Pragmatic the way that we use language socially

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Alternative and Augmentative Communication
(AAC) EBP GroupExtravaganza Presentation 2011

• What is the best practice for the layout/design
  in augmentative and alternative communication
  systems for people who have a communication
  disability ?
• An update

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Background

• This CAT was completed as a review of the
  original CAT compiled in 2005 by Speech
  Pathologists from The Cerebral Palsy Alliance
  (formerly The Spastic Centre) to appraise the
  evidence for
• Design and layout of communication arrays
• Whether certain design principles were
  advantageous for people who have communication
  disabilities.

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In the beginning

• Originally the idea for this CAT was to look into
  research for PODDs (Pragmatically Organised
  Dynamic Display) however limited evidence was
  found to formulate a CAT.
• Our original question was
• How successful is the design of PODDs for
  individuals
• with complex communication
  needs?

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What is a PODD?

• Pragmatic the way that we use language socially
  
• Organisation words and symbols arranged in a
  systematic way
• Dynamic Display changing pages.
• PODD communication book the words and symbols
  organised in a particular way.
• Devised by Gayle Porter (Speech Pathologist with
  the Cerebral Palsy Education
• Centre (CPEC) in Victoria)
• The aim of a PODD is to provide vocabulary
  (larger range)
• for continuous communication all the time
• for a range of messages
• across a range of topics 
• in multiple environments.
• They can have different formats, depending
• on the individual physical, and
  communication
• needs of the person i.e., direct access,
  partner assisted

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Video examples of children using PODDs

• http//www.youtube.com/watch?vxv-b_GHonJM
• http//www.youtube.com/watch?vTOvC9OoygaANR1

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• However limited evidence was found to formulate a
  CAT regarding PODDS.

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So our next step..

• We expanded the question to look at the layout /
  design of AAC in general.
• Discovered that a CAT had been previously done in
  2005 by CPA speech pathologists with a plan to be
  reviewed in 2007.
• They concluded. Insufficient high quality
  evidence to guide clinicians regarding this
  question. Clinicians should be guided by their
  clinical experience and client and family
  values

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• We decided to review the original CAT.
• Importance of reviewing the original CAT given
  the dynamic nature of AAC and how rapidly it
  changes with new technology.
• On investigation we found that very little new
  research has been conducted since the original
  CAT in 2005 and therefore we were unable to
  achieve our original objective of reviewing how
  effective the new AAC systems (high and low tech)
  are.

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Factors to consider when designing an AAC device

• Layout
• topic, place, colour, alphabet, size, dynamic or
  static
• Other factors
• individuals age
• literacy
• personal preference
• age of onset of disability
• motor skills, positioning, accessibility

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• Method

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Study Design/ Methodology of articles retrieved

• 
  Level Number Located
• Case series IV
  3
• Comparative study III
  4
• Systematic review I
  1

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Key findings

• Colour
• Clinicians should incorporate colour in
  foreground of line drawings when constructing
  visual displays.
• Targets that contain only background colour
  (e.g., Fitzgerald key) but no foreground colour
  make it slower for younger children to locate the
  target.
• When creating AAC displays, results suggest
  symbols that share colour should be placed
  together as the speed of location/access
  increased e.g., Gail Van Tatenhove
• Use of colour may assist in segmentation of
  visual scene to highlight contrasts between
  objects or to highlight detail as a means of
  cueing memory. This would suggest that in a
  natural scene or schema, colour may aid memory
  however this may not be true for a grid layout.
  (from CPA CAT)

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• Example of Gail van Tatenhoves core vocabulary
  approach. www.vantatenhove.com

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• Symbol Organisation
• Adult participants required less time to sequence
  symbols when they were a shorter distance apart.
• Symbols that are high frequency combinations
  should be placed close together on the display.

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• User Preference
• When people have a choice in selecting preferred
  AAC systems, this increases their motivation to
  use the system and thus opportunities to learn
  communication competence
• Children value AAC technologies
• that serve to enhance their self-esteem and
  social image i.e., integrated systems such as
  something you can play with as well as a
  communication system (e.g., iPAD, iPOD).
• That have a high smile value i.e., should be
  fun. Light J., Drager, K. (2007)

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• Age
• In young children.. generally have a preference
  for personally relevant schematic layout.
• (5 ways to group vocabulary - Taxonomic
  (categories), schematic (event schema), semantic
  / syntactic, alphabetic, idiosyncratic) ( from
  CPA CAT)
• Embedding language concepts within contextual
  scenes maybe an effective approach for young
  children learning dynamic display technology

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Clinical bottom line

• Preference and motivation will greatly impact on
  the outcomes of AAC competence.
• Colour aids with speed and accuracy of use
  (e.g., Minspeak and core vocabulary)
• Highly used symbols should be grouped together.

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Alternative and Augmentative Communication (AAC)
EBP GroupExtravaganza Presentation 2011

• Is a high tech AAC system more effective than a
  low tech AAC system for people with ASD?

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Taking EBP back to the workplace
Current best evidence
Clients values
Clinical expertise
From http//www.asha.org/members/ebp/default
10/23/08
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Why this clinical question?

• Therapists are finding that a lot of clients with
  ASD and their families are interested in high
  tech devices such as Proloquo2go on iPad/iTouch
  so we wanted to look at the effectiveness of both
  high and low tech AAC on people with Autism

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Taking EBP back to the workplace
Current best evidence
Clients values
Clinical expertise
From http//www.asha.org/members/ebp/default
10/23/08
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http//www.foxnews.com/scitech/2011/03/09/can-appl
e-ipad-cure-autism/ixzz1fd1ugwHt
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What system should I use?
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Benefits of Low Tech AAC systems

• Low cost
• Easy to use
• Easy to replicate
• Easier to use in a number of settings
• Easier to implement with those new to AAC
• Easier to implement in acute settings (infection
  control)
• More widely recognised and used

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Disadvantages of Low Tech AAC

• May have limited vocabulary
• Communicator needs to get the communication
  partners attention first before sending message
• Communication partner needs to be able to see the
  message. For example, seeing visuals in a dimly
  lit room
• Communication partner needs to be trained in the
  use of the low tech AAC, e.g., PECS
• General public may not recognise AAC as a means
  of communicating (e.g. community request cards)
• Can be bulky and cumbersome (e.g. PODD)

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Benefits of high Tech AAC systems

• May be able to store a large amount of vocabulary
  for dynamic display devices
• Able to get feedback to the user, i.e. says the
  word/sentence that you have pressed
• Reduces the communication partners burden
  because the output is spoken language and
  provides information in a mode that is familiar
  and non threatening.
• Allows partners who are non literate to
  participate in conversation (if device has voice
  output)
• Allows communication to happen at a distance
• Allows predictability
• More recognised in the digital age

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Disadvantages of High Tech AAC

• Expensive (although it is getting more affordable
  now with things like iPads)
• Takes a lot of time to program
• Some high tech AAC devices are heavy
• External factors such as battery life. For
  example, if battery in High Tech AAC is gone they
  have no communication method
• High tech devices are not as durable, e.g.,
  dropping it on ground
• Cant be used in all settings (e.g. pool, at the
  beach)

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Disadvantages of High Tech AAC

• Even though the speech is fairly intelligible, it
  still may be difficult to hear in noisy
  environments by people with hearing impairments,
  non-native English speakers or those with reduced
  receptive language abilities.

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Taking EBP back to the workplace
Current best evidence
Clients values
Clinical expertise
From http//www.asha.org/members/ebp/default
10/23/08
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Critically Appraised Papers

• 45 identified articles referenced and sourced.
• 14 were deemed relevant however only 10 were
  accessible.
• 4 articles subsequently CAPped and used for CAT
  as remaining 8 did not directly relate to
  question on closer scrutiny of paper

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Schlosser et al (2001)
LEVEL 1

• Objective
• To synthesise research regarding the potential
  benefits of speech output for persons with ASD
• Results
• Several studies have compared PECS but no
  mention of speech output made
• Speech output devices as part of computer
  assisted treatment packages
• Packages had potential to teach reading and PA
  skills for stimulating verbal expression
  improving interactions of kids with ASD and their
  comm partners
• Speech output from voice output devices (SGD)
• Contribution of SGD to effectiveness of treatment
  package unclear
• Speech output as independent variable
• Promising results speech output increased
  spontaneous utterances but poor design and small
  sample size
• Strengths and weaknesses
• Further research since 2001

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Schlosser et al (2001)

• Clinical bottom line
• There is a role for speech output devices for
  people with ASD, however the benefits still
  remain unclear at this time and more research
  into specific SGDs is needed

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Schlosser et al (2007)
LEVEL 3a

• Objective
• Use of Vantage Speech output device with voice on
  and off to determine benefits of voice output
• Results
• Overall non-speech goal did not increase in ¾
  participants, however increase by two fold in
  requesting skills in children with ASD using SGD
• ½ participants showed increase in vocal imitation
  skills using SGD vs. those that were not exposed
  to use of SGD
• Strengths and weaknesses
• 2 fold aim of paper looking at requesting with
  high tech devices as well as looking at changes
  in natural speech production as a result of
  intervention
• Detailed information about how each participant
  met the criteria for the study
• Difficult methodology to follow
• Very strict participant criteria needed for study
  

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Schlosser et al (2007)

• Clinical bottom line
• Could not determine specifically if a high tech
  AAC system is more effective than a low tech AAC
  system. However it is essential to look at
  the child / adults preferences and ensure that
  these are taken into account when prescribing a
  specific system

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Sigafoos et al (2006)
LEVEL 4

• Objective
• Comparison of PECS vs. VOCA system for requesting
  desired items
• Results
• In baseline no preference of PECS over VOCA vv
• All participants increase percentage of correct
  responses using both systems (PECS VOCA)
  86-100
• Reported increase in speed in responding using
  VOCA
• 1 of 3 participants preferred use of VOCA, other
  2 participants preferred PECS
• All 3 participants continued to use preferred AAC
  6 months post study
• Strengths and weaknesses
• Small number of participants
• VOCA device not specified
• No comprehensive follow-up
• No generalisation data collected

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Sigafoos et al (2006)

• Clinical bottom line
• All participants in the study learnt to
  functionally use PECS and Voice Output
  communication system with comparable speed and
  proficiency. Child preference appeared to be
  driving force in success of administration of
  communication system

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Trembath et al (2009)

• Objective
• To measure and compare effectiveness of peer
  mediated teaching with and without SGD, and to
  determine whether changes generalised.
• Results
• Peer mediated naturalistic teaching with SGD
  resulted in more communicative behaviours per
  minute than peer mediated naturalistic teaching
  without SGD for 2 of the 3 subjects.
• All 3 subjects generalised slight increases in
  communicative
• behaviours with peers during mealtime
  interactions.
• Strengths and weaknesses
• Only 3 subjects - ? Ability to generalise
  results.
• Number of prompts provided by researcher not
  controlled may have influenced peers ability
  to implement interventions.
• Affect of factors such as different abilities of
  peers and different settings
• Only small number of generalisation probes taken
  due to time constraints.

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Trembath et al (2009)

• Clinical bottom line
• Preliminary evidence for the effectiveness of
  combining peer-mediated naturalistic teaching
  with the use of SGDs for preschool-aged children
  with autism.

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Take home message

• There is no absolute system that would suit every
  client
• There are both advantages and disadvantages to
  both a high and low tech AAC systems and on top
  of this we also have to take in to account client
  abilities and preferences as well as financial
  situation.
• It is best not to use a single mode of
  communication but a combination of both high and
  low tech AAC to ensure its use in a variety of
  environments with a variety of communication
  partners

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In 2012

• Meetings will take place at Cerebral Palsy
  Alliance Ryde .
• 3A Smalls Road, Ryde
• 1st meeting for 2012 15th February at 10 am
• Please contact Natalie Alborés or Cecilia Rossi
• nalbores_at_nsccahs.health.nsw.gov.au
• cecilia.rossi_at_facs.nsw.gov.au

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References

• Chiang, H Lin, Y. (2008). Expressive
  communication of children with autism. Journal of
  Autism Developmental Disorders 38(3), 538-45
•  Goldstein, H. (2002). Communication intervention
  for children with autism a review of treatment
  efficacy. Journal of Autism and Developmental
  Disorders, 32(5)
• Johnston et al. (2003). The use of visual
  supports in teaching young children with ASD to
  initiate interactions Augment Altern Commun. 2003
  , 19, 86-103
• Schlosser, RW. Blischak, DM (2001). Is there a
  role for Speech Output in Interventions for
  Person with Autism. Focus on Autism and Other
  Developmental Disabilities Fall 2001 16, 3
  170-178
• Schlosser, RW. Sigafoos, J. Luiselli, JK.
  Angermeier, K. Harasymowyz, U. Schooley, K.
  Belfiore, PJ. (2007). Effects of synthetic speech
  output on requesting and natural speech
  production in children with autism A preliminary
  study. Research in Autism Spectrum Disorders 1(2)
  139-163
• Sigafoos et al. (2009) A comparison of Picture
  Exchange and Speech Generating Devices-
  Acquisition, preference and effects on social
  interaction Augment Altern Commun. 25(2)99-109.
• Sigafoos, J. Drasgow, E. (2001). Conditional use
  of aided and unaided AAC A review and clinical
  case demonstration Focus on Autism and Other
  Developmental Disabilities 16(3) 152-161
• Son,SH. Sigafoos, J., O'Reilly M. Lancioni, GE.
  (2006). Comparing two types of augmentative and
  alternative communication systems for children
  with autism. Pediatric Rehabilitation 9(4)
  389-395
• Thunberg, G., Ahlsen, E. Sandberg AD. (2007).
  Children with autistic spectrum disorders and
  speech generating devices communication in
  different activities at home. Clinical
  Linguistics and Phonetics 21(6). 457-79
• Trembath, D. Balandin, S. Togher, L.
  Stancliffe, RJ. (2009). Peer-mediated teaching
  and augmentative and alternative communication
  for preschool-aged children with autism. Journal
  of Intellectual and Developmental Disability
  34(2) 173-186