American Speech-Language-Hearing Association
National Joint Committee for the Communication Needs of Persons with Severe Disabilities

Communication Development and Concerns

Communication Services and Supports for Individuals With Severe Disabilities: FAQs

Can all children learn to communicate?

Yes, all children can and do communicate from the moment of birth. It is important to remember that communication is not just speech. There are a variety of ways to communicate, such as crying when hungry, tugging on mother's skirt to get juice, and speaking in sentences.

Evidence from research shows that all children can benefit from appropriate communication services to improve the effectiveness of their communication.

For more information:

Guidelines for Meeting the Communication Needs of Persons With Severe Disabilities
These Guidelines, prepared by the National Joint Committee for the Communication Needs of Persons With Severe Disabilities, includes a Communication Bill of Rights, and information about program philosophy, communication goal setting, and communication intervention.

What should we do if an individual does not communicate with signs or pictures?

It is common to think of "communication" as spoken words, written words, and also sign language. Individuals use many different behaviors to communicate. There are many who do not use forms of communication such as signs, pictures or other symbols. These individuals will express themselves with nonsymbolic forms of communication such as sounds, facial expressions, body movements, eye gaze, and other behaviors. Intervention should focus on providing the individual opportunities to influence family members, staff and peers by expressing wants, needs, and preferences and having others respond to their expressions.

The educational team might focus on providing opportunities for these individuals to use their behaviors to influence what happens during their school day and at home. Individuals who do not talk can participate in interactions and activities in the same manner as their classmates if team members/staff:

  • Expect the individual to communicate,
  • Notice the way that communication is expressed, and
  • Respond in a predictable manner.

For example, when the teacher asks the class to choose partners for a math game, one individual may stare at the friend she wants to play with to express a communication message. The teacher would notice each child's answer to her question "Whom do you choose as your partner today?" The teacher would be responding predictably by noticing the student who gazes at the friend and saying "I see you looking at Arturo. The two of you can find the game you want to play together today." By doing this, the teacher expresses her understanding that everyone can communicate as she asks children who they prefer as a partner whether they talk, sign, or use eye gaze to communicate.

It is helpful for the primary communication partners to respond in a predictable manner at school and home. Staff and family members should know how the individual communicates. A gesture or communication dictionary may be one strategy to use to be sure everyone notices the same things. The dictionary would be set up to describe WHAT these behaviors look like, what each one MEANS, and HOW everyone should respond. Creating a communication or gesture dictionary may be one way to ensure that staff and family member are aware of the individual's communication behaviors and agree on how to respond. The educational team and family members would create the dictionary collaboratively. The dictionary would use three columns:

What the student expresses (form) What it means (function) How partners should react (consequence)

As the individual uses the nonsymbolic behaviors more frequently these can be paired with more conventional symbols such as a digital photograph, a line drawing or in some cases sign language. Thus, the individual is being exposed to a more conventional, symbolic way to communicate while they are successfully expressing themselves without symbols.

For more information:

Information about building opportunities and nonsymbolic communication:

Beukelman, D. R., & Mirenda, P. (1998). AAC strategies for beginning communicators. In D. R. Beukelman and P. Mirenda (Eds.) Augmentative and alternative communication (2nd Ed., pp. 265–94). Baltimore: Brookes. (Information on gesture/communication dictionaries on pages 292–294.)

Harwood, K, Warren, S. F., & Yoder, P. (2002). The importance of responsivity in developing contingent exchanges with beginning communicators. In J. Reichle, D.R. Beukelman, and J.C. Light (Eds.) Exemplary practices for beginning communicators (pp. 59–96). Baltimore: Brookes.

Iacono, T., Carter, M., & Hook, J. (1998). Identification of intentional communiation in students with severe and multiple disabilities. Journal of Augmentative and Alternative Communication, 14, 102–114.

Mirenda, P. (1999) Augmentative and alternative communication techniques in inclusive classrooms. Disabilities Solutions, 3(4), 1–9. (Order the newsletter.)

Siegel. E., & Cress, C. J. (2002). Overview of the emergence of early AAC behaviors: Progression from communicative to symbolic skills. In J. Reichle, D. R. Beukelman, and J. C. Light (Eds.) Exemplary practices for beginning communicators (pp. 25–57). Baltimore: Brookes. (Information on communication dictionaries on pages 36–38.)

What are functional communication skills?

Functional communication skills are forms of behavior that express needs, wants, feelings, and preferences that others can understand. When individuals learn functional communication skills, they are able to express themselves without resorting to problem behavior or experiencing communication breakdown.

When children and adults can functionally communicate, they also are ready to learn choice-making and increase their independence. Functional communication skills vary in their form and may include personalized movements, gestures, verbalizations, signs, pictures, words, and augmentative and alternative communication devices. The communication forms a person uses must be understood by all communication partners, particularly if these forms are not conventional or only approximate conventional words and signs. For individuals who have severe disabilities, the best times and places for teaching functional communication skills are everyday routines and contexts; and the best teachers are familiar adults and peers. Instruction, however, needs to be planned and systematic, to extend across the student's whole day, and to include ongoing support for using the new skills. Naturalistic methods such as milieu teaching have proven to be effective for teaching functional communication.

For more information:

Downing, J.E. (1999). Teaching communication skills to students with severe disabilities. Baltimore: Brookes.

Kaiser, A. (2000). Teaching functional communication skills. In M. E. Snell & F. Brown (Eds.) Instruction of students with severe disabilities (pp. 453–492). Upper Saddle River, NJ: Merrill/Prentice Hall.

Siegel, E., & Wetherby, A. (2000). Nonsymbolic communication. In M. E. Snell & F. Brown (Eds.) Instruction of students with severe disabilities (pp. 409–451). Upper Saddle River, NJ: Merrill/Prentice Hall.

Is it necessary or appropriate to begin communication services or "speech therapy" for a child younger than 2 years old?

Communication services should be started just as soon as a communication delay or disorder is diagnosed. Long before we expect children to be talking, there are many important communication skills that should be developing. These early skills include how to interact with other people and things, how to understand spoken language, and how to communicate to others using gestures or symbols. A professional evaluation can determine if a child is developing appropriately in all these areas. If not, an intervention program can be designed to help the child develop these skills. Learn more about early intervention services required under Federal law, and locate the early intervention agency in your state.

For children with the most significant disabilities, the need for some type of communication services is usually evident before the child's second birthday. For these children, it is especially important to conduct a comprehensive, interdisciplinary assessment of the child's receptive and expressive communication skills, as well as related areas of cognitive and social development (ASHA, 1989). In recent years, a number of valid and reliable assessment instruments have become available for use with very young infants - even pre-term infants still in a Neonatal Intensive Care Unit (NICU). Such early assessment is critical for determining a child's eligibility for early intervention services, on the basis of either a specific diagnosis (e.g., autism) or a more general documentation of significant communication or developmental delay. Most important, this early comprehensive assessment will provide information that can be used to design an appropriate, individualized intervention plan for the child and family. (See "More Information" for a listing of some of the more widely used assessment instruments for children from pre-term through age 2).

Current research clearly documents the efficacy of communication services and supports provided to infants, toddlers, and preschoolers with a variety of severe disabilities (Bondy & Frost, 1998; Cress, 2002; Romski, Sevcik, & Forrest, 2001; Rowland & Schweigert, 2000). In fact, today it is recognized that such services may even be started in the NICU, before an infant even reaches full term (ASHA, 2004). Some of the communication services that are appropriate for very young infants and their families include:

  • Perform developmentally appropriate assessments of prelinguistic and sociocommunication interactions, including neurodevelopmental assessments.
  • Identify additional disorders that impact communication and make referrals to other professionals as appropriate.
  • Enhance the infant's developmental outcomes and prevent related conditions that might develop as a consequence of the communication delay by providing specific interventions to facilitate social, interactive communication.
  • Intervene to enhance communication directly with infants and indirectly through culturally appropriate family and other caregiver education. (ASHA, 2004)

For children with significant disabilities, the use of alternative/ augmentative communication (AAC) systems should also be considered as soon as the child's need for such a system is identified. In the past, many professionals and parents thought that AAC intervention was not appropriate for very young infants and toddlers. Even today, some parents and professionals may believe that the introduction of an AAC mode at an early age will preclude the child from ever developing speech as his/her primary mode of communication. In fact, however, numerous studies conducted over the past two decades have demonstrated that the use of AAC does not interfere with speech development (Romski, Sevcik, & Hyatt, in press) and actually has been shown to support such development (Millar, Light, & Schlosser, 2002 [for a review of research demonstrating this effect]; Romski & Sevcik, 1996; Romski, Sevcik, & Pate, 1988).

For more information:

Articles and Chapters

American Speech-Language-Hearing Association. (1989). Communication-based services for infants, toddlers, and their families. Rockville, MD: Author.

American Speech-Language-Hearing Association. (2004). Roles of speech-language pathologists in the neonatal intensive care unit: Technical report. ASHA Supplement, 24.

Bondy, A., & Frost, L. (1998). The Picture Exchange Communication System. Topics in Language Disorders, 19, 373–390.

Cress, C. J. (2002). Expanding children's early augmented behaviors to support symbolic development. In J. Reichle, D. Beukelman, & J. Light (Eds.), Exemplary practices for beginning communicators: Implications for AAC, volume 2. Baltimore, MD: Brookes.

Millar, D., Light, J., & Schlosser, R. (1999). The impact of augmentative and alternative communication (AAC) on natural speech development: A meta-analysis. Poster session presented at the American Speech-Language-Hearing Association Annual Conference, San Francisco, CA.

Romski, M. A., & Sevcik, R. A. (1996). Breaking the speech barrier: Language development through augmented means . Baltimore, MD: Brookes.

Romski, M. A., Sevcik., R. A., & Pate, J. L. (1988). The establishment of symbolic communication in a person with severe retardation. Journal of Speech and Hearing Disorders, 53, 94–107.

Romski, M. A., Sevcik, R. A., & Forrest, S. (2001). Assistive technology and augmentative communication in early childhood inclusion. In M. J. Guralnick (Ed.), Early childhood inclusion: Focus on change (pp. 465–479). Baltimore. MD: Brookes.

Romski, M. A., Sevcik, R. A., & Fonseca, A. H. (2003). Augmentative and alternative communication for persons with mental retardation. In Abbeduto, L. (Ed.), International review of research in mental retardation: language and communication (pp.255–280). New York: Academic Press.

Rowland, C., & Schweigert, P. (2000). Tangible symbols, tangible outcomes. Augmentative and Alternative Communication, 16 , 61–78.

Books

Billeaud, F. (2003). Communication disorders in infants and toddlers: Assessment and intervention. Elsevier.

Goldstein, H., Kaczmarek, L., English, K. (2001). Promoting social communication: Children with developmental disabilities from birth to adolescence. Baltimore: Brookes.

Rossetti, L. (2001). Communication Intervention: Birth to three. Singular/Delmar Learning.

Assessment Instruments

Als, H. (1995). Manual for the Naturalistic Observation of Newborn Behavior (NIDCAPÆ). Boston: National NIDCAPÆ Center.

Als, H, Lester B. M.; Tronick E. Z.; Brazelton T. B. (1982). Toward a research instrument for the assessment of preterm infants' behavior (APIB). In H. E. Fitzgerald, B. M. Lester & M. W. Yogman (Eds.) Theory and Research in Behavioral Pediatrics, 1, 36–63.

Brazleton, T. B. (1984). Neonatal Behavioral Assessment Scale. Philadelphia: JB Lippincott.

Bzoch, K. R., League, R., Brown, V. Receptive-Expressive Emergent Language Test-Third Edition (REEL-3 ). Austin, TX: ProEd

Coplan, J. (1993). The Early Language Milestone Scale-Second Edition (ELM Scale-2). Austin, TX: ProEd.

Dubowitz, L., & Dubowitz, V. (1981). The neurological assessment of the preterm and fullterm newborn infant, Clinics in Developmental Medicine, 79.

Fenson, L., Dale, P., Reznick, S., Thal, D., Bates, E., Hartung, J., Pethick, S., & Reilly, J. (2003). MacArthur Communicative Development Inventories (CDIs). Baltimore: Brookes.

Jackson-Maldonado, D., Thal, D., Marchman,V., Fenson, L., Newton, T., & Conboy, B. (2003). MacArthur Inventarios del Desarrollo de Habilidades Comunicativas (Inventarios). Baltimore: Brookes.

Wetherby, A. M., & Prizant, B. M. (1993). Communication and Symbolic Behavior Scales™ (CSBS). Baltimore: Brookes.

Wetherby, A. M., & Prizant, B. M. (2002). Communication and Symbolic Behavior Scales Developmental Profile™ (CSBS-DP). Baltimore: Brookes.

What if the individual shows no interest in communication?

Lack of interest may indicate that the individual is not being exposed to preferred activities and events during the times that communication is being evaluated. It may be worth spending time doing what are called preference assessments to identify more activities that interest an individual. A good way to start a preference assessment is to interview parents, teachers, or others who are very familiar with the individual. Ask about any and all activities that the individual seems to like or prefers to do when given a choice. Then follow up the interview by providing opportunities for the individual to participate in the activities that familiar partners have suggested as preferred. Watch for any indication that the individual is interested in these activities. Preferred activities are ideal contexts for teaching individuals to request. An alternative strategy is to identify items that an individual really doesn't like. These activities can be appropriate contexts for teaching communication responses that indicate, "I don't want to do that." Caution must be exercised when teaching rejecting, however. No item that is harmful to the individual should ever be used in evaluations or instructions.

When I believe that an individual is using problem behavior to communicate, should I ignore it or respond to it as communication?

Actually both! Problem behavior will be ignored and prevented once its communication function(s) is assessed and appropriate alternative communication responses are taught. To assess the function of a problem behavior is to identify why the problem behavior is occurring - that is whether the behavior serves a particular function(s) for the individual and, if so, what function(s), under what circumstances. The second goal is to teach the individual alternate and appropriate ways to achieve the same function while ignoring or preventing the problem behavior; this is accomplished through team development and implementation of a positive behavior support (PBS) plan that extends across the daily routines and environments used by the individual. A typical component of PBS plans is the instruction of communication, often through augmentative and alternative communication (AAC) methods.

Behavioral assessment is accomplished through either a functional assessment or, when the problem behavior is dangerous or has been resistant to treatment, a functional analysis. Traditional functional analyses are complex and require the involvement of trained experts, because they involve often brief experimental manipulation of the problem behavior and the antecedent conditions that trigger it in order to more conclusively identify the function and explore effective interventions (Horner, Albin, Newton, Todd, & Sprague, in press).

To assess the function of the problem behavior, the team uses a formal process if it is a serious and/or long-standing problem behavior (through interviews, hypothesis setting, and observation to support or revise the hypotheses) and a less formal process (through team discussion, checklists, and possible interview) if it is less serious (Horner et al., in press; Janney & Snell, 2000). Functional assessment is accomplished with several steps: (a) describing the behavior; (b) interviewing those who know the individual to identify the events, times, and situations that predict when the problem behaviors and the consequences that seem to maintain the behavior; (c) identifying hypotheses that describe the situations in which the behaviors occur and the reinforcers that maintain them; and (d) collecting direct observation data to support the hypotheses. Several approaches have been described and validated for functional assessment (Carr, Levin, McConnachie, Carlson, Kemp, & Smith, 1994; O'Neill, Horner, Albin, Sprague, Storey, & Newton, 1997), while various checklists also have proven helpful when direct observation is not called for or to supplement observation, such as the Motivation Assessment Scale (Durand & Crimmins, 1985) or the Functional Assessment Checklist for Teachers & Staff (March, Horner, Lewis-Palmer, Brown , Crone, Todd, & Carr, 2000).

Because PBS support programs aim to prevent problem behavior, to teach replacement behaviors, and to improve the daily routines of the individual, they involve more elements and more collaborative effort than traditional behavior reduction programs. If the problem behavior is serious, a crisis management plan may need to be designed and put into place before a functional assessment can be conducted; but as the PBS program is implemented there will be less need for crisis intervention.

Functional communication training (FCT) is often a part of PBS plans. FCT may target AAC communication responses and involves several instructional steps to teach the communication responses that will replace the problem behavior and typically match its function (Horner et al., in press; Mirenda, MacGregor, & Kelly-Keough, 2002). FCT involves several steps:

  • Identify the function of the problem behavior
    • Getting comfort, attention, or preferred materials, activity
    • Escaping or avoiding something boring, difficult, painful
      • If a speaking device is used, program the device to make the request
      • Getting more food: "I want more please"
    • Before a problem behavior starts, prompt the student to use the new communication response and immediately fulfill request.
  • Identify a request response to teach
    • That is easy for the person to learn (efficient)
    • That matches the function (effective)
    • Have team-designed AAC materials in reach and ready
    • Getting attention: "I want to play"
    • Avoiding a difficult task: "I need help" "I want a break"
  • Engage student in a task or activity related to problem behavior and teach the communication response
  • Gradually introduce the triggers for problem behavior (difficult step in task, period of low attention, period of no preferred food/objects), prompt student to use the new communication response, and immediately fulfill request.
  • Be alert to trigger and signs of problem behavior; prompt student to use the new communication response and immediately fulfill request.

For more information:

Carr, R. G., Levin, L., McConnachie, G., Carlson, J. I., Kemp, D. C., & Smith, C. E. (1994). Communication-based intervention for problem behavior. Baltimore: Brookes.

Durand, V. M., & Crimmins, D. B. (1985). The Motivation Assessment Scale: An administration manual. Unpublished manuscript, State University of New York at Albany.

Horner, R. H., Albin, R. W., Newton, J. S., Todd, A. W., & Sprague, J. (in press). Positive behavior support for individuals with severe disabilities. In M. E. Snell & F. Brown (Eds.), Instruction of students with severe disabilities (6th ed.). Upper Saddle River, NJ: Merrill/Prentice-Hall.

Janney, R. E., & Snell, M. E. (2000). Teachers' guides to inclusive practices: Behavioral support. Baltimore: Brookes.

March, R., Horner, R. H., Lewis-Palmer, T., Brown, D., Crone, D., Todd, A. W., & Carr E. (2000). Functional Assessment Checklist for Teachers and Staff (FACTS). Eugene: Department of Educational and Community Supports, University of Oregon.

Mirenda, P., MacGregor, T., & Kelly-Keough, S. (2002). Teaching communication skills for behavioral support in the context of family life. In J. M. Lucyshyn, G. Dunlap, & R. W. Albin, (Eds.), Families and positive behavior support: Addressing problem behaviors In family contexts (185–207). Baltimore: Brookes.

O'Neill, R. E., Horner, R. H., Albin, R. W., Sprague, J. R., Storey, K., & Newton, J. S. (1997). Functional assessment and program development for problem behavior. Pacific Grove, CA: Brooks/Cole.

What should we do if a child demonstrates communication skills at home, but doesn't use those skills at school?

This situation is quite common, and may be due, in part, to the family's familiarity with the child's unique communication style and the idiosyncratic behaviors that convey meaning. It may also be because family members, perhaps unknowingly, are supporting the communication interactions in ways that they are not even aware of (for example, initiating all communication in the form of simple questions, and interpreting affect changes as meaningful indicators of agreement or disagreement). The recommended course of action is to gather evidence about the home behaviors, preferably through direct observation but also through parent report. It is VERY important to document the details of the situation leading up the child's communication behavior (the antecedents), the characteristics of the behavior itself, the consequences of the behavior (e.g., the parent's response), and the child's reaction to that response. The analysis of authentic communication behaviors at home may reveal communication strategies that the child uses effectively, which can then be incorporated into the child's school program, and can serve as the foundation for facilitation of more conventional communication skills through intervention.

What is "evidence-based practice" and how do I determine if a communication intervention is "evidence-based"?

The phrase, "evidence based practice" (or EBP) is heard frequently today in both educational and health care settings. At the most basic level, EBP simply means that there is empirical evidence to document the effectiveness of a particular treatment procedure or assessment instrument. In the past, it has not been uncommon for an intervention method to be promoted and used just because it seemed to "make sense," and because one or more "experts" could share anecdotes of how well this procedure has worked in their experience. Today, however, there is a growing demand from consumers, health care insurers, and policy makers for actual proof that a procedure is effective. Such evidence increasingly is required before an insurance company will pay for a procedure, or a state education agency will approve funding for a particular program. There are many ways to evaluate and document the effectiveness of a method, and knowledge of the principles of applied research and experimental design are needed to evaluate the quality of evidence offered in support of a particular method. At a minimum, however, it is appropriate for professionals and consumers alike to ask about the evidence base for any assessment or treatment procedure they are considering.

The 'gold standard' of evidence for any intervention is to have its effectiveness demonstrated in a large, carefully controlled experimental research study, involving hundreds, or even thousands of subjects who are randomly assigned to experimental and control (or comparison) groups. The advantage of these designs is that they allow us to be certain, up to a specified level (e.g., 95% or 99% certain) that the reported results for an intervention were actually due to that particular intervention, and not to other uncontrolled factors, like changes in environment or health status. Such designs are referred to as "true experimental designs" (Campbell & Stanley, 1963).

In reality, however, it is often not practical or even possible to conduct randomized trials with large sample sizes when we want to study the effectiveness of a communication intervention method for use with individuals who have the most severe disabilities. For this reason, we must be willing and able to evaluate the quality of evidence along a continuum from least to most convincing. While there are many unique ways to design research, or combine research designs, we can identify three basic points along this continuum of evidence:

Case Studies >> Controlled, single subject (N=1) and Quasi-Experimental Designs >> True Experimental Designs

With very rare conditions or disabilities, or when a procedure is very new, the only "evidence" available may be a published case study. Case studies are written by clinicians to share information about a unique case or treatment result. High quality case studies will include detailed documentation of the specific history and characteristics of the individual who received the treatment, as well as a detailed description of the intervention used and the apparent outcomes. By definition, a case study involves no experimental controls, so the results must be considered with great caution. While a case study may sound convincing, it must be remembered that any number of uncontrolled variables might actually account for the positive outcome of an intervention. While a case study report may include descriptions of more than one case, this still does not compensate for the lack of experimental control.

For most interventions that are employed with individuals who have severe disabilities, the evidence base will consist of studies that have used either a "Single subject (N=1)" or a "Quasi experimental" research design. In a single subject design, treatment conditions are scheduled so that each participating subject can serve as his or her own experimental control. For example, the target response may be measured before there is any treatment, then during treatment, and then again without any treatment. If the response only improves during treatment, and goes away without treatment, then we may be more convinced that the treatment caused the improvement. In most so-called "single subject" designs, there are actually several subjects, and the effect of the treatment is replicated across each subject.

In addition to these "single subject" designs, there are a number of creative, quasi-experimental designs in which groups of subjects are compared to assess the effect of a particular intervention, but without the types of randomized assignment required for true experimental designs. For example, a researcher may select two preschool classrooms serving children who are similar in age and socioeconomic background, and then provide an experimental intervention to the children in Classroom A, but not Classroom B. If the children in the A classroom perform higher on the target response measure than the children in Classroom B at the end of the study period, the researcher may conclude that the difference is due to the intervention. The stronger the evidence that these two natural groups of children were truly comparable at the outset of the study, the stronger will be the believability of this conclusion. There are many different variations and combinations of such quasi-experimental designs and these represent by far the largest evidence base for most communication services provided to individuals with severe disabilities.

For more information:

Chapters, Articles, and Books

Campbell, D. T. & Stanley, J. C. (1963). Experimental and quasi-experimental designs for research. Boston: Houghton Mifflin.

Dollaghan, C. (2004, April 13). Evidence-based practice: Myths and realities. The ASHA Leader, p. 12.

Frattali, C., Bayles, K., Beeson, P., Kennedy, M. R. T., Wambaugh, J., & Yorkston, K. M. (2002). Development of evidence-based practice guidelines: Committee update [PDF]. Journal of Medical Speech-Language Pathology. 11(3), ix–xviii.

Joseph, G. E., & Strain, P. S. (2003). Comprehensive evidence-based social-emotional curricula for young children: An analysis of efficacious adoption potential. Topics in Early Childhood Special Education, 23(2), 65–76.

Robey, R. (2004, April 13). Levels of evidence. The ASHA Leader, p. 5.

Sackett, D. L., Rosenberg, W. M. C, Gray, J. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence-based medicine: What it is and what it isn't. British Medical Journal, 321, 71–72.

Schlosser, R. W. (2004, June 22). Evidence-based practice in AAC: 10 points to consider. The ASHA Leader, pp. 6–7, 10–11.

Shadish, W. R., Cook, T. D., & Campbell, D. T. (2002). E xperimental and quasi-experimental designs for generalized causal inference. Boston: Houghton Mifflin.

Sigafoos, J., & Drasgow, E. (2003). Empirically validated strategies, evidence-based practice, and basic principles in communication intervention for learners with developmental disabilities. Perspectives on Augmentative and Alternative Communication, 12 (4), 7–10.

Yorkston, K. M., Spencer, K., Duffy, J., Beukelman, D., Golper, L. A., & Miller, R. (2001). Evidence-based medicine and practice guidelines: Application to the field of speech-language pathology. Journal of Medical Speech-Language Pathology, 9(4), 243–256.

Web Resources

What Works Clearinghouse: This website is funded by the U.S. Department of Education and presents information on evidence base standards for educational practices

Paper by K. Hill and B. Romich, entitled AAC evidence-based clinical practice: A model for success.

The evidence-based practice home page of the U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ).

Are yes/no questions a good way to start teaching someone to communicate?

Teaching children to use "yes" and "no" correctly is a lot more difficult than you may think. "Yes" and "no" have many different meanings. For example, a child may use "yes" to indicate that they want something, as in response to "Do you want this cookie?" But "yes" is also used to answer fact-based questions such as "Are you done?" Similarly, "no" could indicate that a child doesn't want something offered to them, or a negative answer to a fact-based question. Sometimes an early goal in a language intervention program is for a child to indicate "yes" when presented something they like and "no" when they are presented something they don't like. Children who have learned these responses are easily confused when faced with different situations. For example, if a parent was bouncing a child on her leg and the child began to fuss, the parent might ask, Do you want me to stop? The child is likely to indicate no if they have been taught to indicate "no" when presented with something they don't want. A recent article in Child Development indicated that typically developing children often confuse the meanings of "yes" and "no" well into their fourth year (Fritzley & Lee, 2003). In addition to the confusing aspect of differentiating "yes" and "no," the appropriate use of these words is in response to a question. This may increase the likelihood that a child will have to wait for his or her communication partner to ask a question and limits the child's ability to initiate a request or a refusal.

In summary, "yes" and "no" are very important vocabulary that all of us use often. However, it may be difficult for children with severe disabilities to learn these responses at the beginning stages of communication. Alternative symbols and signals that indicate a desired or an undesired object or event may be easier to learn.

For more information:

Fritzley, V. H., & Lee, K. (2003). Do young children always say yes to yes-no questions? A metadevelopmental study of the affirmation bias. Child Development, 74 (5), 1297–1313.

If we are supposed to provide "communication services and supports" what is that supposed to include beyond teaching and therapy?

Communication services and supports refer to a more holistic approach to meeting the communication-related needs of children with severe disabilities. Traditionally, service providers have worked one-on-one with students in isolated treatment contexts. This has frequently resulted in less than meaningful outcomes for persons with severe disabilities. A major concern has been that discrete skills learned in "therapy" may not generalize to non-treatment settings. Attempting to intervene more holistically means creating a broader group of individuals from school, home, or community settings who are invested in facilitating a child's communication success. This extended group works in consultation with the speech-language pathologist to create, implement, and evaluate treatment plans. For example, the group may learn about and use augmentative communication systems and specific assessment and treatment methodologies. The network of treatment created and the various methodologies used comprises the student's communication supports and services.

What is the difference between direct and indirect services?

The term "direct services" usually describes services provided by a specialist while in direct contact with a child or adult learner. These services may be provided in a one-to-one context, where the specialist is working with only one learner at a time or in a group context where the specialist is working directly with more than one learner at a time. For example, a speech-language pathologist might facilitate a learner's use of natural gestures by providing communication opportunities while playing with a child or teaching a learner how to select pictures to request foods at meal time. These would be examples of direct services.

Whenever a specialist works with a teacher or parent or other individual who will be responsible for directly working on communication, the services are described as indirect. Sometimes a specialist will consult with a child's teacher or other individuals who frequently interact with an individual with communication impairments about strategies that will improve communication. For example, a specialist might teach a parent how to position a child in a way that promotes good breathing for speech, or teach a classroom teacher how to use a picture schedule to facilitate transitions between activities. These would be examples of indirect services.

Both direct and indirect services are effective methods used to teach communication skills to individuals with severe disabilities. The decision regarding which method or combination of methods to use should depend upon the intervention goals. If the goals are to increase someone's facility producing a particular skill or behavior, direct services are often appropriate. However, if the goals are to increase spontaneous use of a communication skill or behavior across many settings and with many different communication partners, indirect services are appropriate. If the goal is to increase interactions with peers or answer questions in class it may be more beneficial to provide services in the context of the classroom. For example, teachers may need to learn to use gestures or visual cues to enhance comprehension of class routines or lesson content. Peers may need to learn to interpret a child's behavior to interact with them in meaningful ways. In this case, a speech-language pathologist may act as a communication and language coach for the learner, teachers, and peers. Indirect services may allow students with severe disabilities to have increased time with peers, fewer disruptions to class routines, and increased communication among specific team members.

For more information:

Downing, J. (1999). Teaching communication skills to students with severe disabilities. Baltimore: Brookes.

What role does culture play in serving children and families with severe communication disabilities?

With an increasingly diverse population, it is necessary that individuals providing for the communication needs of persons with severe disabilities become sensitive to cultural influences. Recognizing that we all have and represent a culture is an important step. It's important to be aware of the many cultural variables that can impact assessment and intervention. Culture is defined by the Department of Health and Human Services as "the thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups."

Some of the cultural variables that may influence the perceptions and behaviors of both the clients and the clinicians are

  • Age
  • Gender
  • Occupation
  • Sexual orientation
  • Presence of a disability
  • Socioeconomic status
  • Religious beliefs
  • Ethnicity

Rules for verbal and nonverbal communication may vary across cultures. As an example, gestures and their meaning may vary from culture to culture. A gesture indicating a positive behavior for one culture, such as a "thumbs up," may be viewed as inappropriate in another culture. The communication roles that partners play also may vary with cultural expectations. For example, helping a child to initiate communication more often may not be as valued by some cultures. Silence may be a sign of respect shown to a communication partner, rather than a failure to respond or understand. The linguistic diversity of clients may affect aspects of communication such as vocabulary, dialect, and beginning literacy. In designing an augmentative and alternative communication system (AAC) for a child whose family speaks a language other than English, selection of vocabulary for home and for school activities requires a consideration of the languages used and their context.

Individuals vary across cultures, but they also vary within a culture.

Service providers should attempt to be as knowledgeable about clients' cultural backgrounds as possible. Perhaps the most important consideration for practicing clinicians is that culturally based differences in communication may not necessarily be considered deficiencies or disorders.

For more information:

American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speech-language pathologists and audiologists to provide culturally and linguistically appropriate services.

American Speech-Language-Hearing Association. (2005). Cultural competence.

Mahendra, N., Ribera, J., Sevcik, R., Adler, R., Cheng, L. L., McFarland, E. D., et al. (2004). Why is yogurt good for you? Because it has live cultures. Perspectives on Augmentative and Alternative Communication, 13, 17–20.

Moxley, A., Mahendra, N., & Vega-Barachowitz, C. (2004, April 13). Cultural competence in health care. The ASHA Leader, pp. 6–7, 20–22.

Stockman, I. J., Boult, J., & Robinson, G. (2004, July 20). Multicultural issues in academic and clinical education: A cultural mosaic. The ASHA Leader, pp. 6–7, 20.

The school district assistive technology (AT) team says that a student we serve does not qualify for augmentative and alternative communication/assistive technology (AAC/AT) because she has some speech. The student is about 50% unintelligible to familiar partners under known context conditions.

AAC interventions are used when individuals are unable to rely on speech to meet all of their daily communication needs. The student you describe clearly fits into this category, as even familiar communication partners can understand her speech only half of the time, even when the context is known. No doubt, she has even more difficulty being understood by those who don't know her well, as is commonly the case in the school environment.

Special education law requires each student's needs to be evaluated, with the student's educational team making determinations about the services and supports that are needed for the youngster to access a free, appropriate public education. From your question, it sounds like the student's team recognizes that AAC supports should be explored for the benefit of this youngster. If you haven't already done so, a communication assessment should be conducted to determine those educational settings in which her unintelligibility poses a barrier and also the means of AAC support that are both appropriate (i.e., they allow her to participate and show progress in the general education curriculum) and preferred by the student. This information should be brought back to the team so it can determine if, when, and how AAC supports will be provided.

If the team agrees that the student needs AAC supports, then the nature of the tools/strategies to be used and the settings in which they are to be used should be specified in the student's Individualized Education Program (IEP). The student is guaranteed access to the needed supports (and related services) only when they are documented in this manner. Don't forget to consider whether AAC supports are needed for homework and/or extracurricular activities as well. By law, access to AT in these domains may also be considered by the team because they are an important part of the student's educational experience. Another element that can be incorporated into an IEP is training for educators and/or family members to maximize their effective incorporation of AAC supports into the student's educational activities.

How should I set up a grapheme/text based AAC system for a young student who speaks English as a second language (at school), but who has family that does not speak English?

Family preferences regarding cultural priorities should be reflected in the AAC mode. For children who live with families that speak another language, these multiple language factors need to be taken into consideration. Although guidelines suggest that instruction in a child's first language helps build a strong base for further language instruction, including AAC (Harrison-Harris, 2002), there is limited research supporting the specific strategies involved in teaching AAC to children from multilingual backgrounds. Therefore, we recommend working closely with family and other members of the team to provide the child with opportunities to communicate both at home and at school in the language that will be most effective within that context. This may mean using different systems or a different set of vocabulary across settings at some time during the course of instruction. Careful data collection will help guide the team regarding the use of multiple systems. For example, if the child is using symbols and text in his or her first language, data are needed to evaluate how well school personnel respond to the child's first language. Similarly, if two different systems are used, the team may consider whether the child responds less often (perhaps due to confusion). The clinician and team members will need to create their own data set to make decisions that are best for the specific child in question.

For more information:

Harrison-Harris, O. L. (2002, November 5). AAC, literacy and bilingualism. The ASHA Leader, pp. 4–5, 16–17.

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