Evidence-based AAC Interventions for Infants, Toddlers, and Preschoolers

1
Evidence-based AAC Interventions for Infants,
Toddlers, and Preschoolers

• Janice Light and Kathryn Drager
• Penn State University
• Seminar presented at ASHA 2007, Boston

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The Penn State Team

• Jen May
• Holly May
• Ashley Maurer
• Rebecca Page
• Elizabeth Panek
• Sarah Pendergast
• Kate Shapiro
• Nicole Sherman
• Kristin Stoltzfus
• Melissa Witte

• Emily Angert
• Julia Birmingham
• Jacky Cammiso
• Jen Curran
• Elizabeth Hayes
• Melissa Ihrig
• Lauren Karg
• Line Kristiansen
• Wendy Lewis
• Ashley Marzzacco

3
The challenge

• How do we provide access to the magic and the
  power of language and communication for young
  children with complex communication needs who
  require AAC?

4
What did I learn watching my kids learn language?

• Young children
• Start learning communication language at birth
• Learn language during daily activities in their
  environment, especially play
• Learn language in the context of social
  interactions with familiar partners
• Communicate not just to express needs and wants,
  but also to build social closeness and share
  information
• Social interactions are prime times to build
  language
• Depend on context to learn language
• First words are context-bound

5
What did I learn watching my kids learn language?

• Young children
• Receive scaffolding support from their parents to
  help them learn language
• Parents provide opportunities for communication
  language learning
• Parents adjust language input to childrens
  understanding
• Parents respond to childrens communicative
  attempts
• Receive 100,000s of models of language use
• Parents say words to children before they know
  the words
• Learn language rapidly
• Have fun learning language

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Principles to guide AAC intervention with young
children

• Start as early as possible
• Intervene with infants, toddlers, preschoolers
  who are at risk
• Intervene in natural environment during daily
  activities
• Maximize functionality, familiarity,
  meaningfulness
• Focus on sustained social interactions with
  familiar partners
• NOT just expressing needs and wants,
• but also building social closeness sharing
  information in sustained social interactions

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Principles to guide AAC intervention with young
children

• Provide contextual support to help children learn
  language
• Use context to support comprehension expression
• Infuse familiar experiences /contexts into AAC
  systems
• Show parents how to provide appropriate
  scaffolding support
• Provide frequent opportunities for communication
• Provide appropriate language input
• Respond to childs communicative attempts

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Principles to guide AAC intervention with young
children

• Provide models of AAC speech
• Use AAC speech when talking to child
• Sign speech
• Aided AAC speech
• Expand on childs messages using AAC speech
• Ensure that AAC systems are dynamic
• Support language learning
• Regularly introduce/ add new concepts for child
• Model their use

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Principles to guide AAC intervention with young
children

• Ensure that intervention is FUN!!
• Integrate communication play
• Enhance motivation of child and family
• Ensure that AAC systems are appealing and fun!
• Ensure that AAC systems are easy to learn and use!

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Goals of the presentation

• Share the results of a research study that
  developed, implemented, evaluated the effects
  of AAC interventions on the language and
  communication skills of young children with
  complex communication needs
• Multiple baseline across participants
• Share case examples to illustrate AAC
  intervention and outcomes

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AAC-RERC

• Project is part of the AAC-RERC II
• Collaborative virtual research center funded by
  the National Institute on Disability and
  Rehabilitation Research
• Grant H133E030018 (2003-2008)
• For more information
• http//www.aac-rerc.com to access the webcast or
• Janice Light JCL4_at_psu.edu

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Participants

• Single subject multiple baseline design
• 9 participants to date
• 6-40 months old upon referral
• Significant communication disabilities
• All nonsymbolic or minimally symbolic at baseline
• 0-25 symbols expressively
• Evaluated impact of AAC intervention
• Collected longitudinal data to track language
  development
• Pragmatic, semantic, syntactic development

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Goals of AAC Interventions

• The overall goal is to build social interaction
  between young children familiar partners
• Maximize childs functional communication
• Enhance childs language development
• Increase participation /turn taking
• Express range of communicative functions
• Develop breadth of semantic concepts
• Build greater complexity of language structure to
  support more complex communication
• Build phonological awareness skills /foundations
  for literacy development

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AAC Interventions

• Scheduled for 1 hour per week
• In natural environment
• Typically at home
• Sometimes at preschool
• Within play and other activities of daily living
• Involved parents and other primary facilitators

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Departure from typical AAC intervention

• Focus on sustained social interaction
• Dont just focus on needs and wants
• Redesign AAC to better meet young childs needs
  and skills
• Provide contextual support to support language
  learning
• Encourage language learning through AAC
• Dont require language learning prior to AAC

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Components of effective evidence-based AAC
intervention

• Identify meaningful social contexts for
  communication
• Develop appropriate AAC systems for the child
• Set up the environment to support social
  interaction
• Use appropriate strategies to support childs
  communication
• Meaningful opportunities for communication
• Appropriate supports to ensure successful
  communication

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Case 1 AAC intervention with infants - Initial
intervention

• Goals
• To increase active participation in social
  interactions with familiar adults
• To increase communicative turns /social bids
• To introduce range of communication purposes

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Identify meaningful contexts for social
interaction

• Meet with parents observe child
• Select contexts that are
• Interactive
• Rich in opportunities for participation
• Reciprocal
• Easy to sustain over multiple turns
• Motivating to the child
• Meaningful / familiar for the parents and child
• Frequently occurring
• Valued by the family
• Fun!!

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Identify meaningful contexts for social
interaction

• Focus on contexts that provide
• Sustained social interaction
• Offer multiple opportunities for participation
  /communication
• Not just expression of needs and wants
• Single opportunity for communication e.g., snack
• Initially choose contexts that
• Involve only the infant and the partner (and AAC)
• Minimize the joint attention demands
• Have predictable structure

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Identify meaningful contexts for social
interaction

• Social games
• E.g., Peek-a-boo, So Big
• Songs (line by line)
• E.g., Itsy Bitsy Spider
• Musical instruments toys
• E.g., Winnie the Pooh, crib toy / mobile
• Books
• E.g., Brown Bear, Whos hiding?, Baby Faces

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Develop appropriate AAC systems

• Communication is multimodal
• Identify modes that are used currently by child
• Vocalizations
• Facial expressions
• Introduce additional modes to augment /enhance
  communication
• Signs
• Light tech symbols
• Speech generating device (SGD)

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Introducing AAC to parents

• AAC intervention results in significant gains in
• Functional communication
• Language development
• Will AAC inhibit speech development?
• Meta-analysis (Millar, Light Schlosser, 2006)
• 0 demonstrated decreases in speech production
• 11 showed no change
• 89 demonstrated gains in speech
• Gains observed were modest ones
• 20 spoken words or less
• Ceiling effects in many cases
• AAC does NOT inhibit speech development

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Develop appropriate aided AAC systems

• AAC systems should
• Be fun
• Be easy for infants to understand and use
• Be dynamic

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AAC systems should be fun (from Light, Drager,
Nemser, 2004 Light, Curran, Page, Pitkin, in
press)

• AAC systems should appeal to infant
• Multiple bright primary colors
• Familiar motivating content
• Preferred people and activities
• Fun interactive play activities
• Engaging characters
• Expressive faces
• Engaging speech output, songs, musical
  instruments, sound effects, laughter
• Childs preferences

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AAC systems should be easy to use

• AAC systems should be easy for infants to
  understand use
• Use touch screen for selection if possible
• Immediate cause and effect / direct relationship
• Selection upon activation not release
• Provide scaffolding support to assist with
  navigation
• Set up menus / arrows for future navigation
• Model use, but do not require use
• Use visual contextual scene displays to provide
  meaningful interactive contexts to promote social
  interaction

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Traditional grid layout

• Vocabulary represented by separate AAC symbols in
  boxes
• Language is taken out of context
• Decontextualized
• Concepts are presented separately
• Visual-spatial relationships are not preserved
• Contextual relationships are not preserved
• Imposes greater cognitive /linguistic demands

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Visual scene display layout

• Graphic metaphor (Shane, 1998)
• Vocabulary embedded under hot spot in visual
  scene display (VSD)
• Digital photo of childs experiences
• Scanned image of familiar book
• Vocabulary presented in meaningful context
• Concepts related visually and conceptually as in
  life

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Develop appropriate VSDs

• Develop visual contextual scene displays that
  represent the selected interactive contexts to
  expand the childs communication
• VSDs are designed to provide a high level of
  contextual support
• VSDs provide a context to support the
  communication of young children and their
  partners
• VSDs can be implemented
• On dynamic display speech generating devices
  (SGDs)
• As low tech systems
• Choose appropriate representations for VSDs
• E.g., digital photos, scanned images

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What makes a good VSD?

• Visual scene displays for young children should
• Be meaningful and relevant
• Represent motivating contexts /activities
• Portray interactive social experiences
• Provide a rich context for communication
• Reflect the childs perspective on the event
  /experience
• Reflect the childs conceptual development
  /understanding
• Be appealing

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Develop appropriate VSDs

• Adapt VSD as required to accommodate
• Visual skills
• Reduce complexity for very young children,
• Remove background to increase contrast for
  children with visual impairments
• Motor skills
• Number of hotspots
• Size of hotspots
• Cognitive/ Language skills
• Amount of vocabulary
• Type of vocabulary provided

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Select appropriate vocabulary

• For each interactive context, select appropriate
  vocabulary to expand the childs communication
• Individualized
• Motivating / fun
• Functional
• Developmentally appropriate
• Kids should sound like kids!
• Culturally appropriate
• Supportive of language learning
• Include a range of developmentally appropriate
  functional concepts
• people, actions, objects, places, social words,
  relational concepts, questions, etc.
• Support participation in social interaction not
  just expressing wants
• Young children can only learn language if we
  provide access

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Select appropriate vocabulary

• Identify appropriate hot spots in the VSD for
  vocabulary related to the context
• Be sure hot spots are an appropriate size
• accommodate childs motor sensory perceptual
  skills
• Consider childs language and cognitive
  development when adding vocabulary
• Initially beginning communicators may only have a
  single hotspot in a VSD
• Gradually add more hotspots / vocabulary concepts
• Observe childs interests in VSD
• If child selects same area of the VSD, add
  vocabulary to this area of interest to reflect
  the childs intent / meaning

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Develop appropriate VSDs

• VSDs can be very simple or more complex depending
  on the needs and skills of the child
• Single image with a single hotspot
• Single image with a few hotspots
• Single or multiple images with multiple hotspots
• Hybrid displays including a visual scene as well
  as additional vocabulary items organized outside
  the scene in a grid
• Traditional grid displays with symbols displayed
  in rows and columns

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Introduce appropriate AAC systems

• Light tech symbols
• Meaningful appealing representations of
  concepts
• Digital photos, scanned images, color line
  drawings
• Covered in contact paper backed with Velcro
• Taught in meaningful contexts paired with the
  referents

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AAC systems should be dynamic

• AAC systems should be dynamic
• Start with systems that provide potential access
  to 1,000 of concepts
• Do not let AAC systems limit language development
  
• Gradually build language

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AAC systems should be dynamic

• Young children experience qualitative
  quantitative changes in development
• AAC systems must reflect these changes
• Introduce new activities regularly
• Respond to childs preferences
• Introduce new concepts regularly
• Provide access to range of language concepts
• Model their use in meaningful contexts
• Dont wait for child to prove comprehension
• Introduce more hotspots as motor skills develop
• Embed more language

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Set up the environment to support social
interaction

• Ensure appropriate positioning to maximize
  attention and participation
• Accommodate motor skills cognitive skills
• Minimize joint attention demands and maximize the
  childs attention to partner and AAC system
• Sit directly in front of the child at eye level
• Hold the AAC system directly in front of the
  child, just below the partners face

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Use appropriate strategies to support childs
communication

• Have FUN!!
• Engage in social interaction using appropriate
  strategies to ensure
• Meaningful opportunities for communication
• Appropriate supports to ensure successful
  communication

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Initiate the context / identify opportunities for
communication

• Initiate the interactive context / start the
  activity
• Locate the appropriate display for the child
• Initially do not expect the child to navigate
  independently
• As the child develops competence, model
  navigation to the appropriate display
• Identify numerous opportunities for the child to
  participate within the context
• Initially context may be repetitive
• As child develops competence, build in numerous
  varied opportunities for interaction

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Mark opportunities for child to communicate

• Clearly mark each opportunity for the child to
  communicate
• Use expectant delay
• Focus attention on child maintain eye contact
• Use expectant body posture
• Wait and allow the child time to communicate

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Respond to the child

• If the child attempts to communicate, respond
  immediately
• Fulfill the intent
• Repeat or expand on the childs message
• Model AAC speech
• Continue the activity
• Continue to provide meaningful opportunities for
  child to communicate
• Repeat over successive turns
• Introduce new context as required
• Watch for loss of interest

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• If the child does not attempt to communicate,
• Model an appropriate turn
• use AAC speech
• Use a third party model to demonstrate if
  available
• Parent, sibling, or aide demonstrates for the
  child what to do
• Present the opportunity again

43
Model AAC speech

• When talking to child, always model AAC
• Speech sign/ gestures
• Speech aided symbols
• Speech SGD
• Model AAC use to
• Support childs comprehension
• Show the child how to communicate
• Provide opportunities for child to learn new
  language concepts new structures
• Make note of gaps in available vocabulary add
  required concepts

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Work with parents to enhance participation

• Identify opportunities for communication
• Infuse into familiar, meaningful, motivating,
  social activities
• Opportunities to sustain social interaction
• Model use of AAC plus speech
• Demonstrate how to use AAC to communicate
• Provide scaffolding support in AAC use
• Locate appropriate light tech symbols to offer
  choices
• Help locate appropriate pages in VOCA
• Recognize and respond to childs communicative
  attempts
• Fulfill communicative intent
• Expand and model more complex messages using
  aided AAC
• Have fun!

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Intervention Stage 2Developing semantic concepts

• Goals
• To continue active involvement in social
  interactions with familiar adults
• To expand expressive vocabulary to communicate
  more diverse meaning
• To teach questions gradually to provide control
  over vocabulary acquisition /language learning

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Work with parents

• Continue to
• Set up numerous opportunities for communication
• Recognize and respond to childs communicative
  attempts
• Model use of aided AAC
• Model known concepts as well as new ones
• Expand on childs messages
• Teach new concepts
• Link new symbol to the concept directly
• Demonstrate concept
• Model use

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• Provide scaffolding support in AAC use
• Help locate appropriate pages in VOCA as required
• Teach organizational system
• Organize vocabulary according to meaningful
  events
• Use appropriate menu symbols

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Intervention - Stage 3Learning syntax and
morphology

• Goals
• To continue active involvement in social
  interactions with familiar adults
• To take turns with peers with adult scaffolding
• To continue to expand expressive vocabulary
• e.g., question words, etc
• Read, read, read
• To encourage communication of more complex, novel
  meanings by combining symbols
• To introduce early morphological structures to
  specify meaning

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Developing the foundations for social
interactions with peers

• Important to develop the foundations for peer
  interactions
• opportunities to develop friendships
• testing ground for communication skills
• Develop repertoire of activities as contexts for
  interactions with peers
• books
• songs
• games
• play activities

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Learning the form of language

• Begin to introduce more complex forms of language
• Model AAC speech
• Build up sentences
• Break down sentences
• Use message bar with VOCA to provide visual
  /auditory feedback
• Teach in context demonstrate appropriate use
• Explain rules as appropriate
• Expect use only in contexts where obligated
• E.g., writing activities / publishing books

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• Gradually introduce expression of morphology/
  syntax
• e.g., present progressive, plurals, past tense,
  auxiliary
• Challenges
• How do we represent grammatical parts of speech?

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Intervention Stage 4Phonological awareness /
literacy

• Goal
• To continue active involvement in social
  interactions with familiar adults
• To interact socially with peers
• To continue to expand expressive vocabulary
• To continue to develop syntax and morphology
• To teach phonological awareness skills and
  literacy skills

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• AAC systems
• Introduction of alphabet board light tech
• Access to alphabet on high tech system
• Speech output letter sounds not names
• Introduction to literacy curriculum
• Letter-sound correspondences
• Phonological awareness skills
• Sound blending
• Initial phoneme segmentation
• Early decoding shared reading
• Early writing activities

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Ongoing literacy instruction

• Ongoing reading of books, talking about stories
• Teaching reading skills
• Decoding of more complex words
• Sight word recognition skills
• Reading simple stories
• Building comprehension
• Teaching writing skills
• Writing stories

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Summary of results to date

• All children have demonstrated significant
  increases in their rate of turn taking
• All children sustain interactions with others for
  significantly longer
• All children participate in interactions that
  involve
• Social routines
• Play activities
• Not just expression of needs and wants

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• Children use their AAC systems independently for
  play learning as well
• Children use their systems as contexts to
  interact with peers
• Shared books
• Shared singing
• Play
• All children have demonstrated significant
  increases in their expressive vocabularies
• All children have acquired a range of semantic
  concepts

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• Children are combining concepts to communicate
  more complex meanings
• All children have been able to use VSDs on
  initial introduction once use is modeled
• seem to be more interested motivated when scene
  displays are used to integrate AAC play, book
  reading, music
• Children have learned to use other displays
• Hybrid displays
• Grid displays

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• All children started with adult scaffolding
  support to find appropriate pages in aided
  systems
• Children have learned some navigational tools
• Menu
• Forward and back arrows to change pages
• Some children navigate independently
• Some children are developing phonological
  awareness and literacy skills

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• Early AAC intervention supports language
  development and communication
• Increase participation and build social
  interaction
• Develop breadth of semantic concepts /vocabulary
  to support more diverse communication
  conceptual development
• Build greater complexity of language structure to
  support more complex communication
• Build phonological awareness skills and
  foundations for literacy development

60
The art and science of AAC intervention

• The science of AAC intervention
• Implementation of evidence-based intervention
  procedures
• Research is available to guide in planning and
  implementing AAC intervention with young children
• Monitoring effectiveness with individual child
• Evaluating outcomes

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The art of AAC intervention

• The belief and the commitment to the right of all
  individuals to express themselves fully and seek
  their full potential

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For further information,Visit www.aac-rerc.com
for the webcast on young children who require
AAC or E-mail JCL4_at_psu.edu
This research is part of the AAC-RERC II and is
funded by the National Institute on Disability
and Rehabilitation Research of the U.S.
Department of Education, under grant
H133E030018 (2003-2008). The opinions contained
in this presentation are those of the grantee and
do not necessarily reflect those of the U.S.
Department of Education.