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Alternative and Augmentative Communication (AAC) EBP Group Extravaganza Presentation 2011


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Title: Alternative and Augmentative Communication (AAC) EBP Group Extravaganza Presentation 2011

Alternative and Augmentative Communication
(AAC) EBP Group Extravaganza 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

  • 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

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
  • with complex communication

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
  • needs of the person i.e., direct access,
    partner assisted

Video examples of children using PODDs
  • http//
  • http//

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

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

  • 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)

Factors to consider when designing an AAC device
  • Layout
  • topic, place, colour, alphabet, size, dynamic or
  • Other factors
  • individuals age
  • literacy
  • personal preference
  • age of onset of disability
  • motor skills, positioning, accessibility

  • Method

Study Design/ Methodology of articles retrieved

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

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
  • 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)

  • Example of Gail van Tatenhoves core vocabulary

  • 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.

  • 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)

  • 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

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.

Alternative and Augmentative Communication (AAC)
EBP Group Extravaganza Presentation 2011
  • Is a high tech AAC system more effective than a
    low tech AAC system for people with ASD?

Taking EBP back to the workplace
Current best evidence
Clients values
Clinical expertise
From http//
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

Taking EBP back to the workplace
Current best evidence
Clients values
Clinical expertise
From http//
What system should I use?
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
  • More widely recognised and used

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)

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
  • Allows communication to happen at a distance
  • Allows predictability
  • More recognised in the digital age

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

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.

Taking EBP back to the workplace
Current best evidence
Clients values
Clinical expertise
From http//
Critically Appraised Papers
  • 45 identified articles referenced and sourced.
  • 14 were deemed relevant however only 10 were
  • 4 articles subsequently CAPped and used for CAT
    as remaining 8 did not directly relate to
    question on closer scrutiny of paper

Schlosser et al (2001)
  • 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

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

Schlosser et al (2007)
  • 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
  • Detailed information about how each participant
    met the criteria for the study
  • Difficult methodology to follow
  • Very strict participant criteria needed for study

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

Sigafoos et al (2006)
  • 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)
  • Reported increase in speed in responding using
  • 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

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

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
  • behaviours with peers during mealtime
  • Strengths and weaknesses
  • Only 3 subjects - ? Ability to generalise
  • 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.

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.

Take home message
  • There is no absolute system that would suit every
  • 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
  • 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

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

  • 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
  • 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)
  • 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)
  • 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