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Assessment, Intervention and Resources.

Children who have severe speech communication disorders can significantly benefit from augmentative and alternative communication (AAC) systems. However, the issues surrounding the selection and application of AAC systems can be complex. This three-part series is intended as a resource for parents. Empowering parents to contribute in a substantial way will assure that their children receive the AAC system and services that will maximize a child's potential for personal achievement. Part 1 covered the goal of AAC, the AAC team, and AAC Rules of Commitment. Part 2 presented AAC success stories based on the Rules of Commitment. Part 3 is dedicated to assessment, intervention, and resources for parents.

NEEDS MODEL ASSESSMENT

Most AAC assessments have been based on either a Needs model or a Language based model. A Needs model starts by identifying the communicative needs in the daily environments or academic curriculum. Then it emphasizes the selection and organization of vocabulary. Team members make vocabulary and symbol choices based on the abilities and predicted needs of the child and then match these abilities and needs to AAC technology features

However, recent research suggests that clinicians are poor predictors of vocabulary and topics of conversation. In addition, a Needs model frequently results in limited vocabulary choices. For example, many nouns related to a topic are available, but few "structure words" (words that give structure to sentences, such as prepositions, determiners, conjunctions) are options. Finally, grammar is often not considered for the available vocabulary. Consequently, the child may have no means to express plurals, possessives or verb tenses.

In the excitement of providing speech output technology for the first time for their child, parents may not be focusing on limitations to the vocabulary. Parents may initially feel that providing words/messages, especially words/messages that seem to relate closely to specific needs identified by the team, will achieve the desired outcomes for improving communication. However, the team that relies exclusively on a Needs model may never completely provide all of the essential vocabulary necessary for having a conversation. Furthermore, by using a Needs model the team may see only a very narrow view of what is possible with AAC, and what a child might potentially accomplish. Parents should ask professionals to look at more than the environment when doing an AAC assessment. After all, the reason for AAC systems and services is to help the child "learn to talk."

LANGUAGE BASED MODEL

An AAC Language-based model starts with the goal for AAC: to provide the AAC systems and services that result in the highest level of personal achievement possible. To achieve this goal one must understand how a person acquires and develops competence in language. A Language-based model forces teams to define a successful assessment outcome by more than needs and wants. Can the selected language representation method(s) and technology fulfill other purposes of communication such as information exchange, social closeness, and social etiquette? An AAC assessment should identify how a child might efficiently and effectively transmit messages based on his/her feelings, interests, circumstances, abilities, motivation, and environment.

Language uses rules governing the sequencing of basic units such as sounds and words, and rules governing how words are used to convey meaning. An individual knows a language when he or she internalizes its basic structure and naturally follows its rules. Most languages have basic rules of vocabulary, grammar, and pragmatics. The basic rules of language apply to AAC. Awareness of how a given AAC system handles these basic rules helps enable one to select the most appropriate AAC language representation method(s) to achieve the goal.

Being able to identify the characteristics of the different AAC language representation methods and how each method handles the rules of language is more important than understanding the electronic functions of the technology. Part of this series introduced the three major AAC language representation methods commonly used in AAC technology: 1) single meaning pictures, 2) traditional orthography (alphabet-based systems), and 3) semantic compaction. Basic definitions and descriptions of each method were presented. Part 3 will briefly highlight issues that teams should discuss in selecting a language representation method.

The size of the symbol set is determined by two things: the method chosen and the specific number of symbols programmed into the system for an individual child.. (Anticipated vocabulary size is one item that should be covered during the assessment.) Since every word/message requires a separate symbol, the single meaning picture method has a symbol set as large as the number of items in the vocabulary. Teams need to remember that a normally developing 3-year-old has a vocabulary of over 1100 words. The symbol set for traditional orthography is limited to the letters of the alphabet, numbers, and punctuation marks. Semantic compaction has a small icon set to represent core vocabulary.

Learnability or guessability of the symbol set is based on how readily a symbol is recognized to represent a given word or message. Concrete symbols of common objects such as ball, table, glass may be guessed easily. However, less concrete, but more commonly used words such as more, want, help still need to be taught. Nearly all of the most frequently used words are not object nouns. The symbols are learnable, but only after training and practice. However, think about a child requiring more than a small symbols set. The individual could have multiple pages of very similar line drawings to learn. For example, how would you distinguish picture symbols for money, buy, shop, and change? You would probably use stories to teach the meanings of single meaning pictures.

Literacy or reading and spelling skills become important considerations for most any child to use any of the language representation methods. A single meaning picture with an associated word may be far more obvious to a reading adult than to a non-reading child. Semantic compaction is generally used with either single meaning pictures or spelling to represent extended vocabulary. This method, also called Minspeak[TM] (trademark of Prentke Romich Company), uses a symbol set, but assigns more than one meaning to each symbol or icon. The same icons can be rearrange in short sequences to produce different meanings.

VOCABULARY: SINGLE WORDS VS. PRE-STARED MESSAGES

Vocabulary Management is related to the types of words and/or messages that are selected. The first consideration is related to the use of single words versus pre-stored messages. Using a Needs model, teams may typically identify messages such as "May I have a drink of orange juice, please," or "I want a red crayon, please," as "I need to go to the bathroom," or "Please, help me get out of my wheelchair." Several critical assessment questions may be answered based on the individual's performance during a trial period with technology. Some of these questions might be "Does the child comprehend the messages?" and "Does the child have the ability to independently make appropriate selections?"

However, accessing these does not necessarily address identifying how a child comprehends language or is able to sequence symbols to construct messages using single words such as "help me." Basing the vocabulary on pre-stored messages around environmental themes/activities does not promote learning how to use language.

VOCABULARY: CORE AND EXTENDED

The second consideration regarding vocabulary management is related to the use of core and extended vocabulary. Managing vocabulary based on the model of core and extend words allows the child access to single words that can be spontaneously constructed into messages using the rules of language (grammar). In addition, access to core and extend vocabulary can be managed to support the development of language.

How fast can two people carry on a conversation using a particular AAC method? Conversational partners will comment frequently on the length of time required to wait for a response. Various strategies to increase rate have been developed to compensate for the slowness of using an AAC system. These strategies are called acceleration techniques. One acceleration technique, for example called "word prediction," uses menus of pre-stored scripts or messages grouped by conversational topic. The user has easy access to view and select these menus. However, no matter how quickly the child may access a message, he/she is limited to the pre-programmed words/messages exactly as they are in that script. If what the child wants is not there, he or she must change menus to look for different words/messages, a procedure that can take time. This can feel like choosing rather than generating language. Further, a child may become distracted by the technology.

Choosing the language representation method(s) that are best for the individual requires some understanding of the above methods. Both present and future abilities should be considered, keeping in mind the goal of the highest personal achievement. True communication only happens through SNUG (spontaneous novel utterance generation). Single meaning pictures would be appropriate for a child with a small vocabulary. However, the meanings of pictures representing commonly used words must be taught. Spelling systems require reading and spelling skills, but allow the generation of any word. However, spelling is very slow. Rate enhancement strategies may reduce keystrokes but do not make communication any faster. Semantic compaction is generally used with single-meaning pictures or spelling to represent extended vocabulary.

INTERVENTION

AAC professionals have a strong interest in outcomes management. For parents, outcomes management means, "What are the AAC-related goals and objectives on my school aged child's IEP?.... What progress is my child making with the AAC system?" and "How is progress being measured?" Empowered parents play an important role in providing checks and balances to assure that intervention leads to successful outcomes and the desired goal.

WHAT ARE THE AAC-RELATED GOALS AND OBJECTIVES ON MY CHILD'S IEP?

The IEP objectives should reflect what the child might reasonably be able to achieve using the language representation method(s) selected during assessment. In addition, outcomes need to incorporate several areas of competency to achieve the goal of AAC. Most clinicians would agree on the importance of building language and social skills, improving skills for using the device, and learning other strategies to be more successful with communication partners. These various skill areas of communicative competence should be accountable and easily identified on the IEP.

WHAT PROGRESS IS MY CHILD MAKING WITH THE AAC SYSTEM?

A common approach for initiating intervention is planning vocabulary around communication environments. Progress is evaluated on performance in natural settings which focuses on functional skills. Teaching practices that encourage and foster use of AAC strategies in various daily-living activities is recommended. However, service delivery that only includes intervention within natural settings does not provide the same quality and depth of service received during clinical one-on-one instruction. Including instruction for the child in the clinical setting, rather than limiting it to the child's daily environment such as school and home, is more effective in teaching proficiency with a system. Progress, however, is evaluated by examining the child's performance in natural settings and focuses on functional skills. Vocabulary needs become ever changing, and team members are in a constant struggle to update or add new vocabulary. Core vocabulary stays consistent across time and activities. One-on-one instruction may be needed to learn "the core," but progress can be generalized and observed in all daily environments.

HOW IS PROGRESS BEING MEASURED?

Daily journals provide anecdotal observations about progress and enhance the communication among all team members, including parents, teachers, SLPs, etc., Ongoing, consistent communication between home and school is important. Anecdotal records, however do not measure small changes in an individual's performance. In order to measure progress, it is essential to identify the level of communicative ability at the beginning of an intervention. Clinicians and educators are well trained in observing and charting performance. However, the time required to collect and analyze language samples using traditional methods may be discouraging for most team members.

Performance monitoring tools to facilitate the process are being developed. These include the Language Activity Monitor (LAM); being developed under funding from National Institutes of Health. LAM records the content and time of language events, the generation of one or more letters or words. LAM data is already providing new knowledge that corroborates previous anecdotal evidence on the efficacy of AAC methods and systems. These automated measuring systems are already being built into high performance AAC devices. In the future, use of LAM data will provide teams with detailed information on AAC system competence, including analysis of a child's progress with language and technology. Until that time, parents should request that pencil and paper recording, video taping and/or audio recording be used to document and measure their child's progress.

KEEP YOUR EYE ON THE PRIZE

The assessment and intervention processes can be complicated and overwhelming. However, a continued focus on the goal, the most effective communication possible, can minimize the burden and maximize the outcomes. Investing in best practice will lead to high personal achievement for people who rely on AAC.

GLOSSARY OF TERMS

Core vocabulary/core words: Approximately 85 percent of what we say in daily situations consists of a few hundred core words. These tend to be the structure words, such as verbs, adverbs, prepositions, adjectives, pronouns, determiners (e.g., this, that, these, those), etc. that allow us to speak about the abstract. They do not include familiar nouns typically associated with given activities or situations, which are considered extended or "fringe" vocabulary.

Extended vocabulary: Situation-specific or content words--particularly nouns--typically associated with given activities or situations. Also called fringe vocabulary.

Language representation methods: Ways in which a communication system provides access to vocabulary and the linguistic structures (rules of grammar) of language. The three commonly used language representation methods are:

* Minspeak: AAC language representation method based on short sequences of multi-meaning icons from a small non-changing keyboard which do not require spelling or reading skills. Minspeak can handle both vocabulary and rules of grammar and can support the notion of a core and extended vocabulary.

* Semantic compaction: Also called "Minspeak."

* Single-meaning pictures: This method involves graphic or line-drawn symbols to represent single words, phrases, or messages.

* Spelling: Sometimes referred to as traditional orthography, this method involves the use of the alphabet, abbreviations, and/or word prediction. Also see word prediction.

Pragmatics: Social language and conversational skills.

Stakeholders: Those with an interest in the outcomes of the AAC service delivery process (i.e. the individual who relies on AAC, family members, service delivery team members, teachers, administrators, funding agencies, manufacturers, researchers).

Symbol set: Number of items (pictures, letters, or icons) used individually or in combination to represent language elements.

Word prediction: A variation of spelling in which the AAC system tries to guess a word that is being spelled. The user is presented with a list from which to make a choice. Otherwise, the user continues to spell until the choice list includes the desired word. Word prediction reduces the number of keystrokes required to form words and sentences.

RESOURCES

Here are a number of resources that can empower anyone interested in AAC.

ACOLUG

(Augmentative Communication On-Line User Group) is a free e-mail listserve dedicated to addressing the interests of people who rely on AAC. Participants are AAC consumers and family members. Web site: http://www.temple.edu/inst_disabilities/acolug

ASHA

(American Speech-Language-Hearing Association) is a membership organization of speech-language pathologists (SLPs) and audiologists.
10801 Rockville Pike
Rockville, MD 2085
Tel: (301) 897-5700
Fax: (301) 571-0457
Consumer Helpline - (800) 638-8255
Web site: http://www.asha.org
see "special interest division" on site index


CAMA

(Communication Aid Manufacturers Association) is an organization of manufacturers of AAC systems distributed in North America. CAMA sponsors workshops and distributes the product literature of its members.
518-526 Davis St., Suite 211-212
PO Box 1039
Evanston, IL 60204-1039
Tel: (800) 441-2262 and (847) 869-5691
Fax: (847) 869-5689
E-mail: cama@northshore.net
Web site: http://www.aacproducts.org


ISAAC

(International Society for Augmentative and Alternative Communication) membership is open to anyone interested in AAC. National chapters, such as USSAAC, address national issues.
49 The Donway West, Suite 308
Toronto, Ontario M3C 3M9
CANADA
Tel: (416) 385-0351
Fax: (416) 385-0352
E-mail: isaac_mail@mail.cepp.org
Web site: http://www.isaac-online.org


PEC

(Pittsburgh Employment Conference) is the largest gathering in the world of people who rely on AAC and as such is a wonderful place to observe firsthand the communication performance that is possible using different systems. PEC is organized by SHOUT (Sharing Helps Others Utilize Technology), a non-profit organization.
c/o SHOUT
PO Box 9666
Pittsburgh, PA 15226
Tel: (800) 668-4202 and (412) 885-0943
E-mail: SHOUT@sgi.net


RESNA

(Rehabilitation Engineering and Assistive Technology Society of North America) is an interdisciplinary association for the advancement of rehabilitation and assistive technology.
1700 North Moore Street Suite 1540
Arlington, VA 22209-1903
Tel: (703) 524-6686
Fax: (703) 524-6630
E-mail: natloffice@resna.org
Web site: http ://www.resna.org


Editor's note: We received the following ASHA, the American Speech-Language-Hearing Association. The first two articles in our series on "Choosing and Using Augmentative Communication Systems," contain information on the mission of the ASHA, including its role in certifying professional in speech-language pathology, its Code of Ethics, and ASHA's special Interest Division 12 (SID-12), Augmentative and alternative Communication (AAC). According to ASHA, the organization is committed to advocating for its member in the discipline of communication sciences and disorders and for those they serve. Consistent with ASHA's goals, the Association's SID-12 seeks to advocate for speech-language pathologist interested in AAC, to provide networking opportunities, and to offer continuing education for division affiliates. Affiliation with SID-12, or with any other special interest division does not necessarily imply greater expertise in a given area of communication sciences and disorders. Unlike the Association, Affiliation with SID-12, or any of the 15 Special interest Divisions, is not limited to professionals in communication sciences and disorders, but is also open to consumers. Consumers are defined as an individual receiving services, family members, or nonprofessional caregivers. For information on joining a special interest division, contact the ASHA action Center at (800) 638-8255 or visit the ASHA Web site: http://www.asha.org/professionals/sidivisions/sid_list.htm. Neither ASHA nor the Special Interest Divisions endorse any commercial products, including devises used for augmentative or alternative communication.

Katya Hill, MA, CCC-SLP, is an Assistant Professor at the Edinboro University of Pennsylvania, Assistive Technology Center. You can contact her at: Edinboro University of PA, Dept. of Speech and Communication Studies Assistive Technology Center, Edinboro, PA 16444; telephone: (814) 732-2431; fax: (814) 732-2184; e-mail: KHill@edinboro.edu.

Barry Romich, PE, is President of the Prentke Romich Company. You can contact him at: Prentke Romich Company, 1022 Heyl Rd., Wooster, OH 44691-9786; telephone: (800) or (330) 262-1984, ext. 211; fax: (330) 263-4829; e-mail: bromich@aol.com; Web site: http://www.prentrom.com. The authors welcome questions and comments.

Prentke Romich Company AAC products support all three major AAC language representation methods.
COPYRIGHT 1999 EP Global Communications, Inc.
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1999 Gale, Cengage Learning. All rights reserved.

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Author:Hill, Katya; Romich, Barry
Publication:The Exceptional Parent
Date:Dec 1, 1999
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