Handout for a workshop presented for SPOT on DD in August 2011. Video files have been removed for privacy reasons.

1. AAC, All Day, Every Day

2. Jane Farrall Speech Pathologist AAC Support Services Manager jane@spectronics.com.au Twitter: @janefarrall

3. What is AAC? Augmentative and Alternative Communication (AAC): An area of specialised clinical and educational practice that provides communication options and interventions for people with complex communication needs. The term augmentative in this context means supplemental or additional to speech. Augmentative techniques (e.g. gestures, and facial expressions) are commonly used when communicating and interacting with others. The use of the term alternative acknowledges that there are some individuals whose speech is sufficiently impaired that they must rely completely on standard and special augmentative techniques, which do not augment speech but are alternatives to speech (Vanderheiden & Yoder, 1996). (Speech Pathology Australia AAC Position Paper 2004)

4. AAC System AAC system: An integrated group of components, including the symbols, aids, strategies and techniques used by individuals to enhance communication. The system serves to supplement any gestural, spoken, and/or written communication abilities (American Speech and Hearing Association, 1991).

5. Unaided and Aided AAC Unaided AAC: All techniques that do not require any physical aids (e.g. gesture, sign, facial expression). Aided AAC: Techniques where some type of physical object or device is used (e.g. object symbols, communication boards, books, wallets). Aided AAC is often divided into high technology or low/light technology systems. (Speech Pathology Australia AAC Position Paper 2004)

6. AAC Myths and Legends Introducing AAC will stop someone from developing speech Low tech before High tech Has a little speech so doesn’t need AAC Too cognitively impaired for AAC AAC will fix all communication difficulties Too young for AAC Doesn’t need AAC as they can express basic needs

7. AAC Myths and Legends - Resources Romski, M.A. & Sevcik, R.A. (2005). Augmentative communication and early intervention: Myths and realities. Infants & Young Children, 18:3, 174-185. YAACK http://aac.unl.edu/yaack/ DynaVox Implementation Toolkit http://www.dynavoxtech.com/implementation-toolkit/learning-paths/list/?id=7

8. Good Practice Approaches to AAC Aided Language Displays (ALDs) Engineering the Environment Chat Now PODD Core Vocabulary

9. Additional AAC options to support good practice Small Talk About Me Books Yes/No ++++ Social Scripts Partner Focused Questions Storytelling

10. High Tech AAC Custom Speech Generating Devices Mainstream Technology iPod touch/iPad Android Phones/Tablets Laptops

11. Communicative Competence Light (1989) Linguistic Competence (mastery of the linguistic code) Operational Competence (access methods, on/off) Social Competence Strategic Competence (make the most of the vocab they have)

12. Aided Language Displays Prospective users must be provided with frequent examples of interactive, generative use to acquire any semblance of proficiency. No one would dispute the fact that it would be very difficult to become a fluent speaker of French, if your instructor seldom used French in your presence. Goossens’, Crain and Elder (1988); Goossens’ (1989)

13. Aided Language Displays Likewise, it is difficult for a nonspeaker to become a proficient AAC user if other people never model interactive use of their system during all aspects of the day.

16. Aided Language Displays Aided Language Displays are NOT choice making boards. Choice making boards supplement ALDs. E.g. in music time a choice board of songs is followed by boards for singing the songs.

17. It is critical for an individual to not only have symbols, but also to have experience with those symbols in a symbol rich environment / print rich environment. The typically developing child will have been exposed to oral language for approximately 4,380 waking hours by the time he begins speaking at about 18 months of age.

18. If someone is using a different symbol set and only has exposure to it two times a week, for 20-30 minutes each, it will take the alternate symbol user 84 years to have the same experience with his symbols that the typically developing child has with the spoken word in 18 months!!!

19. The typically developing child will demonstrate language competency around 9-12 years of age having been immersed in and practicing oral language for approximately 36,500 waking hours. For 9-12 years that child has been using and receiving corrective feedback while practicing with the spoken word.

20. At twice a week, 20-30 minutes each time, it will take the alternate symbol user 701 years to have the same experience Jane Korsten (2011) QIAT Listserv 4th April

21. Aided Language Displays If children are to gain proficiency in using their aided AAC systems, others must begin to use the children's AAC system to communicate with them.

22. Aided Language Displays By modelling how to use a display to initiate and maintain communication, you show a student how to initiate and maintain – not just respond!

23. Aided Language Display Design

24. Aided Language Display Design

25. Aided Language Display Design If you (as a person proficient in language) cannot use a communication system or display throughout an interaction then how can you provide Aided Language Stimulation? If you cannot use it, is it designed well?

26. www.boardmakershare.com

27. Engineering the Environment Displays must be stored in close proximity to where they are needed Displays must be stored in a way that helps with quick access and set-up E.g. in dress-up box, on back of bookshelf, on walls, in plastic bucket, inside game box, with props, in eye gaze arrangement

28. CHAT-Now Developed by Gayle Porter (Cerebral Palsy Education Centre) and Marnie Cameron (Communication Resource Centre) Children’s Aided Language Tools Consists of aided language displays for early childhood settings and general interactive board(s)

29. CHAT-Now – Book

30. CHAT-Now General Interactive

31. CHAT-Now A series of ALDs for different activities. Designed for early childhood but suits many special education settings Also includes a general interactive board for use throughout the whole day

32. Special School Project Approx 80% of students in school with CCN A few have individual systems – generally not being used Lots of visual supports in place – all staff carry key caddies and all classrooms use visual schedules, first then boards etc Commonly used AAC is all adult focused language

33. Key Caddies

34. Special School Project Baseline observations and videos end of 2010 No spontaneous AAC use by students

35. Term 1 2011 Every student establish yes/no Begin using CHAT-Now Introducing general interactive board Then aided language displays

36. Week 1 Problem solve how to make general interactive display available in every situation

37. Week 2 Model more and finished all week

38. Week 3 Add I like this

39. Week 4 Add I don’t like this

40. Week 5 Use whole board Made up in Tap Speak Choice, AAC App

41. Weeks 6 - 10 Consolidate use of whole board Ensure all students have yes/no

42. Special School Project Repeat observations and videos end of term one 10 spontaneous uses of AAC by students observed Next term introducing ALDs for a range of activities Term 3 introducing multi-page generic displays

43. CHAT-Now General interactive multi-level

44. Yes/No Need to watch the number of yes/no questions we ask AAC users BUT Every AAC user needs to develop a good, clear Yes/No response

45. Pragmatics Pragmatics – social use of language Using language for different purposes, such as greeting, informing, demanding, promising, requesting Changing language according to the needs of the listener Following conversational rules www.asha.org

46. Pragmatics Need to ensure AAC users have access to and know how to use a range of pragmatic skills Dewart and Summers “Pragmatics Profile” (1998) http://wwwedit.wmin.ac.uk/psychology/pp/

47. PODD PODD is a way of organising whole word and symbol vocabulary in a communication book or speech generating device to provide immersion and modelling for learning.

48. PODD The aim of a PODD is to provide vocabulary: for continuous communication all the time for a range of messages across a range of topics in multiple environments.

49. PODD PODDs can have different formats, depending on the individual physical, sensoryand communication needs of the person who will use it.

50. PODD PODDs have been developed over the past 15 years by Gayle Porter, a speech pathologist with the Cerebral Palsy Education Centre (CPEC) in Victoria. Each PODD format has been shaped by the experiences of both children with Complex Communication Needs (CCN), and their communication partners.

51. Core Vocabulary Using common English words on an AAC display to enable a user to construct their own sentences. Approach used in lots of high tech systems but not used as much in low tech due to difficulty of arranging vocabulary for access.

52. Core Vocabulary CORE VOCA High frequency words Can be combined to get your message across in lots of different situations FRINGE VOCAB Low frequency words Only useful in one or two situations Often related to a specific topic

53. Core Vocabulary

54. Core Vocabulary WordPower 24 in TouchChat, AAC App

55. Pixon http://www.vantatenhove.com/showfolder.php?id=57

56. Core Vocab to supplement ALDS From the Disability Services Commission WA http://www.boardmakershare.com/Activity/969086/Core-Vocabulary-Display

57. Technology

58. High Tech and Light Tech Both are just tools Both need good vocabulary design and good modelling to ensure success High Tech can be less forgiving but can offer more access options Some students more motivated by high tech and some don’t like it!! Most people need both – for different situations

59. Speech Generating Devices STATIC DISPLAY DYNAMIC DISPLAY

60. Static Display May be more durable Generally cheaper Often run off AA or AAA batteries Overlay based - require Boardmaker or other tool Need to work out system for storing and changing overlays Need to ensure vocabulary is updated Harder to maintain in many ways

61. Dynamic Display May be more durable Usually rechargeable Tools for generating pages in device – and sometimes in free software too Can change vocabulary on the spot Can change pages and levels easily Generally offer a wider range of access options

62. Access Options For a user who need alternative access, SGDs can offer: Large range of access options Flexibility Complete control over device and other software

63. Scanning and Eye Gaze

64. High Tech Scanning

65. Low Tech Scanning and Eye Gaze

67. Mainstream Mobile Devices for AAC

68. www.spectronicsinoz.com/article/iphoneipad-apps-for-aac

69. How do I choose? Are they worth the cost? What do they offer that traditional speech generating devices don’t? What don’t they offer that SGDs do?

70. Media, Stories, Opinion http://socialtimes.com/iphoneipad-app-helps-autistic-children-communicate_b10778

71. Media, Stories, Opinion

72. Media. Stories, Opinion www.spectronicsinoz.com/blog/resources/2011/04/aac-apps-speaking-appropriately/

73. Media, Stories, Opinion Apple iPad2 launch

74. Media Stories and Opinions http://www.wired.com/geekdad/2011/03/ipads-are-not-a-miracle-for-autism-geekdad-opinion/

75. Apps with Symbols/Pictures

76. Apps with Symbols and Text-to-speech

77. Apps with text only

78. Traditional SGDs

79. Research http://aac-rerc.psu.edu/index.php/pages/show/id/46

80. Accessories

81. Access

82. Other mobile devices

83. Resources www.spectronicsinoz.com/blog/apple http://a4cwsn.com/ iTeach Special Education – iDevices in Special Education (Facebook group) Assistive Technology (Facebook Group)

84. Expertise

85. Case Study

86. Additional AAC options to support good practice Yes/No ++++ Small Talk About Me Books Storytelling Social Scripts Partner Focused Questions Introducing yourself Taking non-obligatory turns

87. Social Communication Social communication is a BIG part of our day. We use different forms of social communication – small talk, storytelling, greetings, wrap ups and farewells.

88. Social Communication Social communication is more than 50% of our daily conversation. Light (1998) found that reasons for communication between adults were (in ranked order) Social closeness Social etiquette Information transfer Wants and Needs

89. Small Talk A type of conversational exchange used for initiating and maintaining conversational interaction. Some conversation never progresses beyond small talk e.g. at a cocktail party.

90. Small Talk Small talk is used as a transition between the greeting and information sharing stage, especially when people don’t know each other well or don’t possess a lot of shared information. Small talk is often the first step towards social closeness. A quick check at Amazon showed 16 books aimed at helping people improve their small talk skills. Including “How to get people to like you in 90 seconds”. There are even websites to teach you how to small talk! e.g. www.ehow.com, www.englishclub.com, www.ivillage.co.uk and many more!

91. AAC Users and Small Talk Many AAC users use little or no small talk This can be because They don’t have access to small talk in their communication system They don’t see the need for it They think it is a waste of time. Light and Binger (1998) found that AAC users were seen as more intelligent, valued and competent communication partners if they used small talk.

92. Generic Small Talk Generic small talk is small talk that people can use with a variety of different conversational partners because it doesn’t refer to specific shared information. Particularly effective for many AAC users as it has many different uses.

93. Generic Small Talk Several groups of researchers at the University of Nebraska-Lincoln looked at the frequency and types of generic small talk used by speakers of various ages without disabilities. 3 – 5 year olds - 48% of all utterances at both home and pre-school/school were generic small talk 20 – 30 year olds - 39% of all utterances were generic small talk 65 – 74 year olds – 31% of all utterances were generic small talk 75 – 85 year olds – 26% of all utterances were generic small talk

94. Generic Small Talk Most of the age groups used continuers as the most common form of small talk. Really? Yeah? Great! Cool! Go to aac.unl.edu for more detailed information.

95. Differences in Small Talk Vocabulary The small talk vocabulary lists showed that some words were used more frequently than others e.g. OK Some words were common across all age groups e.g. great Some words were specific to certain age groups e.g. “bummer” was used by the 25 – 35 year age group but not by the others. Small talk also differs based on your friendship groups, your geographical location, your interests and life experiences.

96. Small Talk and Mealtimes Balandin and Iacono (2000) found that it was nearly impossible to script the content-specific vocabulary needed for mealtimes for an adult in the workplace (although there was a good chance on Mondays and Fridays that footie would be the topic during the footie season). In this situation, the only predictable thing was small talk.

97. Pre-school Generic Small Talk

98. Adult Generic Small Talk

99. George’s Small Talk 21 year old male with athetoid cerebral palsy Attends a day centre for young adults Uses a Dynavox3100 but only uses the spelling page Controls communication device with a head switch

100. George’s Small Talk Over 20 other people with disabilities and 6 staff attended George’s centre, most of whom talked. George rarely used his device during the day. Staff requested a review of his device because he didn’t “ever” use it. George had previously had a setup with core vocabulary on his device but found it frustrating to find words he wanted when he could just spell them.

101. George’s Small Talk A speech pathology student observed him in two sessions. He “used” his device constantly but only spoke with it twice. George was accessing his device with a head switch and block/row/column scanning. She observed that by the time he had formulated a message the conversation had moved on and he erased and moved onto a new message. A two pronged approach was used. Firstly, a conversational topic was established before each group e.g. “What are your favourite films?”. This allowed George to compose messages in advance. A small talk page was programmed and George practiced using this in one-to-one and then small group conversation.

102. George’s Small Talk At the end of 8 weeks the same speech pathology student observed George in the same two sessions. George used his device 46 times. Five of these were topic setters, 41 were small talk continuers. Several other people in the centre commented spontaneously that “George was much cleverer than they thought” or that “They enjoyed talking to George much more”. And….he’s still using it!

103. Michael’s Small Talk 14 year old with autistic spectrum disorder. Attends a mainstream school with a full-time integration aide. Michael has a DynavoxMiniMo but has recently developed quite a lot of speech, which is only understood by familiar people. Michael’s device has core vocabulary with lots of fringe vocabulary around his topics of particular interest e.g. SpongeBob Squarepants.

104. Michael’s Small Talk Michael has been very keen to interact with his peers. However, as his peers have got older verbal skills have become more important to these interactions. Michael will often walk up to a group and simply stand there. The other children do not try to include him in their conversations, nor does Michael try to join in. Some of the children Michael was friendly with in primary years will occasionally sit down and talk with him, but always on his terms. These occasions are decreasing in frequency.

105. Michael’s Small Talk Introduced Michael to Small Talk. Each of his favourite topic areas had a page built with partner directed questions and small talk continuers. His old friends are very impressed with this change in Michael. They are more likely to have a chat with him and will sometimes call other people over to take part in the conversation.

106. Sequenced Social Scripts Sequenced social scripts can really help a user to Get a 'feel' for the anatomy of a conversation Develop turntaking skills Learn to interact with a variety of partners.

107. What are Social Scripts? They support students in learning to claim, start, and maintain turns in a conversation. Much of the information in this section is taken from “Can We Chat? Co-Planned Sequenced Social Scripts: A Make It / Take It Book of Ideas and Adaptations”by Caroline Musselwhite and Linda Burkhart Also called Participation Scripts

108. What are Social Scripts? Social Scripts are interactions such as joke-telling, sharing life stories and general conversations. They help persons using augmentative and alternative communication (AAC) move beyond wants and needs to using 'real' communication for conversational purposes. Often give developing communicators a sense of the power of communication.

109. Anatomy of a social script Attention getters Starters Maintainers, holders and interjections Turn transfers Closings

110. Communication Passports Template available from CALL Centre Scotland www.communicationpassports.org.uk iPhone App coming soon Also from SCOPE UK at http://www.scope.org.uk/help-and-information/publications/scope-communication-passport

111. Communication Passports Useful for exchanging information about an AAC User between others Often not a tool used by the AAC user directly

112. This book is about me!My name is Mike Please read! This book will help you to get to know me and how I communicate.

113. Page Index All about me You need to know My Family My Friends Special people, special things Things I like to talk about How I communicate How I communicate (2) You can help me communicate Fun things I like to do Places I like going Things I don’t like I’m working on this... Help! Eating and Drinking What’s my eyesight like?

114. All About Me! CALL Centre page 1

115. You need to know... I have epileptic seizures. They don’t last for long, please just make me comfortable and let me have a snooze afterwards. 2. I am allergic to penicillin CALL Centre page 2

116. CALL Centre page 3 I love my FamilyI like to talk about them so you need to know who everybody is This is my Mum and Dad And my sister Larissa.

117. My Friends CALL Centre page 4 This are my friends. John, Mike, Peter, Sally and Sue.

118. CALL Centre page 5 Special People Special Things I love having a weighted blanket on my lap – it helps me concentrate.

119. You can help me to communicate Please DO give me plenty time Please DON’T ask me more than one question at a time CALL Centre page 9

120. Personal Storytelling As we get older the percentage of small talk decreases and the percentage of storytelling increases. Older adults, in particular, use stories to entertain, teach and establish social closeness with their peers. As individuals lose their spouses and move to retirement and care facilities the need to socially connect with individuals their own age becomes important and storytelling becomes a vehicle for this.

121. Personal Storytelling Schank (1990) discussed story formulation, refinement and storage in detail. He found a few different “types” of stories in common use: First person stories Second person stories Official stories Fantasy stories Marven et al (1994) found that for preschoolers, 9% of their communication at home and 11% at preschool involves fantasy of some sort.

122. AAC and Storytelling Storytelling with AAC systems has become practical and possible with improved technology. However, we must be careful that the stories are ones which the person would choose to tell. Storytelling is very personal and must be individualised.

123. John’s “chat” cards John is an 11 year old with autism spectrum disorder. John uses words (which are mostly intelligible to familiar people), signs and a multi-page communication book. John also has some challenging behaviour. Five years ago, John had challenging behaviour every night when he got home from school. His mum felt that this was due to his frustration over trying to tell her about his day. His team decided that “chat” cards about his day would help. They setup a process to write a sentence about each day.

124. John’s “chat” cards

125. John’s “chat” cards

126. John’s “chat” cards

127. John’s storytelling Many of John’s old chat cards are in a milk crate in his room. John began spontaneously using them with new people a couple of years ago. He selects a few cards and then brings them to the new person. They read them with him and if they show particular interest in one topic e.g. playing basketball he will go and get more things around this topic. He brings out fewer chat cards as people become more familiar with him and understand more of his speech.

128. Ted’s Storytelling Ted is a 78 year old who had a CVA when he was 72. Following the CVA he regained some spontaneous speech, mostly small talk. He can understand everything that is said and can read the paper and magazines. He cannot speak (apart from small talk) and he cannot write. Prior to the stroke he was president of his local RSL Club. His wife and his friends miss his storytelling. His wife was able to work with him and write out many of his stories. These have now been stored in a Macaw, with one of his friends doing the recording. He and his wife are delighted as he is once again able to tell stories and delight his family and friends.

130. Personal Photo Stories A series of photos about a person to give the “listener” a sense of who the person is Can be used to let them have a “conversation” with their “listener”

131. Sarah’s Storytelling Sarah is a woman in her sixties who lives in her own house. In her forties she was in a motor vehicle accident and is now a quadriplegic. She has a good understanding of spoken English but very limited expressive communication, including very little facial expression. She has control of a single switch with her left thumb, but tends to fatigue quickly, although her stamina is increasing. She has a multi-level communication book which she accesses with eye pointing.

132. Sarah’s Storytelling She has a range of in-house care staff who tend to stay around for between 5 months and 3 years. Many of these staff assume she doesn’t understand what is said to her because she doesn’t give body language feedback.

133. Sarah’s Chat Book Inside this book are some of my photos. The writing tells you about them. The questions are things I am interested in about you. Please read out the writing and the questions and we can find out about each other together - but be warned - it might take more than one visit! Sarah

134. Sarah’s Chat Book Sarah’s chat book has completely changed the way staff see her. Each new staff member sits down and goes through the book with her over a few different sessions. They realise how interested Sarah is in them and they gossip with her more. It also gives them topics to talk about that they think will interest her.

135. Maggie’s Storytelling A series of photos about a person to give the “listener” a sense of who the person is Can be used to let them have a “conversation” with their “listener”

136. http://sheldonhickey.com/maggie/All%20about%20me/index.html

137. Just how important is social communication? In Building Communicative Competence with individuals who use Augmentative and Alternative Communication Light and Binger (1998) looked at just three different social communication skills. 1. Use of an introductory strategy when meeting new people 2. Use of nonobligatory turns to increase participation in social interactions 3. Use of partner-focused questions to demonstrate an interest in the partner.

138. Use of an introductory strategy when meeting new people Teaching a 35 year old with a closed head injury to use an introductory strategy to explain his use of AAC and his communication resulted in much more positive interactions with unfamiliar people, with fewer breakdowns and made the new partners more at ease. Teaching a 44 year old with cerebral palsy to use an introductory strategy allowed her to be more confident and assertive with new people. Twenty adults with no previous experience of AAC viewed tapes of Maureen meeting new people pre and post. 100% of them reported she was a more competent communicator when she used an introductory strategy.

139. Use of nonobligatory turn taking Teaching a young (4½ year old) child with cerebral palsy to use non-obligatory turn taking via AAC meant that the child was initiating more frequently and was more eager to participate in group activities. One of her peers said she was more fun to play with. Her speech improved and she acquired 30 new words. Teaching a 14 year old with autism to take non-obligatory turns also resulted in a increase in initiating and turn taking. There was a decrease in his inappropriate behaviours and he was less disruptive in class. 20 adults who were not familiar with AAC rated his pre and post videotapes and rated him as a much more competent communicator in the post tapes (although they didn’t know which were pre or post).

140. Use of partner focused questions Teaching a 13 year old child with developmental disability to use partner focused questions produced a change in the focus of his interactions. His partners began to see his communication as more appropriate. Teaching a 24 year old with athetoid cerebral palsy to use partner focused questions meant that he became a more valued communication partner with those he regularly communicated with.

141. So how do I decide what’s important in an AAC system? Beukelman (2004) wrote that “vocabulary selection in AAC can be viewed as the process of choosing a small list of words or items from a pool of all possibilities”

142. Choosing vocabulary for pre-literate individuals For people who are pre-literate those designing an AAC system face a hard task. Generally we consider there are two forms of vocabulary for this group – vocabulary that is needed to communicate essential messages and vocabulary to develop language (which includes small talk and narratives). Many people like to make this decision around core vocabulary ie words and messages which are commonly used and occur frequently. Small talk vocabulary fits well within these criteria.

143. Choosing vocabulary for non-literate individuals Aim to meet their daily, ongoing communication needs in a variety of environments.

144. Choosing vocabulary for literate individuals For literate individuals, they may need some phrases or words which need to be pre-stored for quick access either so they can participate in the conversation in a timely way or so they can reduce fatigue.

145. What do we know about aided AAC use?

146. Many people who use AAC (Kraat, 1985; Light, 1989; Muller and Soto, 2002) Play a passive role Rarely initiate interaction Express a limited number of speech acts Use restricted linguistic forms Limited opportunities to interact with other people

147. Communication board use is frequently less than one might expect.

148. When the communication board is used, it is often used primarily to provide information requested by the facilitator.

149. The range of communicative functions produced is typically restricted.

150. Functionally non-speaking partners tend to assume a respondent role using primarily yes/no answers and other short provisions of information.

151. Patterns of turntaking, initiation and conversational control tend to be asymmetrical in nature ie the speaking partner dominates the conversational exchange.

152. Speaking partners are frequently observed a) to ask closed-ended questions and specific Wh-questions and b) to repeat and rephrase previous turns, often initiating topics without expecting a response from the child.

153. In the classroom setting, AAC users tend to communicate predominantly with the adults in the class, not their classmates.

154. AAC should be…

155. Used frequently, interactively and generatively to express a wide range of communicative intents;

156. Occurring during at least 80% of ongoing classroom programming (as speech or manual sign use is);

157. Being used to mediate communication with classmates as well as personnel (ie teachers, aides, therapists, clinicians);

158. Being designed and implemented in as time and cost effective a manner as possible.

159. What we know Communication displays and devices are often not used AAC users are typically responders not initiators Interaction patterns focus on “closed” questions such as “What do you want?” Conversational partners control interactions (turn taking is unequal) Peer interaction is minimal (Kraat, 1985)

160. Four main issues Lack of Modelling Lack of Access to Vocabulary Communicative Competence Passivity/Learned Helplessness

161. We know how to fix this... We just need to do it! And model, model, model