CD 5672Week 2

Augmentative and Alternative Communication Interventions for Individuals with Developmental

Disabilities

Summary of Chapters 9, 10 and 11In Beukelman, , & Miranda, (2005).

Augmentative and alternative communication: Supporting children & adults with complex communication

needs (3rd Ed.) Baltimore, MD: Brookes Publishing.

Ch. 9 AAC ISSUES FOR PEOPLE WITH

DEVELOPMENTAL DISABILITIES

CEREBRAL PALSY Typically used to refer to a developmental neuromotor disorder

that is the result of a nonprogressive abnormality of the developing brain

Describes a group of chronic conditions affecting body movements and muscle coordination, caused by damage to one or more specific areas of the brain, usually occurring during fetal development, or during infancy (can also occur before, during or shortly following birth)

"Cerebral" refers to the brain and "Palsy" to a disorder of movement or posture.

Cerebral palsy is neither progressive nor communicable. It is also not "curable", although education, therapy and applied technology can help persons with cerebral palsy lead productive lives.

Individuals with cerebral palsy usually have a significantly lower life expectancy

Incidence approximately 1 in 500 (varies little across industrialized countries)

Motor ProblemsCharacterized by an inability to fully control

motor function, particularly muscle control and coordination

Vary depending on the location of the brain lesion:Spastic Cerebral Palsy

Diplegia HemiplegiaQuadreplegia

Dyskinetic Cerevral Palsy Dystonic Cerebral PalsyAthetoid Cerebral Palsy Ataxic Cerebral Palsy

Spastic Cerebral Palsy - Most common type, pyramidal (spastic) cerebral palsy, results in hypertonia (increased muscle tone) and occurs in about 50% of all cases

Diplegia - Legs are affected more than the arms

Hemiplegia - One side of the body is primarily affected

Quadreplegia - Diffuse and severe damage affecting all four limbs as well as the trunk and oral-motor structures

Dyskinetic Cerevral Palsy - Characterized by involuntary movements as well as changing patterns of muscle tone across the day (often, spasticity when awake and normal or even decreased tone when asleep)

Dystonic Cerebral Palsy - Involves rigid posturing of the neck and trunk

Athetoid Cerebral Palsy - Marked by the presence of abrupt, involuntary movements of the extremities that result in difficulty regulating movement and maintaining posture

Ataxic Cerebral Palsy - Associated with either increased or decreased muscle tone and causes problems with balance and positioning of the trunk and limbs in space. Individuals with ataxia have a characteristic wide-based, unsteady gait when walking.

Associated ConditionsA number of associated disorders are common in

people with cerebral palsy

½ to 2/3 of all children with cerebral palsy also have some degree of mental retardation

Visual problems may include eye muscle imbalances (e/g., strabismus), visual-perceptual problems, and/or loss of visual acuity (especially farsightedness)

Hearing loss, speech, and language impairments occur in approximately 30% of individual with cerebral palsy, and the underlying brain injury precipitates seizure activity in roughly 40% to 50% of these individuals.

Speech and Communication Disorders

Dysarthria estimated to occur in a significant portion (estimates range from 31% to 88%) of all people with cerebral palsy

Speech problems associated with poor respiratory control as a result of muscular weakness and other factors, laryngeal and velopharyngeal dysfunction, and oral articulation difficulties that result from restricted movement in the oral-facial muscles

Learned Helplessness

Many individuals with cerebral palsy do not have a history of being able to successfully control their environments, placing them at high risk for developing the behaviors and attitudes associated with learned helplessness

Team Approach to InterventionCommunication interventions with individuals who

experience cerebral palsy require the expertise of a team of professionals from a number of disciplines

One study reported that across 64 individuals with cerebral palsy, a total of 17 different types of communication devices were prescribed (i.e., several types of nonelectronic devices such as picture and word boards and 13 types of electronic devices)

About 47% of the individuals were able to use direct selection techniques (i.e., use of a finger)

The remainder used a number of alternative access techniques (i.e., optical pointers, joysticks, and a variety of switches for scanning).

Visual and acuity and visual-perceptual problems will affect decisions regarding the size and figure-ground contrast of the symbol system chosen for communication, and comprehensive assessment by a pediatric ophthalmologist is often required

INTELLECTUAL DISABILITY Only been recognized as appropriate candidates for AAC interventions since

the mid-1980s

Characterized by significant limitations in intellectual functioning and adaptive behavior as expressed in conceptual, social, and practical adaptive skills, originating before age 18

Often the result of complex interactions among multiple causes

Approximately 1 to 3% of the population are identified, but only 1% of students receive special education services

Nature and extent of special education is determined by curriculum-based assessment, behavioral observations, or the evaluation of social skills

Curricula used are similar to those used for students with learning disabilities and emotional behavioral disorders: 1) remedial, 2) general classroom support, and 3) adult outcomes

Students with mental retardation are placed in separate classes 61.1% of the time and are five times less likely to be placed in a regular classroom as are other students with disabilities

Opportunity Factors

When designing communication interventions for people with mental retardation, it is vital to address their lack of naturally occurring communication opportunities. Such opportunities can exist only when responsive communication partners interact in real not artificial, at home, school, and community environments.

Challenging Behavior

Behavior problems do occur in these individuals more often than in people without disabilities for reasons that should be quite obvious - a lack of preferred and functional places to go, people to be with, things to do, and ways to communicate.

AUTISM AND PERVASIVE DEVELOPMENTAL DISORDERSAll of the diagnostic systems commonly used

to describe autism agree that there are three main diagnostic features of the disorder: 1) impairments in social interaction 2) impairments in communication3) restricted, repetitive, and stereotypical patterns of behaviors, interest, and activities.

Although the syndrome is defined in terms of a number of behaviors, it is not a “behavior disorder” but rather a profound social, communicative, and cognitive impairment that is lifelong in nature.

Cognitive Impairments

The question of whether people with autism have mental retardation is impossible to answer because the disorder is so pervasive that it affects virtually every aspect of functioning as measured by standardized intelligence tests.

Approximately 50% of all individuals with autism, however, do function in the same IQ range as individuals with mental retardation throughout life; whether this is a reflection of how we educate and intervene or is inherent in the disorder is less clear.

Social/Language/Communication Impairments

Approximately 50% of people with autism never develop sufficient speech as a means for communication

If speech and language do develop, certain abnormalities are common, including echolalia, repetitiveness, literalness of meaning, monotonous intonation, and idiosyncratic use of words or phrases

People with autism often have language impairments as well, and substantial delays in receptive language ability are not uncommon

Processing Impairments

Underlying the speech/language/communication impairments of autism are a number of developmental and cognitive processing issues that directly affect social and communication interventions.

A number of researchers have demonstrated that the developmental profiles of children with autism, unlike those typically found in children with mental retardation, are characterized by an uneven distribution of skills; this is often referred to as “developmental discontinuity”.

DEVELOPMENTAL APRAXIA OF SPEECH

Developmental apraxia of speech (DAS) AKA: childhood verbal apraxia and childhood dyspraxia, among other terms

Articulation errors accompanied by difficulty with volitional or imitative production of speech sounds and sequences

It is assumed that the speech problems of DAS stem from a motor control impairment that affects the ability to execute and plan motor routines and activities

Often associated with other impairments, including mental retardation and neuromuscular disorders

Co-occur, but not directly related to speech impairments

AAC as a Secondary Strategy

A major concern of parents and others is whether the provision of AAC techniques to individuals with DAS will inhibit their speech…

Not true! Several natural-speech treatment

approaches for DAS incorporate AAC techniques such as gestures in conjunction with speech

Multimodal Communication

Children whose speech is largely unintelligible may benefit from an intervention package that includes AAC techniques

Children with DAS may show evidence of significant language delays that can be traced (at least hypothetically) to their inability to “practice” language in their early years.

Parent Support

Sensitive but systematic parent counseling is often necessary to adequately discuss these issues and to assure family members that the intention is to augment communication in the truest sense of the word rather than to replace speech

It may be useful to have parents visit classrooms where other children are using augmentative communication systems so that they can see for themselves how the system can be integrated into efforts to enhance natural speech

SEVERE AND MULTIPLE DISABILITIES

Two major characteristics:1) Extent of the disability is beyond mild or

moderate levels2) Two or more disabilities occurring

simultaneouslyFive categories of typical characteristics:

1. intellectual functioning2. adaptive behaviors3. physical development4. health care needs5. communication

Causes are unknown for 40% of casesKnown causes: genetic metabolic disorders

Service Delivery Three approaches used to determine the nature and

extent of special education: 1) Developmental2) Ecological3) Behavioral

Most families choose to raise their children with severe and multiple disabilities at home, and increasing friendships and social relationships are issues for these families

Medical and educational personnel, including paraprofessionals and personal care attendants, are needed for these students

The elementary years are a time of stabilization for these children who need specialists who care

Programs for successful adult life have shifted away from facility-based services to support within typical community environments

Ch. 10 AAC STRATEGIES FOR BEGINNING

COMMUNICATORS:

Opportunity and Nonsymbolic Interventions

Young Children: Early Intervention PhilosophyLack of norm-referenced assessment tools that

accurately and meaningfully measure the abilities of children with complex sensory, motor, and speech problems

Important to build on the child’s strengths rather than focusing on the child’s impairments

AAC interventions with young children should operate under the assumption that all children have potential to make significant skill gains

Strategies for supporting development of natural speech and literacy skills should always be included in communication interventions

Early Intervention Services:Adaptive PlayReactivity refers to extent to which the toy “does something”

(e.g., produces sound, sustains movement, creates a visual display)

Young children with severe disabilities engage in longer periods of manipulative play with reactive toys than with nonreactive toys

Many standard movement activities and songs require one or more of the following modifications to be used for communication purposes: 1) simplifying target movements so that the child can participate meaningfully2) slowing the speed of the song/activity3) making directions shorter, simpler, and more repetitive4) simplifying the vocabulary5) pairing words with manual signs6) accompanying movements with sounds or words to encourage speech7) including visual aids or concrete materials for children who do not yet engage in pretend play

SCHOOL-AGE INDIVIDUALS

MAPs : “a collaborative planning process for action that brings together the key actors in a child’s life”, can be used to consider a student’s strengths, lifestyle, and dreams and develop a concrete plan of action for helping the student reach their dreamshttp://challengingbehavior.fmhi.usf.edu/personcentered.htm

Circle of Friends: Interventionists often use the this process in conjunction with MAPs to support the development of friendships among classmates and peershttp://www.ecac-parentcenter.org/packets/friends/index.shtml

PATH: an in-depth, eight-step process for helping people assist a student by solving complex individual, family, or system problems through focused planninghttp://www.arcnm.org/index.php/community/article/31/

Social Networks is based on Circle of Friends model.http://www.connsensebulletin.com/socialnetworks.htmlhttp://

www.augcominc.com/index.cfm/sn-faq.htm

SCHOOL-AGE INDIVIDUALS Cont.

COACH: family members and others are interviewed by a member of the educational team to identify a long-term vision for the student as well as annual educational goals, interventionists identify members of the educational team who will implement the plan, and program content defined to facilitate implementation in general classroom and other settingshttp://www.brookespublishing.com/store/books/giangreco-3238/in

dex.htm

VISTA: picks up where COACH leaves off and provides alternative ways for the student’s educational support team to integrate related services (e.g., speech-language pathology, occupational and/or physical therapy) in general classroomshttp://www.uvm.edu/~mgiangre/related.html

ACE (Analyzing the Communication Environment): identifies ways to encourage communication in activities within the classroom, it targets the properties of specific daily activities rather than the student’s skills; thus, it identifies barriers to communication opportunities rather than what or how to teach the student

Adults The ecological inventory process involves the following:

Observing a peer without disabilities engage in the activity of interestWriting a step-by-step list of the skills requiredAssessing the target individual against the skill inventory to identify

discrepanciesDesigning communication adaptations and instructional programs to

teach compensatory skills

Personal Futures Planning process emphasizes assisting supporters to ‘focus on opportunities for people with severe disabilities to develop personal relationships, have positive roles in community life, increase their control of their own lives, and develop the skills and abilities to achieve these goals”

Steps of Personal Futures Planning 1) “vision plan’ is developed from a group interview of the “focus

person’ and all of the people involved in his or her life (“supporters”) to gather information about past events, relationships, places, preferences, choices, ideas about the future, obstacles, and opportunities

2) the group develops both short-and long-term goals based on the vision plan

3) supporters make commitments of various types and levels to help the individual carry out the plan over time

Adult Intervention PrinciplesThree principles common to both nonsymbolic and

symbolic communication interventions for challenging behavior

1. Functional equivalence: Sometimes, the most appropriate intervention involves teaching the individual an alternative behavior that serves the same function as the problem behavior

2. Efficiency and response effectiveness: People communicate in the most efficient and effective manner available to them at any given point in time

3. Appropriate listening: Sometimes the most appropriate response is to identify the functionof the problem behavior and alter the environment accordingly, rather than to teach an alternative behavior

Building a Communication FoundationThree essential building blocks of

communication:1. Signals for attention-seeking2. Acceptance3. Rejection

Even individuals who have a limited repertoire of gestural or vocal behaviors may be able to communicate these signals.

Attention-Getting SignalsImportant that facilitators be

attuned to attention-seeking behaviors initiated by the individual

Functional Communication Training

http://www.educ.ttu.edu/edsp/burkhartproject/ModuleTwo/Strategies/FCT.htm

http://informahealthcare.com/doi/abs/10.1080/07434610500103467

Accept / Reject SignalsThe basic principles of contingent interpretation and

responsiveness are the corner-stones for building other communicative behaviors, including those signaling acceptance or rejection

http://depts.washington.edu/augcomm/original_modules/module_customizing/custom_vocab_emerge.htm

Interactive Model programs share a number of intervention techniques, which can be summarized as follows:Be child oriented: Respond to the child’s focus of

attention, follow the child’s lead, match the child’s style and abilities, organize the environment to promote communication, and maintain face-to-face interaction with a positive affect

•Promote interaction: Take one turn at a time, wait with anticipation, signal for turns, and decrease directiveness

•Model language: comment on the ongoing activity; use contingent labeling; use repetition and short, simple utterances; and expand or extend the child’s turn

Parent/Facilitator Training Programs

Movement-Based Approach

Scripted Routines

Prelinguistic Milieu Teaching

Gesture Dictionaries

Movement-Based ApproachSystematic method for facilitating the development of communicative signals and

natural gestures: Nurturance: The aim of nurturance is to develop a warm, positive relationship

between the individual with disabilities and the facilitator Resonance: Activities related to resonance are designed to shift the individual’s

attention from him- or herself to the external world of people and objects Coactive Movement: Coactive movement is an extension of resonance with the

basic difference being the amount of physical distance between the facilitator and the individual with disabilities., with the goal to develop sequence and anticipation by gradually building activities that the individual and the facilitator do together

Nonrepresentational Reference: Nonrepresentational reference involves teaching the individual to identify body parts on models that are initially three-dimensional (e.g., a doll, another person) and later, two-dimensional (e.g., a stick figure, a line drawing)

Deferred Imitation: Deferred imitation teaches the individual to imitate movements after the facilitator has completed them, starting with full-body movements (e.g., standing up, sitting down) and proceeding to functional limb and hand movements (e.g., putting on a hat, kicking a ball)

Natural Gestures: The final component of the movement-based approach involves encouraging the individual to produce communicative gestures that are “self-developed”

http://www.projectsalute.net/Learned/Learnedhtml/Definitions.html

Scripted Routines In addition to responding to spontaneous attention-getting,

acceptance, and rejection signals, facilitators can provide structured opportunities for beginning communicators to practice these behaviors in the context of naturally occurring routines.

Five elements, depending on the type of routine and the person’s disability:

1. Touch cue: Information provided in addition to spoken words and should be provided before each step in the routine

2. Verbal cue: A general description of what the facilitator should say while providing the touch cue

3. Pause: After each touch cue and verbal cue pair, the facilitator should pause for 10 - 30 seconds and observe the person for a response

4. Verbal feedback: After the individual’s acceptance signal, verbal feedback in the form of a comment about what the person did and what action the facilitator will do in response should be provided in conjunction with appropriate action

5. Action: For each step in the scripted routine, the facilitator performs an action at the same time as the verbal feedback

http://www.projectsalute.net/Learned/Learnedhtml/TouchCue.html

Prelinguistic Milieu Teaching (PMT)

Purpose: build the first stage of communication, not to make the child talk, leading to developmental milestones, including language

An early intervention method that involves one-on-one services for the child and a program of parent education

Goals: to help a child make frequent, clear requests and comments with gestures and/or sounds, and to look at the person they are communicating with.

Builds motivation and awareness of a communication partner

Children show progress if given specific kinds of supports in an environment that brings out their interests and abilities

"To be able to tell someone -

even in gestures - that you are

hungry is empowering”

Prelinguistic Milieu Teaching (PMT)

Can fill the gap between infancy and age 3 when more intensive early intervention often begins.

Can start as young as 18 months

Helpful in building the child's capacity to initiate communication with clear, frequent acts

http://merrill.ku.edu/IntheKnow/sciencearticles/

PMTintervention.part4.html

Principles of PMT

Follow the child's lead

Set the stage for communication

Use social games like Pat-a-Cake strategically

Gesture DictionariesTo avoid communication breakdowns

Descriptions of the person’s gestures,

along with their meanings and suggestions for appropriate responses, are compiledhttp://www.racgp.org.au/Content/

NavigationMenu/Publications/AustralianFamilyPhys/2004Issues/afp200408/20040803iacono.pdf

Ch. 11 AAC STRATEGIES FOR BEGINNING

COMMUNICATORSSYMBOLIC APPROACHES:

INTRODUCING SYMBOLIC COMMUNICATION

Visual SchedulesA calendar or schedule system represents each

activity in the person’s day with symbols

May serve several purposes:Introduce the individual to the concept of symbolizationProvide an overview of the sequence of activitiesProvide specific information about what will happen nextEase transitions form one activity to the nextServe as one component of a behavioral support plan for

individuals who have a high need for predictability

http://www.specialed.us/autism/structure/str11.htm

Talking Switch Techniques

Facilitators can introduce symbolic communication and provide limited context communication using voice outputhttp://www.pisp.ca/strategies/strategies57.pdf

http://www.pisp.ca/inservice_training/inservice_nonverbal_u.pdf

BIGmack: a small, single-message, batter-powered communication aid that has 20 seconds of memory, with a built-in microswitch that, when activated, plays a recorded message, it is an easy and affordable first step in voice output communication.

http://www.ablenetinc.com/AssistiveTechnology/CommunicationProducts/tabid/56/Default.aspx

Step-by-Step Communicator : can record any number of series of sequential messages up to 75 seconds in total.

http://assistivetech.sf.k12.sd.us/step_by_step_communicator.htm

LITTLE Step-by-Step: Record verses of a song or poem, steps in a recipe or short social scripts to encourage conversational turn taking, each touch of the 2 1/2 inch activation surface plays and advances messages in sequence, or use the message repeat feature to replay one message in the series.

TEACHING BASIC CHOICE MAKING

Choice making occurs when an individual indicates his or her preference from two or more options, either spontaneously or when someone else offers them

People who don’t have preferences find it difficult to make choices - think of the last time you went shopping and couldn’t find anything you really liked!

Types of choice-making:Elicited or “offered” choice: initiated by a facilitator

rather than by the AAC user and involves a restricted array of items from which the AAC user can choose

Requiring the AAC user to initiate the interaction through a generic request such as “want” or “please”, the facilitator then offers a restricted array of items from which the user can choose

Requires the AAC user to both initiate the request and discriminate among symbols to make a choice

Choice-Making Opportunities

People who are learning to make offered choices need frequent, meaningful opportunities to control their environments in this way

The AAC team’s first step in teaching choices is to identify when, where, and by whom choices can be

offered to an individual throughout the day

Choice-Making Items or SymbolsShould employ real, meaningful items (e.g.,

drinks, foods, toys) rather than symbols of those items during choice-making interventions when the concept of “choice” is first being learned

Should incorporate symbols with which theindividual is likely to have the most success.

Err on the side of caution by selecting a more concrete rather than a more abstract type of symbol during the introductory stages of teaching symbol use for choice making

Choice-Making FormatsMake choices simple enough so the person can choose successfully

Consider the individual’s symbolic, yes/no, and receptive object labeling abilities

Choice-Making ArraysFacilitator may:

1. Select two preferred options

2. Opt for one preferred and one nonpreferred option

3. Use one preferred option and a “blank” or “distracter” option for teaching initial choice making

Size of Array

How many options are available at one time.

Usually, initial choice arrays utilize two options, progressing gradually to three, four, and so forth as the individual learns to scan and select from more options

Instructional TechniquesOffer choices using appropriate symbols and then

provide the item selected as feedback

Assessing and teaching symbol comprehension - facilitator offers the person a choice of two preferred items. After the person chooses an item, the facilitator offers two corresponding symbols. A “correct” response occurs if the person selects the symbol that represents the chosen item, whereas an “incorrect” response occurs if the person selects the opposite symbol.

Use a distracter symbol along with one for a preferred item

Natural ConsequencesBeginning communicators need to

experience natural consequences in order to learn, even if this means that sometimes they do not get what they want because they were not paying sufficient attention or failed to weigh the options adequately

Age AppropriatenessWith sufficient exposure and

encouragement from friends and others, most adolescents and adults with disabilities will acquire sensitivity to age-appropriate cultural norms

Due to limited experiences and exposure, to age-appropriate experiences, when presented with unfamiliar options, they may express no interest or may continue to choose options that are age inappropriate

TEACHING BASIC REQUESTINGRelationship to Problem Behavior

Naturalistic Teaching Interventions

Teaching Generalized and Explicit Requesting and Use of an Attention Getting Signal

Picture Exchange Communication System (PECS)

Picture Exchange Communication System (PECS)

A modified applied behavior analysis program designed forearly nonverbal symbolic communication training

Not designed to teach speech, although it is encouraged indirectly

Some children begin to spontaneously use speech while using PECS

Professional training is required in order to implement the program as designed

http://www.bbbautism.com/pecs_contents.htm

TEACHING BASIC REJECTING AND YES/NO

Teaching Basic Rejectinghttp://aac.unl.edu/yaack/d2a.html

Teaching “yes” and “no”http://seab.envmed.rochester.edu/jaba/

articles/2009/jaba-42-02-0209.pdf

Teaching Conversational Skills to Enhance Communicative CompetenceStrategic Instruction Model (SIM)

An approach to reforming classrooms and schools around the goal of increasing content literacy through more strategic approaches to learning and teaching

Key components : Learning Strategies Curriculum to guide teachers in teaching students learning

strategies to help them "learn how to learn" as they develop skill competencies and meet school demands

Content Enhancement Teaching Routines to help teachers ensure that the critical content required for all students to meet standards is mastered during group instruction

Learning strategies and teaching routines have been carefully packaged into instructional materials that provide detailed guidance to teachers and tutors

Support programs have been developed to help teachers, youths, tutors, and parents team and plan in ways that create an environment that promotes a more strategic approach to meeting goals, solving problems, and preparing for the future

Strategic Instruction Model http://www.ku-crl.org/sim/ Adapted Strategic Instruction Model http://www.nichcy.org/Research/EvidenceForEducation/pages/

PowerOfStrategyInstruction.aspx

The End!