speech, despite that speech being highly unintelligible.
What we’re seeing is that, although it is federally mandated that infants and toddlers with disabilities receive AAC intervention if they are eligible and it is appropriate, many are not receiving this intervention. Pre-professional training and ongoing continuing education in AAC are desperately needed for early-intervention providers across disciplines. Ongoing research must continue.
Fast-forward to the future, when AAC options are not only considered in early intervention, but are implemented as soon as infants or toddlers with special needs are identified as AAC candidates, so that they quickly benefit from its support of speech, language and literacy development. Then caregivers and early interventionists work hand-in-hand to ensure that all young children with complex communication needs learn, play and talk to their maximum potential.
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FROM THIS ISSUE
January 2017
Volume 22, Issue 1