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How augmentative and alternative communication can help those who struggle with speech to talk

Most of us take speech for granted. We can open our mouths and say what we want, where we want and how we want. People who use augmentative and alternative communication (AAC) do not have the same freedom of speech that we have. Often, they may be reliant on others to act as a communication partner, to position equipment, to charge equipment and to program in the words the AAC speaker wants or needs.

There is a wide range of technology available to give people who use AAC a voice. This article is not intended to tell you about all the equipment and software available, but to give you ideas for using voice output communication aids (VOCAs) and how we can make the technology meet our AAC speakers’ needs.

The individual has to be able to use AAC with a minimum of physical effort. This may mean that using their hands might not be the most efficient means of access.

How can people who use AAC access technology?

This is the first question to consider when thinking about introducing technology to someone who uses AAC. A wide range of switches is available and it is not just about whether or not an individual can use his/her hands to press a switch; it is also about how s/he uses them. If the individual can only make a big sweeping or “windmilling” movement with his/her arm, there may be other ways of accessing technology that will be faster and less tiring.

With hand switches, it is important to ensure that switches are placed in the best position for the individual. A switch may be located flat on a wheelchair tray or table. If the AAC speaker finds it difficult to release the switch, though, it may be easier to put it on an angled wedge. This means that the AAC speaker does not have to lift his/her hand on and off the switch but can push it and release it by sliding his/her hand away from it. This can be a big help for the individual who can slide his/her hand over a tray or table to push a switch which is in front or to the side.

Switches and interfaces can be mounted in many different ways.Switches can be positioned wherever the AAC speaker has most control, such as close to his/her hand, head, arm or foot. It is important for most users to have clear auditory feedback to let them know when the switch has been pressed.

If the individual cannot use a mouse, a joystick or rollerball might be more effective, and some have speed controls to make it easier to reach large or small targets.

When thinking about a switch, it is important to consider how it will be mounted so that it is always in the same place for the user. It makes things harder and potentially more frustrating for the user if the switch is not placed correctly each time. There are commercially available mounting systems and there are organisations which specialise in making bespoke systems. Local clinicians and rehabilitation engineers may also be able to help with this.

The issue of whether to use one or two switches is often the subject of much discussion in AAC circles. The use of two switches gives the individual control of the scanning cursor so that it only moves when the user presses a switch.  Single switch auto-scanning is a much more advanced skill that two-switch users sometimes progress on to. However, for some individuals who only have one controllable movement, a single switch autoscan may be the most appropriate means of access.

Another option that is becoming increasingly popular is eye-gaze. While this is extremely popular technology, it does have drawbacks; it can be extremely hard work learning to use an eye-gaze system.

Some companies are now installing eye-gaze systems for sensory rooms in schools for children with severe and profound learning difficulties, which is not a client group that has traditionally used eye-gaze. This is proving to be a useful tool in developing an understanding of cause and effect and facilitating the child’s control of his/her environment.

Others who use eye-gaze may be using it in the classroom for writing, drawing, playing games and for accessing the internet, as well as for communicating. The biggest drawback is the fact that eye-gaze does not work terribly well outside, so having an alternative means of access to technology, and a communication book or chart, will give the child a means of communication wherever they are.

What to do with a VOCA

There are lots of games and activities that can be played using VOCAs as an introduction to using them for communication. For example, a single-message device could have the message “turn the page” recorded on it for story-book reading. The repeated lines of stories or songs can be recorded. Messages can travel between home and school (recorded in the first person). With two single-message devices or a device that allows two messages to be set up, the child can, for example, indicate “more” and “finished”, call someone and ask them to do something or play a simple version of Simon Says.

Overlays can be created for static display devices so the child can select messages and begin to build sentences, for example, to give opinions and comments. The device can be used in lessons with curriculum vocabulary programmed in so the child can join in discussions and answer questions. A useful strategy here is for the teacher to ask the AAC speaker a question and then move to another child to give the AAC speaker time to compose a response.

Dynamic screen devices often have pre-programmed vocabularies which contain a large amount of vocabulary. Sometimes, when assessments for VOCAs take place, the vocabulary that the AAC speaker will need is not considered and the team working with the individual are left in the unenviable position of having to start from scratch. There will always be some AAC speakers who need truly individual vocabulary to be programmed, but many will be able to use a pre-programmed vocabulary which can then be personalised.

Pre-programmed vocabularies provide a basic structure to build on and can begin at a very simple level to teach switch scanning or eye-gaze, as well as offering full access to text and all aspects of using a computer just as for someone who uses a keyboard and mouse. While some VOCAs contain different vocabularies, others have vocabularies that are similar but use specific features of the device software.

There are pre-programmed vocabularies that will allow the AAC user to look at photo albums, play music and access the internet from within the communication software. This can increase recreational and access practice opportunities.

It is always helpful for a young child to have vocabulary that is developmental. Some of the commercially available vocabularies are hierarchical, so the child can start with a simple overlay and move through to more complex vocabulary sets. Each level builds on the previous one. This is a very useful strategy for younger children as what is learnt on one level is expanded on in the next, so while there is new learning, this is restricted to essential new vocabulary.

Education and communication

VOCAs are designed to be communication devices. However, in school they are usually used for educational purposes with curriculum specific vocabulary. While this is appropriate for some, a more general vocabulary, to question and comment with, may be more useful for others.

In many cases, children are given access to their AAC devices in the classroom, but not at playtime or lunchtime. This is usually governed by issues around mounting VOCAs on seats and wheelchairs and constant access to a VOCA may not always be possible from a safety point of view. It is essential to seek appropriate advice from an occupational therapist, physiotherapist, speech and language therapist and wheelchair service before mounting a VOCA. There are also companies who will advise and mount equipment.

Where it is not possible to mount a device on a seat or wheelchair, the child will be limited to using the device inside. However, the issue of using the VOCA outside the classroom or home needs to be addressed so that the AAC speaker can access the devise when and where s/he needs to.

While the AAC speaker is learning where vocabulary is stored, activities and games can be set up to encourage the development of communication for fun, for example through “nosy” questions, jokes, imaginative story writing and games such as “Guess Who?”

Fun, functional and effective communication

Communication must be fun and meaningful for all children. It can be such hard physical work for some AAC speakers to access technology, so we need to be sure that we are giving them the most efficient tools to develop communication as far as is possible. We need to be sensitive to the times that technology will work and the times that it just will not do. Then we need to make sure there are alternative methods of communication available, such as a communication chart or book.

We also need to be mindful that there are some potential AAC speakers we may come across who simply cannot manage existing technology because of the immense effort required. Indeed, I recently met a young man who experiences such severe spasms when trying to use technology that he had decided he did not want to use switches or eye-gaze technology. We need to be respectful of this young man’s opinion and make sure that he has an effective communication book so he can talk to his family, friends and carers.

Other young people just cannot wait to use technology and will choose to use their VOCA all day, every day and only use a communication book or chart if their device breaks down or they are in a position or environment where their access method will not work, such as in bright sunlight or a swimming pool.

The communication technology (hardware and software) that is available today offers great opportunities for people who use AAC, provided they are given appropriate equipment through impartial assessment and skilled support.  We need to make sure that we provide the right expertise and vocabularies to support AAC speakers and help them make the most of what the technology can offer.

Further information

Gillian Hazell has 25 years’ experience working on AAC with children, young people and adults with physical disabilities and learning difficulties. She is a member of the Association of Speech and Language Therapists in Independent Practice and her company, AAC Consultancy, provides AAC assessments, support and training:
www.aac-consultancy.co.uk

Information about the different types of communication aids available can be found at:
www.speechbubble.org.uk

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