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Use of AAC by a preshooler with a history of in-utero stroke.


Fetal stroke may follow an ischemic (thromboembolic) or hemorrhagic event which occurs between 14 weeks of gestation and the onset of labor resulting in delivery (Ozduman, et al., 2004). In ischemic strokes, cerebral blood flow falls below a level necessary to maintain nerve cell integrity and neurological function. Hemorrhagic strokes occur secondary to intra-cranial bleeding. A perinatal stroke is similar to an ischemic stroke, but it occurs between 28 weeks of gestation and 7 days of age. Poor understanding of etiologies of fetal and perinatal strokes have led to an estimate of 1 in 4,000 live births, with the true incidence probably being higher. Diagnosis usually includes ultrasound measurement of the fetal cranium and, more recently, fetal magnetic resonance imaging (MRI) and computed tomography (CT), which provide better definition of the injury to the fetal cerebrum. Patients often remain undiagnosed, as clinical outcomes of surviving infants may not be present until later in the first year of life (Ozduman, et al., 2004).

Reports of in-utero strokes began some 30 years ago, based on autopsy data, and continue to follow a case report format, viewing living brains. An early review of nearly 600 infants examined at autopsy (Barmada, Moossy & Shuman, 1979) indicated the presence of cerebral infarcts (necrosis in an area of brain tissue, caused by an obstruction, usually a thrombosis or an embolism) in about one in twenty (5.4%) instances. Neonates delivered at term were more likely to be brain-damaged than premature infants, where multiple smaller infarcts had occurred. Surprisingly, for the infants who survived, disorders associated with focal neurological deficits were not predominant. Rather, the clinical features tended to include such autonomic disturbances as prolonged apnea and episodic seizures, and, in those infants with less severe complications, hemiplegia, mental and motor retardation, and recurrent seizures. As recently as 25 years ago, few infants surviving stroke were reported in the literature (Ment, Duncan & Ehrenkranz, 1984). Among infants who died during the first months of life, necrotic foci (areas of cell death) were generally located in border zones between vascular territories (Lou, 1983). This suggests that the in-utero brain is fragile, offering the brain poor protection against perfusion pressure, with normal birth causing a decrease in oxygen or mild hypotension sufficient to abolish autoregulation (the process by which organs maintain their own blood supply). Inadequate pressure, caused by reduced blood flow to the brain, can cause ischemia. Neonatal ischemia in surviving infants was seen as decisive in development of atrophic encephalopathy, where brain cells decrease in size, with the resultant clinical picture of motor and cognitive dysfunction.

Etiologies of fetal and neonatal strokes are reported both as ischemic (thromboembolic) in "a significant number of these events" (Chalmers, 2005, p. 333) and hemorrhagic, with intracranial hemorrhage occurring in "approximately 40% of infants of less than 32 weeks' gestation" (Huang, Chen, Tseng, Ho, & Chou, 2006, p. 135). One cause of the discrepancy may be the use of ultrasonography (US) for prenatal detection of fetal strokes. The use of MRI to supplement US findings may contribute to diagnostic accuracy and improve prediction of postnatal neurodevelopmental prognosis (Elchalal, et al., 2005). Confirmation of diagnosis by MRI or CT scan has implicated the brain's ventricles, which produce the cerebrospinal fluid (CSF) needed to surround and protect the brain. Periventricular venous infarction may result in a focally enlarged lateral ventricle (Takanashi, Barkovich, Ferriero, Suzuki, & Kohno, 2003; Takanashi, Tada, Barkovich, & Kohno, 2005), or in hydrocephalus following hemorrhage in the choroids plexuses, which manufacture CSF in the ventricles (Huang, et al., 2006). Motor outcomes, after follow-up of more than five years, included leg hemiparesis and spasticity, if the basal ganglia were involved; non-motor disorders associated with cortical involvement included cognitivebehavioral impairments, visual deficits, and epilepsy (Kirton, Deveber, Pontigon, Macgregor, & Shroff, 2008).

Another avenue of investigation in neonatal stroke is mutation in the factor V gene (factor V Leiden mutation), which is the most common cause of familial thrombosis, an inherited deficiency of antithrombin III (Thorarensen, Ryan, Hunter, & Younkin, 1997). Although not a risk factor for ischemic stroke in adults, the factor V Leiden mutation may be associated with in-utero cerbrovascular disease and hemiplegic cerebral palsy. Anticoagulants taken by the mother may be a factor in a fetal hemorrhagic stroke. Although heparin , which inhibits the activity of thrombin in coagulation of the blood, does not cross the placenta and cannot cause a fetal stroke, anti-epileptic medications may be associated with a decrease in vitamin K-dependent coagulation factors (Ozduman, et al., 2004).

Varied outcomes and uncertainties regarding long-term prognosis following fetal strokes have been reported in the literature. Ozudman, et al., (2004) reported that 55% of the 22 children with a history of fetal stroke in their study were handicapped at follow-up ages of 3 months to 6 years. Sreenan, Bhargava, & Robertson (2000) reported that two-thirds of children in their study suffered from mental retardation, visual impairment, motor disabilities, or seizure disorders. Children with a history of fetal stroke may have good short-term outcomes but also the possibility of later onset of seizures, cognitive deficits, and sensory impairments (Roach et al., 2008; Sran & Baumann, 1988). Although motor deficits such as hemiplegia and asymmetries often are associated with neonatal infarction, signs of neuromotor impairment affecting speech, cognition, and behavior may also be evident at early school age. Neonatal or postnatal clinical evaluations have not always been predictive of outcomes; rather the extent of the damage as evidenced on the MRI is usually a better predictor (Mercuri, et al., 2004). Improvements in the diagnosis and understanding of the neuropathology underlying strokes in children have resulted in increased attention to implementing appropriate therapeutic interventions (Hartman, Lunney, & Serena, in press).

Alternative and Augmentative Communication

Management of the speech, language, and communication disorders which affect survivors of in-utero stroke can require augmentative and alternative communication (AAC) strategies, particularly when the clinical picture includes cerebral palsy. Augmentative communication is operationally defined here as a system which supports or enhances currently existing language and communication abilities. Alternative communication refers to a system which replaces the communication of non-vocal individuals (Nicolosi, Harryman & Kresheck, 2005).

According to the American Speech-Language-Hearing Association (ASHA, 2005, p. 1):
   AAC refers to an area of research, clinical, and educational
   practice. AAC involves attempts to study and when necessary,
   compensate for temporary or permanent impairments, activity
   limitations, and participation restrictions of individuals with
   severe disorders of speech-language production and/or

Modes of AAC

Unaided AAC: Unaided AAC methods, such as sign language or gestural cueing systems, require no external device. American Sign Language (ASL) is a complex visual-spatial language that is used by the Deaf community in the United States and the English-speaking parts of Canada (Humphries & Padden, 2004). It is a linguistically complete and natural language. ASL encompasses hand gestures, facial expression, and the use of the space surrounding the signer to aid in the description of places and persons. Many signs represent ideas and are therefore iconic, using a visual image to represent a specific idea (Riekehof, 1987). A number of manual sign systems, including ASL, also have been used by individuals with severe communication disorders, but no hearing impairment (Beukelman & Mirenda, 2005). Unaided AAC requires a certain level of motor control to produce signs or gestures. This method of AAC has the advantage of speed, portability, and access to a wide number of messages, but it also has limitations. Signs require a certain level of fine motor dexterity, and there is a restricted set of potential listeners, as not everyone understands sign language (Wilkinson & Hennig, 2007).

Aided AAC--Light Technology: Aided AAC involves an external component to communicate, using symbols or voice output. Light technology involves little to no technology (e. g., electronic output), but requires external aids of some sort. These may include alphabet boards, communication/ picture books/boards and communication programs such as the Picture Exchange Communication System (PECS). PECS was developed by Frost and Bondy (1998; 2002) as an augmentative and alternative communication method using operant-based procedures. Designed for children with autism and related developmental disabilities, it is a self-initiating and functional communication system that is rapidly acquired. PECS begins with the exchange of simple icons and builds sentence-like structures. It emphasizes a request function before the child responds to or comments about simple questions. An independent validation of PECS (Charlop-Christy, Carpenter, Le, LeBlanc, & Kellet, 2002) used a multiple-baseline design with three children with autism. All three children met the learning criterion for PECS, with concomitant increases in verbal language, as well as ancillary increases in social-communicative behaviors and decreases in problem behaviors.

Light technology does not provide voice output, and therefore requires a communication partner to interpret the messages that the AAC user selects.

Aided AAC- High Technology: Communication devices classified in the category of high technology may consist of a standalone device with voice output or a computer operating with communication software. A device designed specifically for communication is called a dedicated communication device, although it may be able to interface with a computer and perform environmental control functions. Computer communication devices are typically not considered to be dedicated devices, because communication is just one of the many software functions that can be accessed. The voice output provided by high technology has advantages over light technology, especially when the user is communicating in situations such as a classroom. Changes in technology continue to occur at a rapid pace with progressive changes in memory capacity, processing speeds, and battery life in high technology devices. The ability to integrate new technology such as digital cameras, a variety of software programs, scanners, and the ability to interface with the internet have resulted in a wider application of use and functions for individuals with severe communication impairments.

Types of displays: There are two primary methods of displaying symbols for communication on AAC devices: fixed (or static) and dynamic displays. In fixed displays, pages or overlays containing symbols are set up on a board or on a simple voice output communication aid. Fixed displays usually require another person to change the pages/overlays if the AAC user cannot do so independently. These simple voice output devices generally operate via recorded voice. The content of the message can be recorded by a parent, professional, or another child , and can be easily re-recorded. Overlays can be designed around a specific topic or activity, offering opportunities for commenting and requesting using that vocabulary (e.g., house overlay, art activity). The advantages of these more simple fixed-display AAC devices include the ability to record a variety of voices, music, etc.; ease of recording; and relatively inexpensive cost. Disadvantages include the fact that the user is dependent on others to create and change the symbol overlays; only a limited number of symbols are available at one time, and this limits the number of possible messages and communicative interactions (Wilkinson & Hennig, 2007).

Dynamic displays operate via communication software running on an electronic (aided) device, often a modified computer. Symbols can speak words/phrases/sentences via digitized voice. There can be links to different pages of symbols, activated via a navigation button on the device. The AAC user is not reliant on someone else to change an overlay to access additional vocabulary or messages (Wilkinson & Hennig, 2007).

In either type of display, symbols should be organized in ways that promote efficient and effective communication (Beukelman & Mirenda, 2005). One of the more frequently used strategies involves organizing vocabulary according to event schemes, routines, or activities (Drager, Light, Speltz, Fallon, & Jeffries, 2003). Each display includes symbols for the vocabulary items that are relevant to the activity or routine (e.g., vocabulary for participation in morning circle). In this configuration, the use of single-meaning symbols can also support more complex linguistic functioning through symbol combinations and the use of sight words paired with the symbols (Wilkinson, Romski, & Sevcik, 1994). In addition to enhancing participation, schematic and activity displays can promote the use of multiword linguistic structures and facilitate receptive language growth and the development of syntactic skills (Beukelman & Mirenda, 2005).

Roles of AAC as a Communication Mode: The primary role of AAC is to enhance or augment the expressive language skills of individuals who have severe communication impairments. There are no particular prerequisite cognitive skills or receptive language levels that need to be met before introducing AAC. The range of AAC options that are available makes it possible to address a variety of language impairments.

Another role of AAC is to enable the user to express a range of communication functions across different environments and with a variety of communication partners. AAC may also serve to reduce challenging behaviors such as aggression, self-injurious behaviors, or behaviors resulting from frustration. PECS training with the population of individuals with autism has often resulted in a decrease in problem behaviors and an increase in verbal speech (Charlop-Christy, et al., 2002). Students with severe communication deficits have been taught to use assistive devices in everyday environments, resulting in decreased levels of problem behavior (Durand, 1999). AAC may provide a bridge to later linguistic development through the use of orthographic or other generative symbols (Wilk inson & Hennig, 2007).

It is a common misconception that AAC may replace the possibility of speech as a mode of communication. The use of AAC may enhance existing speech skills among children with developmental and intellectual disabilities (Millar, Light, & Schlosser, 2006; Romski & Sevcik, 1996). The predominance of evidence supporting the mutual benefits of AAC to enhance speech development, as well as the acknowledged value of multimodal communication, result in reduced use of cognitive prerequisites as inclusion or exclusion criteria for services, particularly in younger populations (Wilkinson & Hennig, 2007).

The behavioral paradigm of contingent reinforcement applies to AAC intervention for children with expressive speech and language delays. If the antecedent event is a symbol presented with the spoken word, as in high-technology AAC, and the consequent event is receipt of the labeled item, both the AAC mode and speech production should increase in frequency. A meta -analysis supported using AAC to facilitate production of natural speech as well as the development of communicative competence and language skills (Millar, et al., 2006).

A number of teaching strategies have been associated with AAC interventions. In graduated prompting, the goal is to use a least-to-most cuing hierarchy (natural cue, expectant pause, general point & pause, and model), fading cues as soon as possible (Beukelman & Mirenda, 2005). In naturalistic, or milieu teaching, the emphasis is on teaching functional language skills in the context of common activities or routines. In this method, the facilitator initially provides verbal, gestural cues, modeling, or physical prompts to assist the individual to make requests. Requests are then followed by consequences that are functionally related (e.g., obtaining requested object/action) (Goodman & Remington, 1993; Kaiser, Yoder, & Keetz, 1992). The mand-model procedure has been effective in enhancing communication skills by obtaining the child's focus, then delivering a mand (non-yes/no request or command), providing an interval for a response, and providing a model of the desired response, if needed (Venn, Wolery, Fleming, DeCesare, Morris, & Cuffs, 1993).

Case Study

In the present paper we use a case study design to examine in depth a specific individual in specific situations in order to illustrate important principles that might be overlooked in examining group data. Case study research also permits evaluation of phenomena that occur rarely and that may provide exceptions to generally accepted rules. Among weaknesses of case study research are the limitations of generalization and the increased likelihood of subjective biases on the part of the investigators. However, the factors that threaten internal validity in experimental research, especially history (events occurring between the first and second measurements in addition to the experimental variable) and maturation (changes in the subjects themselves that cannot be controlled by the experimenter and whose effects are attributed, incorrectly, to the experimental treatment), may be the substance of the case study approach (Schiavetti & Metz, 2006).

This case study focused on the progression of AAC interventions for a young non-verbal child with a history of possible in-utero stroke and maladaptive behaviors. Often when young children have no consistent means of communication, they may express their wants and needs in socially unacceptable ways. AAC systems can help replace these maladaptive behaviors and often foster the development of natural speech (Cress & Marvin, 2003; Goldstein, 2002; Mirenda, 2003; Romski & Sevcik, 2005). Through this case research, we hope to support the evidence for the importance of individualized modality selection when making intervention recommendations. There has been an increase in the theoretical arguments for the use of AAC with young children but little research to inform clinical practice in this area (Mirenda, 2003). Decisions concerning appropriate AAC interventions must be made with considerations for the individual learners, in specific contexts to meet individual needs (Beukelman & Mirenda, 2005).



The child at the core of this case study, CM, a white, middle-class female, was age 4;5 (years; months) at the initiation of treatment discussed in this article. CM presented with a history of profound hearing loss in her right ear and a high frequency hearing loss in her left ear, as well as significant delay in speech skills, language skills, pragmatic skills, motor skills , and attention skills, which inhibited her participation in age-appropriate activities. According to parental report, CM had been receiving speech-language therapy focusing on American Sign Language (ASL) training. She also received physical therapy, occupational therapy, and parent training through the Committee on Pre-school Education.

According to parental report, CM was using a Phonic Ear Solaris binaural FM hearing system with headset receivers in her school setting. FM hearing systems are personal wireless systems that utilize transmitters and receivers that are small enough to be worn on a person's body. Generally, they are used to compensate for a hearing loss. This Phonic Ear FM system features a receiver that is approximately the size of a deck of cards and can be connected to a hearing aid or used with a head set, ear buds, or other accessories.

Audiological Findings: CM was first seen for audiological testing at Adelphi University's Hy Weinberg Center for Communication Disorders on May 10, 2005 (CA = 5:7). The evaluation continued for a total of eight sessions, over a period of two months. Multiple sessions were needed because of her tantrums and refusal to comply with assessment procedures. CM was accompanied to each test session by her mother, who served as informant.

Otologic history indicated that CM passed her neonatal hearing screening, bilaterally. At about 3 1/2 years of age, CM reportedly contracted scarlet fever. In August of 2003 (CA=3:10), sound field test results from another facility revealed a mild hearing loss in at least one ear. Type A tympanograms were obtained, bilaterally, consistent with normal middle ear function in each ear. Subsequent auditory brainstem response (ABR) testing (CA=4:0) yielded results consistent with a mild hearing loss at 2000 Hz in the left ear and a profound hearing loss in the right ear. Type A tympanograms were again obtained, bilaterally. An FM unit was recommended in November of 2003 for use during group language-based activities in the classroom and for individual speech sessions.

On the initial test date at the Adelphi University facility, spondee recognition threshold (SRT) testing and tympanometry were completed. An SRT of 10 dB HL was obtained in the left ear; no response was obtained when testing the right ear. Type C tympanograms were obtained, bilaterally, indicating significant negative pressure in each ear. On subsequent test dates (4 sessions), sound field warble tone thresholds were obtained at levels between 10 dB HL and 25 dB HL for octave frequencies 500 Hz through 4000 Hz, suggesting adequate hearing through the speech frequencies in the better ear.

Tympanometric testing reflected normal middle ear function on the last test date. Bone conduction testing was attempted in two subsequent sessions, but was abandoned, due to CM's rejection of the instrumentation. In her final testing session, an SRT of 15 dB HL was obtained in the left ear and an SRT of 25 dB HL was obtained in the right ear via bone conduction. Type A tympanograms were obtained, bilaterally.

At age 5:9, CM participated in transient evoked otoacoustic emission (TEOAE) testing. Left ear responses were obtained at frequencies from 1000 to 4000 Hz. Right ear responses were obtained at 2800 Hz and 4000 Hz. EOAEs reflect active cochlear processes and the presence of TEOAEs suggest hearing levels to be no poorer than 30 dB HL. The right ear responses were clearly unexpected, given the previously reported profound hearing loss. It is quite possible that these responses were artifacts, resulting from the equipment or poor probe placement. However, it is also possible that there are some surviving outer hair cells in the 2800 Hz to 4000 Hz cochlear region. A similar case was reported by Prieve, Gorga , and Neely (1991), in which an adult with a bilateral severe-to-profound hearing loss was found to have EOAEs in a restricted frequency in one ear. Unfortunately, CM did not return to this Center following this last test date, and the finding in this case could not be confirmed with a different measurement system (as was done in the Prieve, et al. study).

An alternative conclusion, based on neurologic and audiometric findings, is that part of the behavior that had been attributed to a profound hearing loss may have resulted from an auditory processing deficit secondary to in-utero CVA.

MRI Results: Following oral sedation with chloral hydrate, an MRI study of the brain was conducted when CM was age 1:11. T1, T2, and Fluid-Attenuated Inversion-Recovery (FLAIR) imaging were incorporated, encompassing all three imaging planes. The second author (RG) added ultraviolet digital enhancement to the image in Figure 1.

The MRI study demonstrated scattered abnormalities within the white matter of both hemispheres, as seen on a CT examination. There were hyper-intense signals on the FLAIR and T2 images within the periventricular white matter, most notable within the peri-trigonal white matter. In addition, there were multi-focal, more discrete areas of abnormal signal throughout the frontal, parietal, and temporal lobes, bilaterally. These were scattered within the centrum semiovale. When evaluating the white matter, there was an age -appropriate pattern of myelination, landmarks achieved. There was mild relative prominence of the lateral ventricles, without evidence for acute hydrocephalus. The major vessels were grossly patent, with no gross malformation. The skull base appeared intact.

While there is normal immature periventricular white matter seen on T2 imaging in children, the abovementioned findings are more pronounced. The hyper-intense signals on the FLAIR and T2 images within the periventricular white matter support a consideration of an in-utero stroke, where periventricular venous infarction may result in a focally enlarged lateral ventricle . Compared to the CT examination, the abnormality revealed in the MRI is more generalized but less pronounced.



PECS training and other AAC interventions were conducted at a university speech and hearing center in a suburb of New York City for 10 weeks, 2 times per week for 30-minute durations. The therapy room contained a small table and two chairs positioned facing each other. Sessions were able to be viewed via a camera system with the capability of video-taping. The room was free of visual distractions and external auditory distractions were minimal. A graduate student in Speech-Language Pathology was the primary interventionist, implementing the six phases of PECS as recommended by Frost & Bondy (2002) and later introducing Boardmaker communication boards, the 7-Level Communication Builder, and the Dynamo. A clinically certified speech-language pathologist/university professor supervised 100% of the therapy sessions and a certified speech-language pathologist with extensive AAC experience provided recommendations for the introduction of AAC materials.

CM was not receiving any concurrent speech-language intervention in another setting during the time she was seen at the university clinic.


PECS Materials: Individual cards using colored symbols from The Picture Communication Symbols Combination Book (Mayer-Johnson Company, 1994) were used as recommended by Frost and Bondy (1994) during Phases I and II of PECS training. These pictures were compiled into a PECS communication book during Phases II, III and IV. In Phase IV a sentence strip was added using a Velcro strip at the bottom of the binder with the carrier phrase "I want."

Boardmaker: Boardmaker is a graphic database that contains upward of 3,000 picture communication symbols. Each symbol may be translated into various languages and may be printed with or without text on the symbol. Boardmaker symbols were used to construct supplemental communication boards with a schematic or topic orientation and they were also used as overlays for the 7-Level Communication Builder.

7--Level Communication Builder (manufacturer: Enabling Devices): This is a self-contained speech generating device (SGD) using recorded speech and requiring paper overlays that need to be changed to correspond with each of the 7 levels. It allows the user to use 1, 2, 4, 8, or 16 different messages per level, giving a possible 112 messages (in the 16 window setting).

Dynamo (manufacturer: DynaVox): The Dynamo is a small, portable SGD using digitized speech. It has a dynamic black and white screen display and allows access to several levels.

Clinical Intervention

Baseline behaviors including sitting with trunk alignment, eye contact, and ability to transition across activities without tantrums were identified to be targeted as goals, and were calculated across the 10-week period.

Individual picture cards using colored symbols from The Picture Communication Symbols Combination Book were introduced and PECS (Frost & Bondy, 2002) training was initiated. CM learned PECS in the six phases recommended by the authors.

Phase I, How to Communicate, had the goal of training the motor response after initiation. Accordingly, CM was taught to pick up, reach, and release the stimulus picture. For the two-person prompt procedure, one clinician, who stood in front of the child, served as her communication partner, while a second clinician acted as a physical prompter behind the child, aiding in the motor response. The clinician in front used an empty hand to provide information about where to place the picture, and opened once CM reached for the picture or initiated an action. The empty hand was not used as a prompt. A consequent event (secondary reinforcement) was delivered within 0.5 sec of CM's response, and generally took the form of social praise.

Phase II, Distance and Persistence, had the goal of persistence across obstacles. CM was trained to increase the distance she traveled for the picture, or to deliver the picture to her communication partner or to her PECS book. CM was also trained to gain the attention of the clinician whose back was turned, to carry her PECS book, and to request action during activities.

Phase III, Discrimination, had the goal of demonstrating ability to select from all pictures in the PECS book. In a two-way discrimination task, CM had to select one of two choices, only one of which resulted in reinforcement. When provided with multiple choices of preferred items, CM's actions had to match her request, and she learned to demonstrate correspondence between picture and item.

Phase IV, Sentence Structure, had the goal of building toward commenting. The carrier phrase, "I want" was combined with a symbol of a desired item on the sentence strip of CM's PECS communication book. After combining the symbols on the sentence strip, CM was expected to give it to her communication partner (clinician) and the clinician then read the strip. The clinician added attributes, such as colors, to lengthen the sentence strip.

Phase V, Responsive Requesting, had the goal of responding to the question, "What do you want?" In the first step, the clinician simultaneously asked a question (which served as a cue), and pointed to the sentence starter or carrier phrase (which served as a prompt). The clinician gradually increased the interval between cue and prompt until CM was able to "beat" the prompt.

Phase VI, Commenting, had the goal of spontaneous commenting on the environment. CM was prompted to respond to the question, "What do you see?" and then to comment by combining the symbol for "I see" with an object symbol on her sentence strip.

Successful completion of each phase was attained using a criterion of 80% unprompted successful trials over two successive sessions.

Communication boards using symbols from Boardmaker software were introduced concurrent with the last phases of PECS training to motivate communication during preferred activities. Words were always included with picture symbols to enhance pre-literacy skills (see Fig. 2). A schematic or topic orientation was used, for example, a board with symbols for materials needed for an art activity. Topic strategies allow beginning communicators to initiate and establish topics of communication using various types of basic symbols. Initial training on a fixed display is often desirable to achieve symbol recognition (Beukelman & Mirenda, 2005). These same (fixed) overlays were transferred onto the 7-Level Communication Builder, an SGD with recorded voice output. Finally, the same overlays were programmed onto the dynamic display on the SGD Dynamo. Support for a transition to an SGD with a dynamic display comes from observations that speed and accuracy of use with fixed displays diminishes after 8-9 practice sessions (Hochstein, McDaniel, & Nettleton, 2004; Reichle, Dettling, Drager, & Leiter, 2000). The natural branching capabilities of the dynamic screens were used to promote phrase and sentence construction within specific activities. The use of the SGD to support more complex linguistic functioning through symbol combinations and the use of sight words paired with the symbols was the primary focus to support pre-literacy skills. The same criterion of 80% unprompted successful trials over two successive sessions was used to achieve established goals. During training with these AAC modes, the mand-model procedure (Venn, et al., 1993) was initially used. CM's attention was obtained via verbal/visual prompting, a mand was delivered (non-yes/no request or command), an interval for response was given, and a model was provided, if necessary. Intervention then incorporated more of a graduated prompting strategy utilizing natural cues in context, expectant pauses, and modeled pointing to symbols, if necessary, fading cues as soon as possible.

Long-term follow-up was conducted by interviewing the parent four years after the presented therapy protocol was completed.


Receptive Language : By the conclusion of the 10-week period, CM reached established criterion levels (80%) for following two-step directives and receptively identifying colors, nouns, verbs, adjectives and prepositions by pointing to the symbol representing the words on fixed and dynamic displays. The ability to point to letters of the alphabet when named and some sight words was emerging.

Acquisition of PECS: CM advanced through the PECS phases rapidly and met criterion (80% correct) for each phase.


Expressive Communication: At the initiation of therapy, CM exhibited significantly delayed expressive language skills, using some signs/gestures and sound combinations to communicate. Her limited communication skills may have been contributing to her problem behaviors (e.g. tantrums).

During the course of therapy, the following variables were calculated: number of responses using AAC modes; number of requests using AAC modes; number of word approximations/words used per session.

CM increased her responses (e.g. to a mand-model) using AAC modes from 3 out of 15 to 14 out of 15 trials over the 10-week period. Her requests increased from 1 out of 6 trials to 19 out of 20 trials (see Fig. 3). CM's use of word approximations/words increased from 2 in the initial session to more than 20 in the final session (see Fig. 4). Using PECS and Boardmaker boards, CM was able to label transitive verbs, independently initiate a conversational exchange, and request action.

By the last therapy session, CM had attempted the following words and/or word approximations: go, happy, house, radio, kitchen, cake, table, fruit, bath, computer, pizza, Dad, banana, TV, apple, pool, crab, ice, one, three, and five and the phrases 'I go' and 'I want.'

Behaviors : Appropriate sitting behavior, defined by postural (trunk) alignment, remaining in the chair and eye contact with the clinician increased over the 10-week period from 0% to 75% of observed intervals. CM's ability to achieve and maintain seating posture and eye contact became more spontaneous, requiring fewer verbal/physical cues from the clinician. Tantrums, secondary to CM's difficulties with transitioning across activities were observed in 90% of trials at baseline, reducing to 30% at the conclusion of PECS training and to 0% after the AAC devices (SGDs) were introduced (see Fig. 5).

Long-term follow-up was conducted via interview with the parent when CM entered the 4th grade in a public school setting. According to parental report, CM is no longer using her SGD or any other form of AAC. Her vocal speech has flourished, and CM is clearly understood by most listeners. She is receiving speech-language therapy five times a week in her school setting and once a week privately. CM is awaiting the repair of her FM system, which she continues to use in her classroom settings. According to the results of her New York State 3rd grade assessment tests, she scored above average in the English portion and met the learning standard in the mathematics portion. She is also adjusting well to pushing into mainstream 4th grade settings.





The child in this case study (CM) had previously been diagnosed with a profound hearing loss. Subsequent audiological assessments using TEOAE testing reflected active cochlear processes. These surprising results may suggest the possibility of some surviving outer hair cells in the cochlear region. Alternatively, since CM's MRI results reflect the possibility of an in-utero stroke, auditory processing deficits may account for the inconsistencies in performance. The importance of thorough diagnostic and medical evaluations, especially for the young, non-verbal child is apparent. Bax, Tydeman, and Flodmark (2006) found white-matter damage of immaturity, including periventricular leukomalacia (PVL) to be the most common finding in brain MRI scans of children with diagnoses of cerebral palsy. The authors recommended that all children with cerebral palsy should have an MRI scan to determine the extent of the damage, with the assurance that cranial MRI is a procedure that is safe to use with the pediatric population. Strokes occurring between 28 weeks gestation and four weeks postnatally are seen in at least 1 in 4,000 live births per year. These children may be at risk for long-term learning, language and behavior difficulties (McBride, 2003). The destruction of cerebral white matter or extrapyramidial tracts may play a prominent role in disturbances of motor control, including speech (Paneth, Korzeniewski, & Hong, 2005).

Over the course of therapy, AAC interventions were introduced to CM to increase her communication skills. Steadily, improvements in sitting behaviors and eye contact were observed. At the same time, CM's problematic behaviors (e.g., tantrums) decreased significantly and she was able to transition across activities with more ease. Brady (2000) reported successful use of an SGD to request by a five-year-old child with autism, resulting in increased comprehension of object names. The ability to use SGDs to communicate has been associated with a concurrent reduction in the frequency of problem behaviors such as tantrums (Durand, 1999).

Parents and professionals may be reluctant to initiate AAC interventions , because of the misconception that AAC may inhibit the emergence of natural speech production (Beukelman, 1987; Silverman, 1995). Individuals with developmental disabilities are often perceived to have the tendency to rely on methods other than speech, such as manual signs or picture communication boards (Glennen & DeCoste, 1997). However, natural speech is certainly the most efficient and expedient means of communication. Children typically chose the easiest, most efficient mode of communication, if it is within their capabilities (Millar, et al., 2006). Support also comes from the belief that AAC provides an immediate and consistent model, along with reinforcement for individuals wit h developmental disabilities, especially when there are visual stimuli and voice output (Blischak, 2003; Romski & Sevcik, 1996). It has also been proposed that AAC interventions serve as a mechanism for individuals with severe speech impairments, to bypass the cognitive and motor demands of speech production (Romski & Sevcik, 1996).

The increases in CM's communication skills, including requesting, responding, and production of words/word approximations concurrent with the use of AAC strategies, support the conclusion that AAC can enhance communicative competence and language skills. Millar, et al. (2006) found that 94% of the participants in their meta-analysis review demonstrated an increase in speech production during or following at least one in a range of AAC interventions. They concluded that the gains in speech production were observed shortly after the introduction of AAC interventions, supporting the theory of automatic reinforcement.

Too often, AAC is viewed as a last resort for individuals with developmental disabilities. Evidence supports the early introduction of AAC to facilitate communicative competence and language skills , and the development of natural speech (Millar, Light, & Schlosser, 1999). The implementation of AAC can set the stage for further language and communication development during the preschool and early school years (Romski & Sevcik, 2005).

Clinical Implications

The results of this case research support the importance of individualized modality selection when implementing AAC strategies. Implementation of PECS and SGDs using mand-model procedures and graduated prompting resulted in a reduction in problematic behaviors and a subsequent improvement in receptive language and expressive communication. Delaying the introduction of AAC strategies when behaviors and verbal performance suggest high risk for speech/language impairment can be detrimental to a child's long-term speech and language development (Cress & Marvin, 2003). AAC should not be viewed as a last resort but rather as an early course of intervention that can provide a foundation for the development of verbal language and communicative competence.


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Author Contact Information

Cindy G. Arroyo D.A., Assistant Professor

Communication Sciences & Disorders

Adelphi University

401 Franklin Avenue Room 2442

Garden City, New York 11530

Phone: (516) 877-4768


Robert M. Goldfarb Ph.D., Professor and Program Director

Communication Sciences & Disorders

Adelphi University

401 Franklin Avenue Room 2442

Garden City, New York 11530

Phone: (516) 877-4785


Janet Schoepflin Ph.D., Associate Professor and Program Chair

Communication Sciences & Disorders

Adelphi University

401 Franklin Avenue Room 2442

Garden City, New York 11530

Phone: (516) 877-3343


Danielle Cahill M.S.

Adelphi University

401 Franklin Avenue Room 2442

Garden City, New York 11530

Phone: (516) 877-4770

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Title Annotation:Alternative Augmentative Communication
Author:Arroyo, Cindy Geise; Goldfarb, Robert; Cahill, Danielle; Schoepflin, Janet
Publication:The Journal of Speech-Language Pathology and Applied Behavior Analysis
Article Type:Report
Geographic Code:1USA
Date:Jan 12, 2010
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