Coordinating our Goals Among
Early AAC Service Providers:
Critical Skills in Early AAC
Development
Cynthia J. Cress, Ph.D.
University of Nebraska-Lincoln
Communication Carnival, Goteborg,
Sweden, June, 2009
Case Examples:
• Tyler is a school-aged child on the autism
spectrum. He has been through years of
structured therapy and will say “I want a
cookie” if you directly prompt him to say
these words. However, if you show him a
cookie, he will wait indefinitely for a prompt
without gesturing or making a sound.
• Watch for: Getting Beyond Imitation,
Partner Strategies
Case Example:
• Byron is an adult with developmental
disabilities. He used to say more words
and use signs, but now he mostly
gestures and vocalizes. If you make him
“use his words” with a direct prompt, he
gets upset and won’t communicate with
you at all.
• Watch for: Mastery motivation,
Case Examples:
• Olivia is a school-aged child with physical
and cognitive impairments. She has been
using a VOCA for 2 years, but her
teachers are frustrated. All she’ll do is
push choices of two items like “computer”
or “music”, and never uses her comments
or questions on her own even though they
think she understands them.
• Watch for: Joint Attention, Preference
Case Examples:
• Cameron is an infant with multiple
physical, sensory, and cognitive issues.
Right now, you and the parents are
frustrated because he doesn’t seem to do
much of anything to communicate, and
he’s clearly not paying much attention to
the symbols and switches.
• Watch for: Preference, Partner Strategies
I. Overview - Early Augmented
Communicators
Definition: Augmentative and Alternative Communication
(AAC): anything that helps children or adults to
communicate when traditional strategies are not
sufficient to accomplish a communication goal (Cress,
2002)
• Early communicators can be of any age, including
adults with acquired impairments
• Disabilities can include physical, cognitive, sensory,
and/or pervasive disorders (autism spectrum)
• It’s never too early to start working on communication,
and it’s never too late to see improvement
A. What skills does a child need before you
start AAC?
• Communication starts with interaction and the earliest
behaviors of children
• There are no prerequisites to AAC.
• Previous research that attempted to assign prerequisites to
AAC were only considering symbolic forms of
communication
• Basic AAC intervention includes behaviors, gestures,
cooperative actions, and sounds, and does not depend
upon controlling complex systems or devices. These early
skills do facilitate the gradual development of more
complex skills.
See: Kangas, K.A. & Lloyd, L. (1988). Early cognitive skills as prerequisites to
augmentative and alternative communication use: What are we waiting for?
Augmentative and Alternative Communication, 4 (4), 211-221.
B. How might development in children with
physical/sensory impairments differ from typical?
• Much of early learning typically involves physically
acting on the world, which is difficult for children with
physical impairments or children with visual
processing problems.
• Many early communicative routines familiar to
parents involve hand or vocal skills, both of which
may be unavailable to children with physical or
hearing problems.
• Children may not have a clear sense of their own
body’s movements (kinesthetically) which makes it
difficult to relate their behaviors to play or interaction
effects.
• Parents may not recognize children’s unusual or
subtle movements as intentional or communicative,
and not respond as often.
• Many of children’s early communicative attempts
may be unsuccessful (e.g. using breathing as an
attention signal/behavior), and children often grow
passive.
• Delays in children’s motor behaviors and/or sensory
response to behaviors may limit early awareness of
the relationship between their own behaviors and
other events.
• Learning communication from a primarily receptive
role limits children’s access to trial-and-error
exploration with communication.
• Children may have specific impairments that
additionally impair their ability to process their
experience in the word (e.g., sensory, cognitive,
attention, social interaction).
C. Critical Skills that may Lag
for Children using AAC
• Matching preference & motivation to AAC
• Commenting/shared attention (vs. request)
• Producing recognizable signals for multiple
purposes
• Learning & imitating the world around them
• Getting beyond partner cues & prompts
• Handling challenges and persisting well
** Change only one of these “hard things” at a time
in a given activity
II. Preference, intent, motivation
A. Temptations
• If we can’t find a way to tempt the child to signal this
intent on their own, why are we working teaching a
new way to express that message?
• If the individual is not motivated by the situation to
convey a message, they are doing it for our
reasons, not theirs
• We need to embed communication goals into
temptations, however we structure our intervention
• Assessing moderately preferred activities and
messages is where we usually start
• All of our intervention time with early communicators
may first be spent on these goals
B. Motivation: The biggest “one hard thing”
• Motivation is a complex mix of persons, tasks, contexts,
expectations, and outcomes
• Motivating tasks may change daily, depending on factors
outside of our control. Don’t assume you KNOW this is
motivating for your individual today.
• Functional communication reflects the individual’s own intents
and messages, and depends upon experiencing a wide variety
of real-life opportunities to communicate independently.
• We can’t rely on individuals learning communicative or
supportive skills (i.e. “other hard things”) by observation or
incidental learning.
– Just because they’ve experienced turntaking, for instance,
doesn’t mean that individuals necessarily learn how to initiate and
manage conversational turns.
• Whose communication is this? If individuals aren’t
motivated for “my activities” we need to rethink goals
– Academically - do they have to do the same tasks as
the class (e.g. coin recognition)?
• Consider having independent tasks within similar
activity contexts
– Requesting - does it have to be objects? Consider:
• Activities (esp. kinesthetic or tactile), social actions,
stopping or getting a break
– Getting beyond requesting (e.g. noticing, greeting)
• The primary goal is for individuals to learn independent
initiation of communication that reflects their own
messages, and doesn’t rely on partner cues or prompts to
elicit the behavior.
• Communication in highly structured contexts isn’t enough
to promote independent initiation.
III. Handling Challenges
A.. Mastery Motivation (MM)
• MM is different from just knowing someone’s
preferences (I know you like...)
• MM involves persistence for internal
reasons, not externally imposed ones
• Mastery motivation may be a critical
predictor of success at overcoming effects
of disability - determined to succeed
• NOTE: mastery of task (extrinsic) is very
different from promoting mastery motivation
(intrinsic to child)
1. What affects mastery motivation?
• Probably intrinsic quality for child like other
personality factors (e.g. temperament)
• Just because I have tendencies for having high or
low persistence doesn’t mean I can’t get past
those tendencies with support
• MM is subject to many influences from
environment and experiences
• Moderately challenging tasks promote more MM
than either easy or hard ones
2. How do we support mastery?
• Know child characteristics - how much/when will
they already persist if things get difficult?
• Provide opportunities to persist successfully on a
variety of tasks
• Provide environments with frequent access to these
opportunities
• Have partners that reinforce and scaffold children’s
effort to master difficult tasks.
• Let users explore strategies, including VOCAs, and
“make mistakes” with guidance to learn from them
IV. Why Communicate?
A. Commenting Functions
• Requesting and rejecting are often the
earliest and clearest functions
• They are also the easiest to get stuck in
and may not lead to broader functions
• Remember early functions can be:
– Greeting, teasing, noticing/attention, sharing
emotions, showing, turn taking,
• These early functions support the
development of more complex language
B. The Big Intentional Functions
• Requesting/rejecting
• Commenting/showing
• Social interaction/turntaking
• There are also lots of less intentional
functions of behaviors that we read:
– Judging overstimulation, motivation, emotion,
attention, state, preference, sensory signals
C. Commenting and Joint Attention
• Most children produce requests and refusals earlier and
more frequently in early development.
• As children grow older, more of their communication
revolves around sharing information and commenting,
rather than wants/needs.
• If children’s signals are difficult to read, we may
always interpret their signals as wants/needs
• Many children first using VOCAs may need experience
at how to start a comment and why it’s fun - that may
be why they restrict their use
• Children relying on AAC are at particular risk for
being and staying behind on “joint attention” acts
• Many communication systems focus on wants/needs
much longer than is developmentally or functionally
appropriate for children.
• Children skilled at expressing wants and needs
through behavioral and gestural strategies may find
it hard to express joint attention or word labels
without more formal symbolic strategies.
• For young children who have a limited range of
motor behaviors, skills such as eyepointing may be
particularly important for reference and labeling
activities as well as more basic attention monitoring
functions (with simple gaze shifts).
• We may go back to much simpler joint attention
experiences even for symbolic AAC users
D. Strategies for Promoting
Commenting/Shared Attention
- Practice on unexpected events
- Build on requesting to motivate showing
- Build simple social & predictable routines
involving patting or showing
- Use textured or noisy interesting objects
- Help notice interesting events & expand
natural behaviors like looking or head turns
(watch CSI for likely comment-like acts)
E. Eye Gaze and Attention Goals
• Before you set eye gaze goals (esp. with autism
spectrum), think carefully about what you expect
the child to do with their gaze.
• Typically developing children may gain many
types of information from gazing that may not
apply to children on the autism spectrum
• Just because a child is looking at you doesn’t
necessarily mean they’re paying attention or
processing what they’re seeing
• Insisting on gazing for all attention goals may add
to the cognitive or sensory load of the task
F. Possible Eye Gaze & Attention Targets
• Different behavioral targets may be needed for
each of the following roles of eye gaze:
– Noticing a partner’s behavior
– Monitoring a partner’s attention
– Paying attention to an object or event
– Indicating interest or non-interest in event
– Claiming a turn or directing communication to
a partner
– Meeting social expectations for looking at
partner
V. Learning & Imitating from the World
A. Who may have trouble with imitation?
1. Children who don’t imitate our models when
prompted (verbal or nonverbal behaviors):
– Speech/motor control issues (e.g. apraxia of
speech)
– Attention issues
– Pragmatic issues (e.g. turns, expectations)
– Cognitive issues
– Autism spectrum (e.g. relating to partner’s
actions)
– Communication style or perceived difficulty
A. Who may have trouble with imitation?
• 2. Children who imitate too well, or only when
prompted:
– Autism spectrum issues
– Sensory issues
– Prompt dependency
– Poor generalization of skills
– Pragmatic issues
– Communication style or perceived difficulty
B. What we may not be able to teach:
• Spontaneous imitation for communication
– “Radar” for watching and incorporating useful
actions for a purpose
– Both children with too little and too much
imitation tend to be poor at spontaneously
using imitated skills to communicate a message
(though they may echo)
– Experience at seeing the usefulness of new
actions for accomplishing purposes may help to
build the child’s sense of “radar”, but this is
rarely something we can teach directly
– Comfort with “trial and error” learning will also
help promote spontaneous imitation
C. What makes traditional imitation hard?
•
•
•
•
•
•
Adult initiated action
Expectation of child response
Limited timing and nature of response
Specific motor initiation problems
Knowledge that speech is a hard skill
“You’re not telling ME what to do”
D. How else can we elicit target behaviors?
1. Make use of the environment and task to tempt target
behaviors or approximations
2. Emphasize physical or social play activities that elicit target
behaviors spontaneously
3. Embed our models into following the child’s intent
4. Pair vocal and nonvocal behaviors in simple play
5. Practice embedded models of behaviors the child is
already good at, gradually insert harder actions
6. Make sure we’re only working on “one hard thing at a time”
7. Target speech behaviors no more than one step harder for
a given activity from what children spontaneously produce
Remember: It’s more important that the child produces the
behavior for a purpose and sees its effect than that they do
it because we told them to do it
VI. Partner Strategies & Support
• Family or partner goals and styles will most
critically affect whether a child continues to
use an AAC strategy or device long-term
• Sometimes we first introduce a strategy to
meet a partner’s goal, to get shared value
• The “external device” tool can be extremely
hard for partners, even simple symbols
• We have to embed new AAC strategies into
what the partner is already doing
A. Partner Responsivity
• Changing partner response may be our best (and
only) intervention strategy for persons who primarily
produce spontaneous behaviors
• Children need to know that their behaviors get
responses before they learn new behaviors
• Touch particularly helps children focus on what
behavior got results without cognitive load
• Children with autism may particularly need to develop
an awareness that partner behaviors matter and
convey information that is important to the child’s
own communicative goals
B. Coaching Parents
– One hard thing at a time for parents too
– Suggest one new strategy to try at a time
(e.g. make silly sounds with tickle)
– Some parents are used to relying on
imitation as a primary teaching strategy
– Some parents may not rely on “radar” to
recognize and respond to child actions
– Some parents may see working on “fixing
their speech” as our job
C. Why may parents (& SLPs) rely on imitation?
– Modeling is clear evidence of teaching that
the adult can control
– Imitation is the only reliable way to elicit the
correct response the adult intends
– We are used to relying on imitation with other
children
– It’s easy to see quick results if it works
– We may not see the difference between the
surface behavior and the intent
D. Why can task-based strategies be hard?
– We may not be aware of meaningful behaviors beyond
the “correct” target
– It isn’t real unless it’s speech
– It involves changing aspects of how we do normal
routines and play
– It requires thinking about several things at once
– Results may be gradual and not perceived as change
– We’re making it “too easy for the child”
– We don’t feel in control of the situation
– It’s not my style - I’m used to being direct
– If I have to wait for the opportunity to come up, I’ve
forgotten the new technique I was supposed to use
VII. How can we make AAC
too hard for the partner?
A. Remembering and looking for a “thing”
• If the partner has to hunt at all for the AAC
system, they probably won’t use it
• Most basic communicators want immediate
interaction & have short attention spans
• Changing how I do an interaction means
remembering something unfamiliar
• I already have to manage too many things
B. “You’ve changed how I do things”
• I have already set up interactions the way
I’m comfortable doing them
• Research suggests that incorporating formal
AAC into feeding may not be easy
• For some families, setting up new formal
AAC play routines in my style may be easier
• Accomplishing the goal may be more
important than “teaching” during activities
• I may not see the opportunities as you see
them, and it requires constant “radar”
C. AAC is slower for the partner
• The quickest way to communicate is to
presume another person’s message
• Even stopping to ask a question or offer
choices slows down the process
• Waiting for any response, even gestures,
can delay or lose the point of interaction
• If I don’t already offer an opportunity in this
interaction, formal AAC adds too many
hard and slow things at once
D. Formal AAC doesn’t “buy”
the partner anything
• I already understand their message and
they’re happy - why rock the boat?
• There are too many annoying or wrong
messages for every successful one
• The formal AAC is almost always
incomplete and I have to fill in anyway
• If I don’t see rapid success with the
formal AAC, I won’t probably use it
E. The partner doesn’t get the
big picture about using AAC
• SLPs tend to have specific visions about
communication and models of AAC users
• Research suggests even parents interested
in AAC don’t have these AAC models
• Parents often can’t see beyond their child as
a speaker, and don’t see the point of AAC
• AAC has to lead quickly toward something I
value for me to understand its purpose now
– e.g. speech, frustrations, academics, stories
F. AAC may feel like a thing to
teach not a way to communicate
• Parents may feel they have to make AAC
time in their day as a chore
• Going into a “teaching” role may lead me
to be more directive than I usually am
• Besides, you’re the teacher/SLP and it’s
your job to teach them this
• If it’s too many hard things at once I may
find reasons to avoid it
Take-home Points
• If there’s no “why”, there’s no communication
• You may need to support motivation in
persons with low tolerance of frustration
• Commenting is a separate skill from
requesting and may need basic intervention
• Supporting the context builds relationships
with partners where you build further AAC
• You don’t have to directly imitate to learn
• Communicating only with prompts isn’t
independent yet
Contact Information
Cynthia J. Cress, Ph.D.
Associate Professor, Communication Disorders
University of Nebraska-Lincoln
202G Barkley Memorial Center
Lincoln, NE 68583-0732, USA
Email: [email protected]
Website: www.unl.edu/barkley/faculty/ccress.shtml