TALKING WITHOUT SPEAKING: Developing the communication of adults and children with learning difficulties

Karen Henderson introduces the many aspects of Augmentative and Alternative Communication Karen Henderson, Senior Speech and Language Therapist, Cheeverstown House, Templeogue, Dublin 6W

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Did you know that the majority of our communication attempts are non-verbal? That most meaning is not derived from the words that we use, but the accompanying tone of voice, facial expression, gesture and body language? We have all experienced the challenge of buying something on holiday when we don’t speak the language. Although the process is time-consuming, we inevitably get the message across through a combination of gesture, pointing and mime. Our attempts at the foreign spoken word are generally redundant! This can prove intimidating to many people who prefer to avoid the situation or give up half way through.

If this can happen when engaging with someone who does not have a learning difficulty, it is not surprising that it should happen while communicating with someone who does. Many people find it difficult to interpret their communication attempts and are unsure of how to communicate back. Unlike our foreign shopkeeper, individuals with learning difficulties are often not skilled at adapting their messages to the listener. They may have limited means, if any, of reorganising their message if they are not understood and are unable to analyse the situation from another’s point of view.

What is needed then, is a method of communication that is both meaningful to the individual with learning difficulties and transparent to the people they are communicating with. Such methods come under the umbrella term of Augmentative and Alternative Communication (AAC). This refers to any system that acts as an alternative to or supplements spoken language.

Different forms of AAC

AAC comes in many varied forms that suit individuals of varying abilities. No one method should be used in isolation; a total communication approach encompassing a number of forms is preferable.

  1. No-tech (no technology): This refers to communication behaviours such as eye pointing, gesture, sign language, pointing, vocalisations, etc
  2. Low-tech (low technology): This refers to objects of reference, photograph/picture symbol-based systems (e.g. Boardmaker & PECS) and simple message communicators (e.g. Big Mack).
  3. High-tech (high technology): This refers to more complex electronic voice-output devices and computers.
CHOOSING THE MOST APPROPRIATE AAC SYSTEM

Although there are no pre-requisite skills required for an AAC system, a thorough assessment is necessary in order to choose a tailor-made system. A joint speech and language therapy/occupational therapy assessment is necessary in order to determine the following:

  • Symbolic level: Does the individual recognise objects, photographs, picture symbols or text? There is a developmental sequence we all pass through as young children. Objects are the most readily recognised representations, but as our knowledge of the world develops, we learn that those objects can be represented in different ways. Individuals with learning difficulties may not progress through the entire developmental sequence, so it should not be assumed that they can recognise photographs or symbols. Learning to use the system communicatively is difficult enough, but it is doomed to fail if the materials are not meaningful.
  • Access: How will they choose the item? Can they isolate a finger to point to the items? If not, can they fist point? Do they need a prop (e.g. pointer etc.) to facilitate using their hands? Can they pick the item up? Is their eye-pointing refined enough to look at what they want? For more high-tech devices, an OT should also be asked to assess for the most appropriate access point and method of scanning. There are many different methods of access on the market and many methods of mounting them securely and appropriately to wheelchairs, tabletops, etc. It is crucial that this is chosen wisely—the best communication system in the world is redundant if it is too difficult to use.
  • Layout: How many items can they deal with at once? How far apart should they be spaced? How large or small should the items be? This is particularly important in facilitating accurate finger and eye pointing. This relates to the clarity of the system to the listener. If they cannot distinguish what the user has chosen and the user is unable to clarify the message, this can lead to frustration and there is a danger that the system will be rejected.
  • Content: What does the individual need to communicate? There is often a tendency to include lists of items that the user might need to request, but it is important to include other vocabulary types (e.g. verbs, adjectives, social words, etc.). A system should encompass many forms of communication other than requesting—such as commenting, asking questions, teasing, volunteering information, describing, etc. For more able people it is important to recommend and set up the system in a manner that will facilitate the development of language, grammar and (perhaps) literacy over time. This can be done by means of colour-coding the various parts of speech, including text on picture items, phasing in the next representation (e.g. moving from photo to symbol) etc. There is a developmental language sequence involved and the speech and language therapist’s expertise is invaluable.
  • Rationale: What is the system needed for? Is it needed to facilitate an individual’s expressive language or can it be used to facilitate their understanding? The answer is both! An individual’s communication system can be used to supplement an educational curriculum and teach new concepts of language. This is a particularly useful course of action if you wish the items to be used expressively in the future—we have to understand it before we can use it. Developing a representation of the daily timetable can be an invaluable tool in teaching the concept of time and sequence. It can facilitate the transition from one activity to another, for individuals who find it difficult to accept changes in their routine.
SPECIFIC AAC SYSTEMS
Objects of reference:

This is a term that describes the use of objects to communicate activities, events, people, ideas, etc. They can range from concrete to abstract representations (i.e. cooking = wooden spoon, miniature spoon, piece of tin foil, etc). Objects of reference are traditionally used by individuals who have visual impairment or who do not understand photographs/picture symbols. They provide a bridge to more complex representations and help people make choices about what they want to do. Objects can also be organised into a timetable to represent the activities of a day, and can be used to introduce a new activity or event for individuals with more severe learning difficulties. More able individuals may learn over time to choose an object and take it to another person to request an activity.

Communication books

Photographs and picture communication symbols can be arranged in a number of different ways. The layout will depend on the size and number of targets that the user can scan and access at one time. The format can be organised in an infinite number of ways depending on the following:

  • Portability: How is the vocabulary to be stored and presented? E.g. binders/filofax/individual items attached to a board or ‘Talking Mat’ with Velcro™/photo album etc. Does it need to be compact enough to be carried by hand or in a pocket?
  • Organisation of materials based on the language skills of the individual: e.g. category-based, syntax-based, topic-based, use of a core vocabulary on each page etc.
  • Visibility: Is the communication book readily available to the user, carer, and teacher? If a wall-mounted timetable is being used, is it visible? If the teacher is using materials to supplement the curriculum, are they organised in a user-friendly manner? Photographs, symbols and text can be further reinforced if they are used as ‘signposts’ around the home, classroom, centre etc. By this, I mean attaching photos etc. to specific items (e.g. door, window, phone, shelf), which engineers the environment, making it AAC-friendly. Corresponding symbols can also be added to each page of a favourite book or organised into song boards to be used in morning circle, for example. The more frequently materials are seen, used and reinforced, the quicker they are learned.
  • PECS: (The Picture Exchange Communication System)

This programme was developed in the USA in response to the difficulty in training children with autism to communicate. It involves training the individual to use a picture to request a particular item. This approach has proved very successful for individuals with autism who require this form of structured training to learn how to communicate with others. In its purest form PECS may be less useful with individuals who have a learning difficulty, who may already have the basic communicative behaviours of eye contact, requesting, etc and may have difficulty understanding the PECS materials. (Ed. Note: It is hoped to have a full article on PECS in our next issue of Frontline.)

Lámh:

Lámh is the most commonly used form of sign language within learning disability services. It is a signed vocabulary system that supports both comprehension and expressive language development. The signs visually reinforce language where the auditory route alone may be difficult to cope with. There a number of factors that need to be considered to ensure Lámh is a success, for example, does the individual have sufficient hand function to be able to make the signs? An OT assessment is important in deciding what signs might be introduced, based on their physical abilities. Are the family, carers and school staff etc willing to use Lámh on a day-to-day basis? If the signs are not used and reinforced, they will not be generalised. Does the individual understand that signs are meaningful and do they have something to communicate? Lámh is often a motivating method of communication, as is it immediate and intrinsically produced. (See article on pp. 20–21.)

Single message voice output devices:

These devices are in the low-tech category and include Big Macks, One Step Communicators, Talking Frames, etc. They are communication aids onto which a single message is recorded and activated by pushing a button or the top of the device. This is a simple device that enables an individual to exercise some control over their environment and connect socially with other people. It can be used in the following ways:

  • bringing news to and from school
  • joining in a story by recording a phrase that is repeated throughout the book e.g. ‘I’ll huff and I’ll puff and I’ll blow your house down.’
  • ordering food in McDonalds etc
  • requesting a turn
  • attracting attention
  • joining in songs and games
  • running errands
High Tech devices:

This refers to the more complex voice output devices, including computers. There are a wide range in the market and the cost can run to thousands of euro, therefore a comprehensive assessment is vital. There are two main types of device, static and dynamic. Static devices have a picture overlay that remains unchanged until another is physically affixed. Dynamic devices have a computerised screen that changes much like windows on a PC. It can be programmed so that when a picture is accessed, the screen changes e.g. touching the dinner picture might change the screen to a page of food items etc. Both types of device are programmed to speak out a message once a picture is accessed with both synthesised and recorded voice options available. Both types of device have equal merit and suit different types of user. A speech and language therapist and OT generally carry out the assessment to determine which device is most appropriate, how the vocabulary should be organised/programmed and how it should be accessed.

ENSURING SUCCESSFUL USE OF AN AAC SYSTEM

Failure to develop the use of an AAC system, if an adequate assessment has been done, will nearly always be due to a failure to implement the system properly. Implementing AAC consumes an enormous amount of time and energy from therapists, teachers, parents/carers and the user. There are a number of strategies that will facilitate successful AAC use:

  • Ensure the system is as accessible as possible
  • Identify the appropriate symbolic level
  • Develop comprehension of language alongside expressive language
  • Use appropriate spoken language with the user
  • Ensure appropriate messages and vocabulary are available on the system
  • Use a variety of AAC systems (no tech, low tech and high tech)
  • Does everyone involved know about the system and how it is used?
  • Create communication opportunities
  • Offer choices
CONCLUSION

AAC is an invaluable tool in developing the communication of individuals with a learning disability. As there is a growing market for low- and high-tech systems, a team assessment is vital to ensure the most appropriate system is chosen and that it is fully accessible and available for use. There is a responsibility on all involved to ensure that opportunities are created that will motivate the individual to use their AAC system and help them see the value in communicating with others.

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