Augmentative-alternative communication (AAC) is a quickly growing field. Speech-language pathologists (SLPs) across all settings are finding themselves helping more and more clients who would benefit from AAC. How and where does an SLP start when there is a student on their caseload who may benefit from AAC? This is part 1 in a 3-article series that will provide a foundation for evaluating a student for AAC, incorporating AAC into therapy sessions, and providing training to caregivers and school staff.
Depending on the school system or district, SLPs may have access to an assistive technology (AT) specialist or team who can help out with AAC assessments. Even with this resource, it is helpful for SLPs to have an idea of where to start and what communication systems to trial. This can speed up the process of getting a student a dedicated communication system.
Do they need a communication system for augmentative or alternative reasons?
Some students have some verbal speech, but it may be unintelligible to some communication partners. Some students have some verbal speech, but it is echolalic and scripted, or it is difficult to produce spontaneously. These students may benefit from AAC as an augmentative system, or to support the speech they already have.
Some students are unable to produce verbal speech or have a limited repertoire of speech sounds. These students may benefit from AAC as an alternative system, or something to use in place of verbal speech. Some students use AAC for both augmentative and alternative reasons! This is important information to explain to caregivers and to note in your referral or evaluation. You will need to explain that the student’s current speech and language abilities are not developed enough to communicate their wants and needs or to participate in the classroom.
How and what can they communicate now?
The first thing to consider is how the student is presently communicating. Are they using unconventional communication behaviors, such as body movements or early sounds? Are they beginning to use abstract symbols, such as word approximations or picture symbols? The Communication Matrix is an excellent resource for identifying emerging and mastered skills at a variety of communication levels. You can use this as a starting point because it serves as evidence that the student needs an augmentative and/or alternative communication modality. It also allows you to identify what behaviors need to be shaped into communication that is functional and recognizable to all communication partners.
Consider access and motor skills
Many students are able to use touch access, but some may need to use alternative access methods, such as step scanning or eye gaze. Collaborating with an occupational therapist and physical therapist can help identify fine or gross motor strengths that can be shaped into a movement pattern for communication. OTs and PTs are great at analyzing what movements are voluntary and controlled and can give recommendations about positioning that can help a student access a communication system better.
It is important to have an idea about what access methods you want to try, especially if an AT team or company representative is visiting you to help with trials. You want to make sure that they are aware that an alternative access point may be necessary, so that they bring systems that can be used with those access methods and the appropriate equipment.
Vicki Clarke, an SLP from Dynamic Therapy Associates, Inc, shared some assessment considerations specifically for students who might use eye gaze in a guest post at PrAACtical AAC that are great starting points for clinicians new to AAC assessments and trials. When considering access, I often find it helpful to ask caregivers what they think looks easier for a student, especially if they are able to use two different access methods. It’s also a good idea to trial systems that allow for different access methods, so that if a student’s medical status or motor abilities change drastically, they are able to use the same vocabulary, but can access it differently.
For example, I work with a student who previously used a dynamic display speech-generating device with touch access. Due to a seizure disorder, she began to demonstrate a regression in motor abilities and had difficulties reaching out to touch the device. The school team did an AAC re-evaluation and found that the student was able to use eye gaze to access the same vocabulary.
Try feature matching
All communicators are unique, so not every AAC system is appropriate for every communicator. When assessing for an AAC system, feature matching can be a great start to the journey. Feature matching was coined in the 1990s by Shane and Costello; it's a process where you identify the student’s strengths, skills, and needs, and match them to available systems, tools and strategies.1
When matching features, consider access needs and abilities, vocabulary organization, symbol set, display settings, and the like. For example, a student may be non-ambulatory and unable to produce any vocalizations. You would want to match to a communication system that has speech output, so they’d be able to gain a person’s attention from across the room. You might observe that a student has difficulty selecting icons when the background is white, so you’d want to match to a system that allows you to change the keys’ background colors.
Another student may be able to attend to a large field size of icons and is able to navigate between pages. You’d want to match to a device where you could trial dynamic and static displays. You may work with a student who can read, and a communication system with word prediction could be a good fit for them. Feature matching is a jump-off point for selecting potential systems to trial, and from there you can see what settings (such as display size, dwell time, speech rate, etc.) make it easier or more difficult for the student to use a communication system.
Consider a system that can grow with the student
The research supporting core vocabulary is everywhere nowadays, and many AAC systems now use a core vocabulary approach. This eases the burden of programming and also allows a user to learn words that can be used throughout different communicative environments. It can be helpful to choose an AAC system that uses a robust vocabulary that grows as you increase display size.
Sometimes students have difficulty with a large vocabulary or a dynamic display when they are first learning to use a communication system. As they develop skilled use of their device, they may be able to switch to a larger vocabulary or a dynamic display. If you are able to recommend a system that can grow with a student, you can change to a higher level of vocabulary that includes the words previously learned in the same location or motor plan. Prentke Romich’s Unity, Saltillo’s WordPower and Dynavox’s Snap + Core First are examples of language systems that can grow with a student.
Trial, trial, trial
After you have some ideas of AAC systems that might work for a student, start trialing! Similar to trying on clothes at the mall, you have to observe the student using different communication systems to determine what works and what does not. I like to trial a low-tech manual communication board, a mid-tech speech-generating device, and a high-tech speech-generating device (keep in mind, some of these systems might not be appropriate depending on access methods).
When considering a high-tech speech-generating device, I trial one-hit and sequenced displays, as well as unmasked and masked displays. During device trials, I think about what strategies or prompts helped the student to be successful. For example, did they attend to aided language stimulation and imitate target words on a masked 60-icon sequenced display, but needed maximum prompting to use a display with 84 icons? You may have to switch up displays or icons on the fly during a trial session.
If I notice that a student is having trouble attending to models and locating icons, I may change the display to a high-contrast to see if that improves things. I like to compare how the student was communicating before I and how many times they initiated communication before I introduced a communication system, and with the communication system at the beginning and end of trials.
Keep in mind that it could take anywhere from two to ten to twenty trials before you figure out a system that meets a student where they are but that they can also learn and grow with! I have a student who I tried six different systems with over almost a year-long period before I figured out what was successful for her. It can also take some time for the student to understand what is expected of them. Aided language stimulation (also known as modeling) is an important learning strategy for all AAC users, so make sure that you are showing the student how and what they can communicate before you expect them to try it too.
Provide necessary documentation
This varies depending on whether you submit the documentation to your school system or through insurance, or if an AT team completes the documentation. Ask the school district or company you are working with what their protocol is. You can also explain the pros and cons to families of getting a school-owned dedicated SGD or an insurance-funded one.
If you are going through your school system, there is probably district-specific paperwork to complete. If you are recommending a high-tech SGD and submitting through insurance, you can go on the company’s website and find their funding documents and learn more about the process.
Companies like Prentke Romich and Dynavox provide overviews of the funding process, and company representatives can assist you if you have questions. The more AAC evaluations you complete the easier it will be to compile the paperwork needed for your school system or insurance.
Completing AAC trials and assessments doesn’t have to be hard. You have to examine the student’s abilities and needs from a few different angles and collaborate with other professionals. Whether you are completing the assessment independently or working with an AT team, the tips I have shared will start you off on the right foot!
- Shane, H., & Costello, J. (1994) Augmentative communication assessment and the feature matching process. Mini-seminar presented at the annual convention of the American Speech-Language-Hearing Association, New Orleans, LA.
Check out the rest of the series!
Part 2 - Use of AAC in Therapy Lessons and the Classroom