Revisiting AAC abandonment: the SLP perspective

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Last month, we reviewed an article about parents’ perspectives on why their children’s AAC devices ended up rejected or abandoned. (Are you picturing a sad, dusty cabinet full of non-functional GoTalks and retro Dynavoxes? I am.) Now, we’ve got a natural companion piece from the same authors, flipping the script and talking to a group of Australian SLPs about similar situations.

Sometimes these interview-based studies tell us a lot of what we already know, and can lead to the pessimists among us getting bogged down in Barriers-ville. This one, though, has some thought-provoking and useful ideas for working with families to implement AAC systems more successfully.

First, commit yourself to family-centered practice. Specifically, the authors discuss:

  • Stepping up our counseling to help families move through any grief and increase their readiness for AAC.

  • Helping connect families of AAC users so they can support each other.

  • Moving away from a deficit mindset with families (they’re overwhelmed, they’ve got other priorities, they don’t have the resources…) and capitalizing on their strengths.

  • Focus on relationships, and bring families into the process as much as possible, through device trials, hands-on support, and follow-ups.

Next, orchestrate some early wins. Families may need to see their child being successful with AAC to overcome doubts, resistance, or previous negative experiences around devices. This might mean making an effort to share progress from speech sessions (via videos, maybe?) or even starting off with simpler systems like activity displays, to build momentum and motivation, before jumping into a complex device*.

Finally, this last point is the part where we clinicians need to humble ourselves a bit. Sometimes devices don’t work because the SLP didn’t recommend the right system for that child. We all have our favorites, the ones we know best, the ones we like most for many, totally valid reasons. But we can’t unilaterally impose that preference on our clients. That’s clinician-centered, arrogant, and just less likely to work. Clinician experience is also important here. The study authors suggest that having newer grads supported by seasoned AAC pros could improve device acceptance.

Selecting and implementing AAC is a complex balancing act between the user, the device/system, the family, the environment, and the clinician. Like the EBP triangle, but more of a pentagon? When we don’t consider all those factors, we’re risking another addition to that sad cabinet of lonely devices.  

*This is NOT to suggest that kids need to start with low tech AAC, or implying any prerequisites to using a robust language system.

 

Moorcroft, A., Scarinci, N., & Meyer, C. (2019). Speech pathologist perspectives on the acceptance versus rejection or abandonment of AAC systems for children with complex communication needs. Augmentative and Alternative Communication. doi:10.1080/07434618.2019.1609577

Why did that AAC device fail? Listen to parents for insight.

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In AAC evaluations, we do our best to select a system that meets the client’s and family’s needs, but far too many AAC systems are rejected or abandoned. Why does this happen—and can we prevent it? Since families are so important in implementation, one way to approach this challenge is to understand family members’ experiences of AAC that didn’t succeed for them.

The authors of this study interviewed 16 mothers who rejected/abandoned an AAC system for their child with complex communication needs when he or she was 6 or younger. The systems included sign-based systems and low and high tech devices. So it’s not that parents dismissed a certain type of AAC; rather, parents rejected or abandoned any AAC system that did not meet the needs of their child and family. It makes sense that some reported abandoning systems if the child did not use them to communicate, but the other main barriers were related to parent needs and values. We’ve laid them out for you below along with suggestions to beef up your support.

  • Barrier: Lack of emotional readiness or resilience to implement AAC

    • Support Strategy: Incorporate counseling with a focus on experiencing disability and readiness to use AAC

  • Barrier: Lack of satisfaction with the AAC system

    • Support Strategy: Get on the same page with families about their values regarding cost, functionality, and language level of AAC systems

  • Barrier: Extra work associated with implementing AAC

    • Support Strategy: Focus parent education on efficient support strategies and how to embed AAC in family routines

This qualitative research article is also jam-packed with parent quotes. To get you geared up for family-centered practice in AAC, there’s no better way to get started than to read straight from the source.

Moorcroft, A., Scarinci, N., & Meyer, C. (2019). “I’ve had a love-hate, I mean mostly hate relationship with these PODD books”: Parent perceptions of how they and their child contributed to AAC rejection and abandonment. Disability and Rehabilitation: Assistive Technology. doi:10.1080/17483107.2019.1632944.

Input–output symmetry: why it matters for AAC users, and a word list to help

Child output = speech

Adult input = speech

Child output = AAC

Adult input = speech……. Whoops!? See how that might be a problem for learning?

How about:

Child output = AAC

Adult input = aided input (pointing to graphic symbols during speech)

“Among children with complex communication needs, vocabulary selection for aided AAC has almost exclusively been driven by consideration of expressive language needs. However, receptive language is critical to expres.png

No matter a child’s mode(s) of expressive communication, it’s our job to help ensure that they are getting receptive examples that match their expressive output, as often as possible. How? Encourage parents to use aided input, right? Simple!

Not simple. Consider this—are the words the family uses most frequently on the child’s device? Often times children’s AAC is programmed only for the child’s lexicon. But shouldn’t it also be set up for the words s/he is learning?

To help tackle the input–output asymmetry issue, this paper provides a list of words you may want to consider for programming young clients’ communication systems. The list is a compilation and comparison of data from three large sets, identifying words mothers use most frequently when speaking to their toddlers, as well as words most commonly spoken by toddlers and preschoolers.

They found that just over 250 words comprise most of mothers’ child-directed speech, with considerable overlap between mothers’ most frequent words and the words used by children (and this includes children unrelated to the mothers!… but arguably from similar cultural backgrounds). Another interesting finding: some mothers talk more than others (like, four times more), but the difference in lexical diversity among mothers (that is, number of different words) isn’t so high.

Though limitations include the fact that this research was done on typically-developing children, and it’s a new analysis of a ton of old data (from the late 80s forward), it “…provides a beginning place for guiding vocabulary selection.” So, basically, this list could be very useful as long as you take generational and cultural considerations in mind. So maybe add words like “tablet”? And please just ignore the fact that the data is on “mothers”, not parents in general—the world wasn’t as woke 20 years ago. 

This review is published in both the Early Intervention & Preschool & School-Age sections. 

Quick, N., Erickson, K., Mccright, J. (2019). The most frequently used words: Comparing child-directed speech and young children's speech to inform vocabulary selection for aided input. Augmentative and Alternative Communication. doi: 10.1080/07434618.201

Note: You can also find a link to this research at the author’s institutional repository, here.

Training natural communication partners how to model AAC

Model, model, model! We all know how important and effective AAC modeling can be (see here and here, for example)—however, modeling is only as good as the partners who are implementing it. If you’re working with kids who use AAC, chances are there are communication partners who need guidance in how to model, and that’s no simple task. If you’re thinking “I agree, but HOW do I teach the partners?”, this review is for you!

The authors of this study gathered 29 studies in which more than 250 communication partners (including peers, teachers, paraprofessionals, parents, and other adults) implemented modeling strategies across various settings. Although they looked at a handful of research questions, the most clinically relevant questions were: How were the communication partners trained and what did they have to say about the training they received?

The most common training strategies were:

  • orally sharing information

  • modeling the strategies, and

  • allowing the partners to practice in controlled settings (role plays), or with a child, while providing feedback

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Overall, partners rated instruction as worth the time, easy to understand, practical, and transferable to other children. Some additionally offered the suggestion to provide more direction on how to model during a child’s regularly occurring activities (something to consider when you are providing training).

Seems pretty straightforward, right? We train the partners using those strategies and then off they go? Not so fast. The authors found that most communication partners also benefited from simultaneous support while learning to model. So after you train the partners, it’s important that you stick around to offer coaching and consultation as necessary.

If this seems daunting (how can I possibly fit this into my already jam-packed day!?), it’s important to remember that teaching communication partners can drastically improve the reach of our interventions—the amount of time we spend with our students is so limited compared to their interactions with natural communication partners.

If partner instruction is something you’d like to improve, be sure to check out the full article (specifically Table 2) for a list of the included studies and the training strategies used in each.

 

Biggs, E. E., Carter, E. W., & Gilson, C. B. (2019). A scoping review of the involvement of children's communication partners in aided augmentative and alternative communication modeling interventions. American Journal of Speech–Language Pathology. doi: 10.1044/2018_AJSLP-18-0024

Mistakes preschoolers make in multi-symbol utterances using AAC

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Preschoolers learning to communicate via AAC systems typically start by using one symbol at a time. Many go on to construct 2–3 symbol utterances, but make mistakes along the way. In this study, the researchers looked back at data from a prior study to explore 10 three–four-year-olds’ errors when producing multi-symbol utterances. In total, they made errors on 45% of their utterances!

We’ll get to those errors, but first, some background. All the preschoolers had a speech sound disorder/delay diagnosis, although one child also had a secondary ASD diagnosis and another was diagnosed with cerebral palsy. During the intervention sessions, the kids used an AAC device (an iPad with Proloquo2Go) to describe videos, then the clinician briefly modeled the targets and facilitated play-based therapy for 20 minutes. Keep in mind that the preschoolers didn’t have access to the device outside of the study, and 8 of the 10 participants actually had no prior experience with AAC before the intervention.  

Because AAC literature has focused heavily on inversions (word order reversals), the researchers checked for other error patterns.

 
The Complexity Approach for Grammar_.png
 

The main takeaway? Inversions and omissions were more common than substitutions and additions overall, but there were differences across targets and—business as usual for AAC studies—there were differences across the children in the study.

So, what can we do with this information? For starters, when you collect data, think beyond the number of words in the utterance. Instead, try classifying the types of errors the students are making. Are they inversions, substitutions, omissions, or additions? We’d wager that you’d approach instruction just a little bit differently depending on the error type—and that type of modification to your instruction could make all the difference!

FYI: As we mentioned, data analyzed here was originally collected for a different study. Although the data set isn’t perfect, this is the first study we have that conceptualizes the errors these children might be making. Also, keep in mind these targets were chosen specifically for speakers of English, which has a Subject + Verb  + Object syntax structure.

 

Binger, C., Richter, K., Taylor, A., Williams, E. K., & Willman, A. (2019). Error patterns and revisions in the graphic symbol utterances of 3- and 4- year old children who need augmentative and alternative communication. Augmentative and Alternative Communication. doi:10.1080/07434618.2019.1576224