Technology updates rapidly, however, so the equipment examples provided in this slide set will likely have changed by the time you are listening to it. The principles of ACC, however, are the same for everyone. They are to allow for augmented or facilitated speech, and they will not reduce the ability of someone to learn language or to talk. They will improve behavior, typically, in a child who is very frustrated with not being able to make their needs known, so AAC needs to be implemented as soon as possible. The beneficiaries of AAC can include virtually any diagnosis in pediatric or adult patients. Some children may not have a voice because they have a tracheostomy, others because they have an expressive apraxia, or receptive language difficulty, which makes it hard for them to put together their thoughts in a way that allows them to respond in an appropriate time manner. There is no age limit for this, so all children should benefit and be allowed to be assessed. AAC and technology devices are covered by insurance, including Medicare and Medicaid. As part of the Assistive Technology Act, the state and federal government needs to fund assistive device technology to the appropriate patients. AAC assessments are typically done by a speech pathologist who specializes in this area, as it is quite technical, and having a vendor come in to show one device is not a really effective way to pick the appropriate one for a child. Vision and OT will be involved because the device requires fine motor coordination and the child may have difficulties with this. Vision can also, of course, impact the device chosen. Schools will often be able to consult CISA agencies to get expertise and recommendations since they often do not have a speech pathologist that specializes in this area. Devices can be obtained through an IEP, but the problem is after school and in the summer, the device typically would not go home, so the child would not be able to communicate and get practice with the device in normal settings. Therefore, most of the time, we look to insurance to provide these devices. A crucial part of this all is that the parents, siblings, friends, and teachers are all trained to use the device so that the child does not become frustrated with either that technology or the speed at which others understand him. It is very important that there be practice and speech therapy sessions with groups at times to test and practice with these devices. The first questions to ask when assessing someone for AAC is who are they going to talk to and when and where will they be talking to them? Who's going to program this device and keep it up to date? Who's going to train the parents, siblings, or teachers to use it? Does the child have the motor, cognitive, and visual skills to use a particular device? And how will the device be placed within their reach? Will it be around their neck on a string so that it has to be lightweight or will it be placed on their wheelchair, but during dystonic or athetoid movements, not swept off and broken? When referring for AAC, the child's ability to communicate with others socially in an appropriate manner has to be considered as well as their ability to understand written and spoken language. Do they have the fine motor or cognitive skills to use a particular system? And do they have the strategic ability to know when to use the AAC device and when to perhaps use facial features? Also, their motivation and attitude about it are crucial, as if they and their parents are not invested, the device will never be used. The typical assistive technology speaker is pretty passive. They don't initiate conversation, they don't understand social pragmatics, they don't know when to take a conversational turn, and they really don't have a lot of practice with peers to learn these skills. The typical speaking partner dominates the conversation, wants the person to speed up, and anticipates what they're going to say so it doesn't give them a chance to finish their sentences. These problems can be addressed with speech therapy, however, and with a type of AAC chosen. For instance, gestures or facial expressions are rapid and can convey very simple messages and make communication exchanges very easy. Gestures, photographs, or pointing to objects can convey perhaps more complex messages, but are still fairly quick and fairly easy for someone to learn. The speech generating device, however, can provide the most complex messages and ability to communicate, but also requires, of course, the most training. Sign language is pretty popular with birth to three therapists, but hardly anybody, once you enter school, will know the signs, so it isn't a very practical way for patients to communicate. Gestures can work if you're not athetoid or dystonic or spastic, eye gaze can work if your head is stable, and verbalizations can work if you do not have dysarthria. However, many children have all of these issues. Therefore, a speech generating device, or AAC, can be very crucial. When using an AAC device, symbols replace words many times. They can be drawings, photographs, or alphabet-based systems. They vary by culture and by the patient's cognitive ability to understand them. Icons are just symbols and what they might mean. A great example is a picture of an apple. In some communication systems, this may mean the color red. It could mean an apple itself, or it could mean just fruit as a general category. Another patient might think that it means school. Icons can be put together to give ideas or phrases, and sometimes this can be very efficient, but it's very open to interpretation. Manual communication devices are a bit slow, but they are easy and inexpensive. These might require eye control or good, fine motor coordination to hit the exact picture that you want. The picture exchange system, often used with autistic patients, requires that you pull a photograph or a picture out of a card ring to show what you want. Again, a picture of a glass versus a photograph of a glass can mean very different things. Communication boards and eye gaze boards are simple places to start, and some therapists feel that if you cannot master this, you cannot go on to a higher device. However, many times we've seen that children are bored with this because they are already adept at iPhones and iPads, and sometimes you just need to move on. Perspective ability, fine motor skills, and of course, who's going to pay for this are key features in deciding what device might be used. Secondary things such as portability, how long the battery lasts, how willing other communication partners are to learn something that might seem somewhat technological, and how much support you will have to update the device, such as having a local vendor or a local speech pathologist that specializes in this are very important. Devices can be accessed in many ways, with a pointer or a mouth stick, with your eyes, with any body part that you can control, and the force needed to activate these switches and the finesse in order to get to exactly the right spot, especially when scanning, can really impact the choices made. Simple switches, such as the Big Mac, are inexpensive, don't require a lot of cognitive ability, and don't require a lot of fine motor ability. They can be programmed with a parent voice or a child's voice to say something that they want, and the patient can activate it with an elbow, a hand, or a foot. The four-button devices, such as the Cheap Talk, might be pre-recorded to say, I want a toy, I want the bathroom, I want a drink. And these do not require a lot of, again, cognitive or fine motor skills to be able to use. They are a great way to start a child down the road of learning to use technology. Talking books can also be utilized, where a parent pre-records a message related to each photograph. iPads are popular because of their availability and their cost. Most schools already have these and have no problem putting the fairly inexpensive apps on them that allow for communication. The device, however, should only be used for communication, not for playing games. Patients will often have two iPads, one for talking and one for doing other things. The next level up of low-tech devices might include something like the Cheap Talk or the Go Talk, which have fixed buttons with pictures on them that you can program and hit in a variety of sequences. However, they don't have different layers to the program, so the static displays are only able to tell you what is there at the moment. They can be changed out over time as you get better, but as you can see, these are very simple. Yes, no, up or down, fingers, etc. The dynamic displays are able to show more levels of information and can have multiple meanings for icons. An example of this would be a Dynavox or a Tobii Eye Gaze, where you go through one button to hit food, and then the next layer will come up what types of food, and then the next layer will come up exactly what item you want. They are much more complicated and they take more time because you have to go through different layers to get information. This requires better cognition, better vision, better hand control, and some abstract thinking ability. Direct selection versus indirect selection. You can read here what the differences are and why you might choose one for a certain patient or a different one for another. Some speech generating devices are keyboard based, so that you can type a message and then they will then state or read the information for others. Some of these have synthesized speech, which is not very natural sounding, but can take a variety of thoughts and create a message individually. Digitalized speech has pre-recorded sound, so does not have the option of making new messages with different content, but only uses what has been pre-recorded. Here is a chart that explains that. So in summary, referrals for AAC should be made early. A child can utilize some type of communication system virtually at any age and it will reduce behavioral problems related to frustration. Upgrades of technology occur all the time, so a child needs to see a speech pathologist who is very savvy in this area on a repeated basis, and that may require going outside of the school system. Their communication partners have to be invested or they will be so frustrated as the communication user that they will give up using their device. About a third of AAC users do give up because of equipment breakdowns, their family being the dominant fast communicator and not waiting for them to give their thoughts, and because it is just simply easier to look at their face and anticipate what they want. But AAC is crucial for children that are going to become adults and have to communicate with others that do not know them as well, and it will provide many good skills for them in the future. Question one, all of the answers to these are at the last slide. A three-year-old child with verbal apraxia, good receptive language skills, and normal fine motor skills should have what type of device? Question two, what would be the most significant reason that a 21-year-old AAC user who has just gotten out of high school through the special education program, why would he abandon his system? Question three, if a referral for AAC is rejected by the family because they feel it will stop their child from developing verbal skills, what would you tell them? Thank you for listening.

AAC

Augmentative and Alternative Communication

communication difficulties

speech pathologist

devices