AAC 101: Myths and Misconceptions - Part 4

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This is part 4 of a six part series on AAC 101:  A Primer for Supporting an Augmentative and Alternative Communication (AAC) User. Look for parts 5 through 6 coming up over the next several weeks.

Myths and Misconceptions

The myths of AAC are a combination of misconceptions and misinformation.  Unfortunately they are both pervasive and dangerous.  They may continue to be perpetuated by beliefs

  • that communication must be verbal
  • that AAC is restricted to specific options
  • that use of AAC will prevent children from developing speech
  • that there are prerequisite skills that must be developed before an individual is able to use AAC
  • that AAC systems are too complex for individuals with intellectual disabilities

Not too long ago I got a call from a mother.  She was interested in looking into AAC for her child, but the school district said the child was too young.  How old was he?  He was 6.  

Last week I had the same experience.  This time, however, the child was 3.  As soon as I put a dynamic display device in front of her with core words to use in our play interactions she began to use the system independently to direct my actions and her choice of activities, including which colors of markers she wanted.  

Too soon for AAC?

Two years ago I attended an IEP meeting for a girl for whom I was providing consultation.  The school district was appalled when I suggested an AAC system as a repair strategy.  She was verbal; but with a repertoire of less than 3 dozen words.  Their response; “We’re not giving up on speech.  It’s too soon!”  How old was she?  She was 9.  

And note that I suggested an AAC system as a repair strategy, not as a replacement for speech.**

Busting the Myths:

Some parents and professionals believe that AAC is a last resort for their nonverbal or minimally verbal children, and should only be used when there is no more hope for developing speech.  

Unfortunately, this all too often means that children (and some adults) have no means of communicating for far too long; resulting in frustration, negative behaviors, and significant limitations on their language development, access to curriculum in school, access to social interactions at home and in the community, and in adapted living skills.  

Waiting too long to provide a mode of communication denies the child the opportunity to learn language, acquire vocabulary, and express himself appropriately.  Waiting too long to provide an appropriate mode too often means communicating with an inappropriate mode.  Research shows that any intervention delayed beyond a child’s first three years has less significant impact, and that children - including those with disabilities - learn faster and more easily when they are young. Lack of access to communication results in the individual being excluded from appropriate educational and vocational placements, restricting social development and quality of life.

Rather than being a last resort, AAC can serve as an important tool for language development and should be implemented as a preventative strategy - before communication failure occurs.  Romski and Sevcik  conclude that young children with complex communication needs (CCN) should receive services early in their development to augment natural speech and support development of language and communication.  Withholding AAC intervention not only impacts building language skills, but also has an impact upon cognitive, play, social, and literacy skills development.

From birth babies communicate to us.  We recognize these communicative behaviors and respond to them; reinforcing them and expanding upon them.  We do not wait until they can speak to us to recognize and build on their communications.  We do not wait until they can communicate independently to provide scaffolding for building more communication skills.  Rather we interpret what they are doing to communicate and model additional possibilities.  We work on building both nonverbal and verbal skills simultaneously.  Similarly we can work on AAC skills and speech simultaneously.

Busting the Myths:

Parents and professionals may also believe that use of AAC will stifle the child’s potential verbal skills and/or serve as a “crutch” upon which the child will become reliant.  However, research has shown that use of AAC often stimulates verbal skills in users with the potential to be at least partially verbal.  

Children need access to appropriate and effective modes of communication as soon as possible.  Without an appropriate way to communicate genuine messages, individuals frequently use inappropriate behaviors to communicate, or withdraw.  Struggling to learn to speak, while having no other way to communicate, leads usually to frustration.  

Further, those who have access to AAC tend to increase their verbal skills.  So, not only is there no evidence to suggest that AAC use hinders speech development, there is evidence that suggests access to AAC has a positive impact on speech development.  

A review of research undertaken in 2003 showed that, as a result of AAC intervention, 11% of children showed no change and 89% demonstrated gains in speech.  In studies those who showed no change did not decline in speech use as a result of AAC.  This concept was observed for many years and reported anecdotally by speech-language pathologists and others working with AAC users.  The research only backs up those observations.  AAC is now cited as evidence based practice for facilitating speech in nonverbal children.

Those working with adults with acquired speech and/or language disorders have also found benefits in use of AAC to begin to rebuild communication skills. “Adults who are experiencing chronic medical conditions use assistive technology to participate in life situations and to stay connected with the world around them.” (Beukelman, Garrett, & Yorkston, 2007).  AAC users have increased participation in a variety of interactions using a variety of communication functions and forms.

Why AAC use promotes speech development is not precisely known.  Theories include the possibility that use of AAC reduces the physical and social/emotional demands of speech and that the symbols/words provided visually serve as consistent cues and the speech output provides consistent models.  Although the goal of AAC intervention is not necessarily to promote speech production, the effect appears to be that it is a result.

Busting the Myths:

Many times parents are told children need to have a set of prerequisite skills in order to qualify for or benefit from AAC, and that their young and/or severely disabled children (and adults) do not yet possess those skills.  

In addition, some professionals believe that there is a hierarchy of AAC systems that each individual needs to move through; utilizing no- or low-technology strategies before gaining access to high technology systems.

In fact, this outlook only tends to limit the type of supports provided and limit the extent to which language may be developed.  

First, there are NO prerequisites for communication; everyone does it.  And as we’ve seen above, all children learn to communicate before learning to speak.  

Second, research does not support the idea of a hierarchy of AAC systems, and shows that very young children can learn to use signs and symbols before they learn to talk.  Research has also shown that very young children with complex communication needs have learned to use abstract symbols, photographs, and voice output devices during play and reading activities.

Requiring an individual to learn multiple symbol systems or AAC systems as they develop skills merely serves to make learning to communicate more difficult.  

One of the things we have learned about teaching individuals to use AAC systems is that the stability of vocabulary is important.  Being able to locate the words in the same location every time they use the system significantly lightens the cognitive load of looking for the words wanted or needed for a message.  The less cognitive attention that needs to be paid to finding vocabulary the more available for formulating the message. When we make the user move through a hierarchy of devices, we constantly present them with different arrangements of words; making it more difficult for them to learn.  

Channeling communicative behaviors and responses into appropriate language skills requires access to appropriate tools and sufficient vocabulary.

Busting the Myths:

Many parents and professionals believe that AAC is only for individuals who are completely nonverbal.  Students who have some speech skills are frequently not provided access to AAC systems in the belief that intervention should focus only on building their verbal skills.  

However, if speech is not functional to meet all of the individual’s communication needs - that is, if the student does not have sufficient vocabulary, is not understood in all environments, or if speech is only echolalic or perseverative - AAC should be considered.  

“Any child whose speech is not effective to meet all communication needs or who does not have speech is a candidate for AAC.  Any child whose language comprehension skills are being claimed to be ‘insufficient to warrant’ AAC training is a candidate for aided language stimulation and AAC.” (Porter, & Caffiero, 2010)

The individual who says a few words or phrases needs to increase his vocabulary and communication functions.  

The individual whose family and care staff can understand him may not be understood by others in the community.  What happens when he is trying to communicate with someone who isn’t familiar with his communication attempts or is in a different from usual context/situation?  

The individual who can repeat everything he hears - is echolalic - does not necessarily use these utterances appropriately and still cannot interact in a social, academic, or daily living exchange.  What happens when he wants or needs to say something for which he does not have a store phrase, or the echolalic phrase he uses is not appropriate to the context?  What would happen in an emergency situation?  How do you know when something is wrong?   

The individual who perseverates on a given utterance lacks the ability to formulate new utterances in the face of desiring to communicate.  Once he has his partner’s attention, how does he communicate what it is he really wants to say but cannot?

None of these individuals has functional speech to meet all of their communication needs.  All are potential candidates for AAC.

Busting the Myths:

When working with individuals with severe disabilities - particularly intellectual disabilities - many professionals assume the individual is too cognitively impaired to use AAC.  

Kangas and Lloyd (1988) wrote that there is no “sufficient data to support the view” that these individuals cannot benefit from AAC because they have difficulty paying attention, understanding cause and effect, don’t appear to want to communicate, are unable to acquire skills that demonstrate comprehension of language,  are too intellectually impaired.

Unfortunately there continues to be this misconception, and professionals continue to posit arbitrary skills that individuals must attain before providing AAC intervention.  All too often professionals - and even family - underestimate the potential abilities of these individuals.  

We must proceed with the notion of the “least dangerous assumption.”  That is, we must proceed with the plan that, if we are incorrect, will cause the least damage to the individual.

Believing the individual can acquire communication skills, we proceed with a plan to provide an AAC system and intervention.  There can be no damage from providing someone with a way to communicate.  

If we believe the individual cannot acquire these skills and thus do not provide an AAC system or intervention, we have done immense damage if we are wrong. Poor performance is more often related to the competence of the intervention; not of the individual.

The relationship between cognition and language is neither linear nor one of cause and effect; they are correlative.  They are intertwined in a very complex way.  We cannot say that a specific level of cognition or skills needs to happen before language develops.  They are interdependent.  We often see language skills in the (supposed) absence of expected cognitive skills.  

Research and observation continue to indicate that there is no benefit to denying access to AAC to individuals with significant disabilities.  Intervention should be based on the idea that learning is based on the strengthening of neural connections through experiences and that repetition of these connections through multiple modes facilitates learning.  Providing users with rich experiences with their AAC systems builds on the neural patterns and facilitates communication skills building.  Not providing AAC services based on preconceived ideas about the cognitive skills of the individuals simply continues to segregate and limit access to life experiences for them.

Busting the Myths:

Many school districts also subscribe to the idea (some call it a myth) that the PECS is sufficiently robust.  

The Picture Exchange Communication System (PECS) is widely used in school districts as the AAC system provided to students. It is good at establishing communicative intent in a child who does not appear to demonstrate this.  In fact, it originated as a way to teach children with autism how to initiate communication by approaching others.

PECS books use velcro to move symbols between their pages and the cover sentence strip.  

Use of velcro means a lack of stability; pictures can be in a different location every time the child opens the book.  Too much cognitive energy can be consumed by trying to find the picture wanted.  Learning through motor planning, which research has shown to be effective for some is obviated by use of velcro and random vocabulary positions (think about getting into a rental car whose brake pedal is in a different place).  Effective AAC users pay little attention to the symbol; rather they rely upon location and motor patterns to find vocabulary.  Instability of vocabulary location can eventually lead to frustration.  And the increased effort needed to use PECS will often lead to the child abandoning it.

PECS books have limited vocabulary.  

I once encountered a young girl who was small and slight.  She had a PECS book that was a large 3-ring binder with many pages full of velcro’d pictures.  It was almost as heavy as she was.  It required someone else to carry it around for her.  It was an effort for her to find the word she wanted at each communicative attempt.  And while teachers, SLPs and parents continued to add vocabulary to it, most of the vocabulary available was nouns.  How was she expected to expand her language skills without the building blocks of syntax?  Where were the adjectives (other than colors) to elaborate.

Busting the Myths:

Unfortunately, there are also those who believe that simply providing access to an AAC system will solve the communication problems of the user.  

The AAC system cannot “fix” the individual or their communication difficulties.  While use of AAC will facilitate development of speech or language, and of literacy skills, and will increase the individuals’ ability to communicate effectively, it will not do so simply by being there.  

The AAC system is a tool and, like any tool, the user needs to know how to use it.  And for most of those individuals, direct, specific, and structured intervention and opportunities need to be provided.  

Users and their partners need to accept the AAC system; they also need appropriate instruction in how to use the system and how to develop effective communication and further language skills with the system.  

One problem often encountered with adults with acquired communication disorders; such as stroke, ALS, or TBI, is acceptance of the device.  This difficulty of acceptance can be present on both sides of the communication exchange.  It is difficult for adults who have been independent communicators to accept the new and usually sudden changes in their abilities and reliance on others and on assistive tools.  It may also be difficult for caregivers who have not been adequately trained to use the AAC system to accept that this is a necessary tool.  They may not understand the importance of the AAC system in allowing the individual to maintain social, medical, and daily needs connections.  Care givers often say, “I know what he wants,” or “Oh, I understand him.”  But they cannot possibly know everything that the individual might want to say.              

The success of the AAC system is not dependent upon only the individual’s skills and cognitive abilities.  It is also not only dependent upon the completeness or robustness of the AAC system.  It is strongly dependent upon the willingness, training, and responsiveness of partners.  Partners who do not understand the need for the AAC system are less likely to respond to the individual’s communication attempt with it.  If the partners have low expectations of the AAC learner, do not respond consistently, do not use aided input consistently or do not provide sufficient communication opportunities the AAC learner is not likely to progress.  Communication partners have a significant responsibility.  

Susan Berkowitz, MS CCC-SLP, MEd., has been a speech-language pathologist for 40 years. She has worked mostly with children and adults with Autism, Cerebral Palsy, and other developmental disabilities, as well as 8 years in the language-based classrooms in a school district. Susan has worked in public and non-public schools, residential settings, and nonprofit community agencies. She has written for peer-reviewed professional journals and presented at international conferences. Visit her website  and blog for additional resources. For her complete resume, click here.

References
Beukelman, D. R., Garrett, K. L., & Yorkston, K. M. (Eds.). (2007). Augmentative communication strategies for adults with acute or chronic medical conditions. Baltimore, MD: Paul H. Brookes Publishing Company.

Kangas, K. A., & Lloyd, L. L. (1988). Early cognitive pre- requisites to augmentative and alternative communication use: What are we waiting for? Augmentative and Alternative Communication, 4, 211-221. 

Porter, G, & Caffiero, J. (2010). PODD Communication Books: A Promising Practice for Individuals with Autism Spectrum Disorders. Perspectives on AAC; ASHA. 

AAC 101: Who Should Use AAC and Why? - Part 5

AAC 101: Terminology - Part 3