Augmentative and alternative communication (AAC) is an area of clinical practice that addresses the needs of individuals with significant and complex communication disorders characterized by impairments in speech-language production and/or comprehension, including spoken and written modes of communication.
AAC uses a variety of techniques and tools, including picture communication boards, line drawings, speech-generating devices (SGDs), tangible objects, manual signs, gestures, and finger spelling, to help the individual express thoughts, wants and needs, feelings, and ideas.
AAC is augmentative when used to supplement existing speech, and alternative when used in place of speech that is absent or not functional.
AAC may be temporary, as when used by patients postoperatively in intensive care, or permanent, as when used by an individual who will require the use of some form of AAC throughout his or her lifetime.
Individuals who use AAC have severe expressive communication disorders that are characterized by impairments in speech, language, reading, and writing. The list of populations below includes those who may have a temporary or permanent need for AAC to augment or replace other more traditional means of communication. It is not intended to be an exhaustive list of individuals who may benefit from AAC intervention.
AAC users fall into two broad categories—those with congenital disabilities and those with acquired disabilities.
Congenital disabilities include
Individuals with congenital disabilities are acquiring language while using AAC strategies. For this population, AAC not only represents existing language but also is a tool to aid in expressive and receptive language acquisition and literacy development.
Acquired disabilities include
AAC needs for individuals with acquired disabilities will vary and may change over time, depending on the intactness of their language and cognition at the time of injury as well as on disease onset and progression.
An AAC system is an integrated group of components used to enhance communication. These components include forms of AAC (aided or unaided), symbols, selection techniques, and strategies.
The design of an AAC system incorporates each individual's strengths and needs. It incorporates the individual's full communication abilities and may include existing speech, vocalizations, gestures, languages spoken, and/or some form of external system (e.g., SGD).
An individual may use multiple modalities or many systems of AAC in combination, allowing for change based on context, audience, and communicative intent. A well-designed AAC system is flexible and adaptable. It allows for changes to vocabulary and mode of access as the individual's language and physical needs change over time. A well-designed system also maximizes the individual's abilities to communicate effectively and efficiently across environments and with a variety of communication partners (Beukelman & Mirenda, 2013).
AAC is typically divided into two broad categories—unaided and aided.
Unaided forms of AAC do not require an external tool. Unaided forms require some degree of motor control.
Aided forms of AAC require some form of external support—either electronic or nonelectronic. Nonelectronic aided forms are often referred to as "light-tech" or "low-tech." Electronic forms are referred to as "high-tech." Examples are listed in the table below.
An individual may use aided forms of AAC, unaided forms of AAC, or both. Whether a person uses aided or unaided forms is determined by his or her needs and abilities and the communication context. People who use AAC should always have access to their communication devices. Concerns about overuse of screentime, particularly for young children, does not apply to the use of screens as part of an AAC system.
*SGDs can be set to use a voice that is appropriate to the user's age and gender and that appropriately reflects race/ethnicity and user preference. These devices use synthesized speech output, digitized speech output, or both.
Other augmentative supports include voice amplifiers and artificial phonation devices (e.g., electrolarynx devices, intraoral devices, and speech valves for individuals with tracheostomies or ventilators), vibratory systems, Morse code, and braille.
Within the population of those who are deaf and hard of hearing, many individuals use hearing aids and hearing assistive technology systems (e.g., personal amplification devices and text telephones [Telecommunications Device for the Deaf (TDD) or Teletype (TTY)]) that aid in communication with hearing individuals who are not able to communicate via sign language or choose not. These devices are considered to be assistive technology but do not fall under AAC, because they do not require skilled speech-language pathologist (SLP) intervention prior to use. (For information about hearing assistive technologies, see ASHA's Practice Portal pages on hearing loss – beyond early childhood and hearing aids for adults.)
Symbols are used in AAC to represent objects, actions, concepts, and emotions. They can include drawings, photographs, objects, facial expressions, gestures, auditory symbols (e.g., spoken words), or orthography (i.e., alphabet-based symbols).
Iconicity refers to the association made between a symbol and its referent (Schlosser, 2003). Iconicity varies along a continuum, based on how easily the meaning of the symbol can be guessed.
Iconicity directly affects the communicator's efficiency and effectiveness, especially with regard to untrained or unfamiliar communication partners. High iconicity (i.e., displaying the symbol along with the written word) can help communication partners learn and interpret symbols, particularly if no voice output is available (Wilkinson & McIlvane, 2002).
There are three common ways that symbols are used to represent language; these are known as language representation methods (LRMs). A person who uses AAC may use a single LRM or a combination of LRMs, depending on preference and the functionality of the system. The following three LRMs are commonly used in AAC systems:
Symbols are a dynamic part of AAC intervention. A person's spoken vocabulary will change based on his or her age, communication partner, language development, environment, mood, and context. The symbols used in an AAC system should allow for the same change and flexibility. Symbols are not universal across cultures. It is important to find symbols that are relevant to the individual and his or her community.
Symbol selection is also based on the person's ability to access, recognize, and learn that symbol's meaning. For example, a person with visual deficits will need a symbol that is modified to be viewable or that is accessible via other sensory modes such as listening or touch.
Symbol organization on an AAC system affects the individual's ability to communicate effectively and efficiently. It plays a role in language learning and development, and it needs to be customized and modified throughout the user's time with the AAC system (Beukelman & Mirenda, 2013).
The way in which symbols are presented on an AAC system is referred to as the display. Different encoding options (e.g., alphanumeric, numeric, iconic, alphabetic, and color) are sometimes used to organize displays. Displays can be static (fixed), dynamic (changes based on user actions), or hybrid (a combination of static and dynamic).
A visual scene is a view of an environment consisting of drawings, photographs, and/or virtual environments organized in a meaningful way. Visual scenes can be used to represent situations, routines, places, or experiences. They can be presented via fixed or dynamic displays (Beukelman & Mirenda, 2013). Elements within the visual scene function as hotspots that trigger message output when selected.
For beginning communicators (e.g., young children or older individuals who are at early functioning communication stages), visual scenes may be easier to learn and use than grid displays. (For more details about visual scene displays and an example, see Tuthill, 2014.)
Most AAC systems, with the exception of visual scenes, are presented in a grid format. The organization of vocabulary, symbol size, and number of symbols on the grid is individualized and determined by the type of display, the type of symbol, and the visual acuity, communication and cognitive skills, integrated sensory system, and motor control of the individual.
Semantic–syntactic displays organize vocabulary based on parts of speech and syntactic framework. Symbols are laid out according to spoken word order and print orientation, and they vary depending on the language used (e.g., left-to-right or right-to-left). Semantic–syntactic displays are useful for adults with relatively intact language (e.g., individuals with ALS) or language learners, and they can facilitate efficient production of grammatically complex messages.
Taxonomic displays group symbols according to semantic category (e.g., people, places, feelings, actions). Typically developing children begin to find this type of grouping helpful at around age 6–7 years, so this strategy may not be appropriate for individuals with complex communication needs who are developmentally younger than 6 years of age (Buekelman & Mirenda, 2013). Use of taxonomic displays for persons with aphasia can add to the cognitive and linguistic load and may lead to increased errors and slower response time (Petroi, Koul, & Corwin, 2011).
Activity grid displays (also known as "schematic grid layouts") organize vocabulary by event schemes, routines, or activities. Each page or display includes activity-specific vocabulary and may be further organized by part of speech (e.g., nouns, verbs). Activity grid displays can increase participation and syntactic development by encouraging use of multiword combinations (Drager, Light, Speltz, Fallon, & Jeffries, 2003). Users may be able to navigate independently from one activity display to another, or they may rely on a facilitator or communication partner to provide the appropriate activity display for a given situation. Context-based displays are similar to activity grid displays but are designed for a particular (usually frequent) context or environment, allowing for greater generalization than vocabulary designed around a single, specific activity.
Selection of appropriate vocabulary is a key consideration and can lead to greater intervention success and decreased likelihood of abandonment of the AAC system. The SLP considers the personal preferences and needs of the individual for communicating with family members and other communication partners (e.g., in social contexts, academic settings, medical settings, vocational settings, etc.) and makes all efforts to use vocabulary that is specific to the individual and consistent with his or her language, age, culture, and personal preference. Nouns tend to dominate vocabulary sets for AAC users (Dark & Balandin, 2007); however, the inclusion of verbs and other parts of speech can increase AAC acceptance and use (Adamson, Romski, Deffebach, & Sevcik, 1992).
Vocabulary is often divided into two categories: core and fringe (or "extended"). Core vocabulary consists of high-frequency words that make up about 80% of the words used by most people every day. Core vocabulary contains mostly pronouns, verbs, descriptors, and question words (Witkowski & Baker, 2012). English language learners use a comparable amount of core vocabulary as do native English speakers (Boenisch & Soto, 2015). Fringe vocabulary consists of lower-frequency words – mostly nouns – which tend to be context specific. Combining core and fringe vocabulary can increase the frequency of AAC use (Buekelman, McGinnis, & Morrow, 1991; Yorkston, Dowden, Hosinger, Marriner, & Smith, 1988).
Selection techniques are the ways in which messages or symbols are accessed by the AAC user. There are two main selection techniques —direct selection and indirect selection (scanning).
Direct selection—The AAC user selects the desired symbol directly from a selection set. Direct selection can be
Indirect selection (scanning)—Each item from a selection set is presented sequentially until the desired item appears and is selected by using a previously agreed upon motor movement or vocalization or by using a switch.
A strategy is a process or plan of action used to improve (e.g., accelerate) performance. An individual's use of AAC can be enhanced by the application of strategies that include topic setting, letter and word prediction, location of vocabulary for efficient access, and one-shot message communication aids that allow for the message to be changed for different activities as needed.
Communicative competence is an individual's ability to freely express ideas, thoughts, and feelings to a variety of listeners across contexts. It provides the means to achieve personal, educational, vocational, and social goals (Calculator, 2009; Lund & Light, 2007; Light & McNaughton, 2014). Individuals must achieve communicative competence whether they use natural speech or AAC, but their paths may vary (Light, Beukelman, & Reichle, 2003).
Communicative competence for AAC users consists of the following five individual competencies (Light et al., 2003).
There are many common myths that can potentially affect an individual's or family member's willingness and motivation to use AAC. However, available research does not support these myths (Romski & Sevcik, 2005).
Myth 1: Introducing AAC will reduce an individual's motivation to improve natural speech and will hinder language development (including the development of social communication skills). AAC should be introduced only after the ability to use natural speech has been completely ruled out.
Myth 2: Young children are not ready for AAC and will not require AAC until they reach school age.
Myth 3: Prerequisite skills such as understanding of cause and effect and showing communicative intent must be demonstrated before AAC should be considered; individuals with cognitive deficits are not able to learn to use AAC.
It is difficult to estimate the prevalence of AAC users due to wide variability across this population in terms of diagnosis, age, location, communication modality, and extent of AAC use. However, it is commonly accepted that the number of AAC users is growing, most likely as a result of increases in access to technology and AAC awareness and increases in the number of individuals with complex communication needs (Light & McNaughton, 2012; Ratcliff, Koul, & Lloyd, 2008).
SLPs play a central role in the screening, assessment, diagnosis, and treatment of persons requiring AAC intervention. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment), advocacy, education, administration, and research.
Appropriate roles for SLPs include the following:
As indicated in the ASHA Code of Ethics, SLPs shall engage in only those aspects of the profession that are within the scope of their professional practice and competence, considering their level of education, training, and experience.
See the Assessment section of the Augmentative and Alternative Communication evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.
The goal of an AAC assessment is to elicit valid and representative behaviors that accurately demonstrate the AAC user's communication potential. AAC assessment is an ongoing process; ongoing evaluation and decision making are required, even after an AAC system has been selected. Elements of dynamic assessment and other informal assessments are used to supplement standardized assessment data. See assessment tools, techniques, and data sources for a description of testing and data collection options.
Exposing individuals to symbols and systems prior to assessment may ensure more accurate assessment results. This can be accomplished by providing core vocabulary supports in the home and classroom and by introducing visually represented language using a variety of communication display forms and sizes prior to the formal assessment process.
Assessment takes into consideration the needs of the individual, which may include one or more of the following:
Primary, secondary, and tertiary components of the AAC system are also considered during assessment.
SLPs also consider perspectives of family members and caregivers because these individuals often are able to report consistent behaviors and current means of communication beyond what the SLP may see during the assessment session. Lack of family involvement in the AAC process is cited as a significant factor leading to device abandonment; therefore, incorporating family members into the AAC process is crucial (Bailey, Parette, Stoner, Angell, & Carroll, 2006).
The assessment is conducted in the language preferred by the AAC user and takes into account unique characteristics, linguistic background, and cultural variables that affect communication style and use. Interpretation services may be needed (see Collaborating with Interpreters, Transliterators, and Translators).
If the individual (and/or communication partner) wears hearing aids or prescription eyeglasses, these should be worn during the assessment. Hearing aids should be inspected prior to the assessment to ensure that they are in working order.
Environmental modifications are made to accommodate vision or hearing deficits and any other physical difficulties. These modifications may include special lighting, physical positioning of the individual relative to his or her communication partner; volume of the SGD if the communication partner has a hearing impairment; additional personal amplification if needed; and modifications of physical space to accommodate wheelchairs or other specialty seats.
Consistent with the WHO's International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2016; WHO, 2014), a comprehensive assessment of individuals with AAC needs is conducted to identify and describe
See Person-Centered Focus on Function: Augmentative and Alternative Communication for Adult with Amyotrophic Lateral Sclerosis (ALS) [PDF] and Person-Centered Focus on Function: Augmentative and Alternative Communication for Child with Cerebral Palsy [PDF] for examples of assessment data consistent with the ICF framework.
The following table lists the typical components of a comprehensive assessment for AAC.
Many standardized assessments include items that require a verbal (e.g., picture naming) and/or motor (e.g., pointing) response. For individuals with significant disabilities (e.g., individuals who are nonverbal, have limited speech, or have significant motor limitations), it may be necessary to modify the task or the response mode.
Standardized scores cannot be used when assessments are modified because the tasks are fundamentally different (Barker, Saunders, & Brady, 2012). Assessment should include elements of dynamic assessment and other informal assessments (e.g., direct observation of language use in a variety of natural contexts) to supplement standardized assessment data.
See Ganz (2014) for a discussion of communication skills assessments and assessments to determine suitability of AAC for individuals with complex communication needs. See also the Assessment section of Written Language Disorders for a discussion of task modifications for assessing literacy skills in individuals who are nonverbal or have limited speech.
When evaluating and planning for AAC intervention, the clinician considers the barriers that affect communication as well as the individual's communication abilities. For individuals with congenital disabilities, AAC intervention is considered whenever a gap exists between the communication abilities of the AAC user and those of his or her peers. For individuals with acquired disabilities, AAC intervention occurs when a gap is identified between pre- and post-injury abilities. See The Participation Model for Augmentative and Alternative Communication [PDF] (Beukelman & Mirenda, 2013).
Use of AAC is considered as early as possible, regardless of etiology of the communication impairment. The goal of AAC intervention is to facilitate communication between the individual and his or her outside world. ASHA aligns with the National Joint Committee for the Communication Needs of Persons With Severe Disabilities (NJC) in support of a zero-exclusion policy for AAC services. See the Communication Bill of Rights (Brady et al., 2016; NJC, 1992).
There are no prerequisites for AAC intervention, and a variety of strategies and techniques should be implemented in order to determine the most effective means of communication for the individual (Zangari & Kangas, 1997). All individuals are considered candidates for AAC intervention as long as there is a discrepancy between their communication abilities and their communication needs. It takes time to establish a means of communication via AAC, but the time and effort involved should not be a reason for exclusion from intervention.
SLPs consider the attitudes, knowledge, and beliefs of the individual and his or her family members with regard to disability and the use of technology for communication. Cultural views can vary widely and may influence all areas of AAC service delivery, including the decision to use AAC, the choice of AAC hardware, and the selection of vocabulary and symbol systems.
Keep cultural variations in mind when assessing communication needs of the individual and the individual's family. A thorough assessment includes gathering information about lifestyle, the desire to communicate, and expectations with regard to AAC use. Ethnographic interviews can be used to supplement information from commercial questionnaires and surveys. SLPs must also recognize that not all individuals who use AAC will share the same beliefs about AAC as their families (O. Harris, 2015).
When assessing individuals who speak more than one language, the clinician collects a thorough description of prior language exposure and proficiency as well as current level of functioning in every language used. Selection of an AAC system should be informed by the individual's current skill level in each language.
For individuals who speak more than one language, clinicians consider changes in language proficiency due to acquired injury. For example, a bilingual individual with aphasia may no longer be as proficient in all languages used prior to the injury. AAC tools should support various languages and dialects when possible; if the AAC system does not support the individual's home language, he or she may be unable to communicate in the home, and carryover will be limited (Dukhovny & Kelly, 2015).
Ideally, AAC systems with the ability to switch between messages in different languages are considered. Several AAC companies offer devices or software that include multilingual functionality. As more apps for tablets are developed, options for language-specific AAC technology are also improving. See Dukhovny and Kelly (2015) for availability of SGDs with multilingual capabilities.
Involving families and caregivers in the assessment process often involves working with an interpreter or translator. See Collaborating With Interpreters, Transliterators, and Translators and Cultural Competence for more information.
In the school-based setting, the SLP works as part of a team that typically includes general and special education teachers, paraprofessionals, physical and occupational therapists, teachers of students with visual or hearing impairment, music therapists, administrators, nurses, case managers, and family members.
The school-based SLP is typically responsible for
Important considerations for this population include
The school-based SLP works as part of a team that may include an AAC specialist who facilitates or completes the AAC evaluation. Implementing AAC in the schools is the responsibility of the school-based team—which includes the school SLP—and may include support from an AAC specialist. If the IEP team determines that AAC is required in order for a student to be provided a free and appropriate public education (FAPE), the technology must be provided to implement the IEP.
In the acute care setting, the SLP works as part of a team that often includes doctors, nursing staff, physical and occupational therapists, case managers, family members, and caregivers.
Important considerations for this population include
Effective augmentative and alternative communication (AAC) assessment via telepractice is a complex process. Refer to guidance from your state, employer, or school district. Some considerations for AAC evaluation include
See a demonstration of equipment set-up, intervention, and engagement strategies that are applicable to remote assessment from Special Interest Group 12, Augmentative and Alternative Communication.
When evaluating an individual for AAC at the end stages of life, the SLP considers
See End-of-Life issues in Speech-Language Pathology for more information.
See the Treatment section of the Augmentative and Alternative Communication evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.
The goal of intervention is to maximize the efficiency and effectiveness of communication for individuals who are unable to communicate via traditional means. Whenever possible, intervention takes place in a naturalistic environment in order to promote generalization. Treatment focuses on using AAC to improve functional communication, increase language and literacy skills, improve speech production and comprehensibility with use of multiple modalities, decrease challenging behaviors, and improve social communication.
AAC interventions address the development of adequate, functional communication skills to support individuals with complex communication needs in developing, rebuilding, or sustaining communicative competence to express needs and wants, develop social closeness, exchange information, and participate in social etiquette routines as required (Drager et al., 2010; Light & McNaughton, 2014).
AAC intervention requires ongoing decision making and training to promote communicative competence and language and literacy development, as well as modifications to AAC systems to support changes in communication needs over time. For individuals using aided approaches, intervention may include customization of vocabulary, rate enhancement features that allow users to produce language with fewer keystrokes, and updates to software for high-tech devices.
Preferred practice for AAC intervention incorporates multiple communication modalities so that the user is not restricted to aided or unaided approaches but can use a combination of communication modalities, depending on the environment, listener, and intent of the message.
See Person-Centered Focus on Function: Augmentative and Alternative Communication for Adult with Amyotrophic Lateral Sclerosis (ALS) [PDF] and Person-Centered Focus on Function: Augmentative and Alternative Communication for Child with Cerebral Palsy [PDF] for examples of functional goals consistent with the ICF framework.
Families are integral to the assessment and treatment process. Family members bring important and unique understanding of the strengths, challenges, and needs of the individual who uses AAC. In addition to helping the individual identify goals and objectives for treatment, family members and caregivers often have input into the type of AAC system used, daily communication needs, and vocabulary incorporated into the system. This helps ensure carryover and functional use of the system in everyday life. Partial or complete abandonment of AAC can occur when family input is not considered during AAC intervention (Angelo, Jones, & Kokoska, 1995; Parette, Brotherson, & Huer, 2000; Parette, VanBiervliet, & Hourcade, 2000).
See Family-Centered Practice for general guidelines.
SLPs often work with other professionals to improve the success of AAC intervention.
In addition to limitations of the AAC device itself and insufficient involvement in device selection, inadequate training of communication partners has been identified as a barrier to device use (Bailey et al., 2006). For example, when communicating with children who use AAC, communication partners are more likely to ask yes–no questions instead of open-ended questions, dominate the conversation, or fail to respond to the individual's communication attempts (e.g., Houghton, Bronicki, & Guess, 1987; Light, Collier, & Parnes, 1985).
Communication partner training facilitates effective communication and incorporates instruction in the following skills:
The SLP trains multiple communication partners, including other professionals who work with the AAC user.
Treatment selection depends on a number of factors, including the individual's communication needs, the presence and severity of co-occurring conditions (e.g., cerebral palsy, apraxia of speech, aphasia, or progressive neurological diseases), and the individual's cultural and linguistic background and values.
Once an AAC system is selected, intervention will initially focus on training the individual and his or her family/caregivers in how to use the device (i.e., operational competence). Interventions quickly move toward incorporating use of the AAC system into a naturalistic environment and using the system to address broader communication goals such as language and literacy development and social interaction.
Below are brief descriptions of both general and specific treatment approaches and instructional strategies for AAC intervention, listed in alphabetical order. Some are prescribed interventions with specified procedures, and some are more general approaches to language organization and/or system presentation.
This list is not exhaustive, and the inclusion of any specific treatment approach does not imply endorsement from ASHA.
Augmented input—also called "natural aided language" or "aided language modeling"—is a receptive language training approach in which the communication partner provides spoken words along with AAC symbols during communication tasks (e.g., partner points to the AAC symbols while simultaneously talking).
Augmented input is based on the concept that language input provides a model for language development. This approach can lead to increased symbol comprehension in young AAC users and in users with severe cognitive or intellectual disabilities (Binger & Light, 2007; Drager et. al., 2006, 2010), as well as increased symbol comprehension and production (Binger & Light, 2007; Goossens', Crain, & Elder, 1992; M. Harris & Reichle, 2004).
Behavioral interventions are used to teach desired behaviors and are based on behavioral/operant principles of learning (i.e., differential reinforcement, modeling, prompting, and fading). Behavioral methods involve examining antecedents that elicit a behavior, along with the consequences that follow the behavior. Adjustments in this chain are made to increase desired behaviors and/or decrease inappropriate ones. Behavioral interventions range from one-to-one discrete trial instruction to naturalistic approaches.
DTT is a one-to-one instructional approach using behavioral methods to teach skills in small, incremental steps in a systematic, controlled fashion. The teaching opportunity is a discrete trial with a clearly identified antecedent and consequence (e.g., reinforcement in the form of praise or tangible rewards) for desired behaviors. DTT is most often used for skills that (a) learners are not initiating on their own, (b) have a clear, correct procedure, and (c) can be taught in a one-to-one setting.
Milieu therapy includes a range of methods—including incidental teaching, time delay, and mand-model procedures—that are integrated into a child's natural environment. It includes training in everyday environments and during activities that take place throughout the day, rather than only at "therapy time." Milieu language teaching and other related procedures offer systematic approaches for prompting children to expand their repertoire of communication functions and to use increasingly complex language skills (Kaiser, Yoder, & Keetz, 1992; Kasari et al., 2014).
Incidental teaching is a teaching technique that uses behavioral procedures to teach elaborated language; naturally occurring teaching opportunities are provided, based on the individual's interests. The clinician reinforces the individual's attempts to communicate as these attempts get closer to the desired communication behavior (McGee, Morrier, & Daly, 1999). Incidental teaching requires initiation by the individual, which serves to begin a language teaching episode. If the person does not initiate, an expectant look and a time delay might be sufficient to prompt language use. The clinician can prompt with a question (e.g., "What do you want?") or model a request (e.g., "Say: I need paint.").
Time delay is a behavioral method of teaching that fades the use of prompts during instruction. For example, the time delay between initial instruction and any additional instruction or prompting is gradually increased as the individual becomes more proficient at the skill being taught. Time delay can be used with individuals regardless of cognitive level or expressive communication abilities.
Using this approach, the clinician teaches the individual an initial set of core vocabulary. This core set often consists of common words used by most people across contexts. This approach also takes into account vocabulary used by typically communicating peers and any additional words needed by the user, based on input from family members, teachers, and so forth. As more words are added to the AAC display, words from the initial set remain in the same location to minimize demands on memory and motor planning. The variety of word types (pronouns, verbs, descriptors, question words, etc.) used in a core vocabulary approach allows the individual to express a variety of communicative functions such as asking questions, requesting, rejecting, protesting, commenting, and describing.
For individuals with congenital disabilities who use AAC, core vocabulary is likely represented by symbols—or by symbols combined with orthography. For those with acquired disabilities, the core vocabulary may consist of only orthography, depending on premorbid and current literacy level. If a focus of AAC intervention is to develop oral and written communication skills, a foundation of language skills based in core vocabulary is crucial (Witkowski & Baker, 2012).
Facilitated communication is a technique by which a "facilitator" provides physical and other supports in an attempt to assist a person with a significant communication disability to point to pictures, objects, printed letters, and words, or to a keyboard in order to communicate.
According to ASHA's position statement titled Facilitated Communication, "It is the position of the American Speech-Language-Hearing Association (ASHA) that Facilitated Communication (FC) is a discredited technique that should not be used. There is no scientific evidence of the validity of FC, and there is extensive scientific evidence—produced over several decades and across several countries—that messages are authored by the "facilitator" rather than the person with a disability. Furthermore, there is extensive evidence of harms related to the use of FC. Information obtained through the use of FC should not be considered as the communication of the person with a disability" (ASHA, 2018).
Often the first focus of linguistic intervention for the AAC user involves development of functional communication skills, including expressing wants and needs, gaining attention, indicating preferences, and protesting. For example, individuals can be taught to make requests by using symbols, objects, or words to indicate desired objects or actions (Johnston, Reichle, Feeley, & Jones, 2012). Functional communication skills help minimize communication breakdowns and reduce the occurrence of challenging behaviors (Carr & Durand, 1985; Mirenda, 1997).
Language Acquisition Through Motor Planning (LAMP) is a therapeutic approach based on neurological and motor learning principles that uses a high-tech AAC system to provide the child with opportunities to initiate activity, engage in communication around activities of their choice, and access consistent motor plans to locate vocabulary (Potts & Satterfield, 2013).
The LAMP approach teaches the individual to independently select words and build sentences on a voice output AAC device using consistent motor plans to access vocabulary. LAMP's emphasis on motor planning may reduce the cognitive demands of choosing from a symbol set and may result in more automatic and faster communication (Autism Spectrum Australia [Aspect], 2013).
The LAMP approach involves a combination of the following principles for teaching language and the programming of the device:
Mentoring programs pair young, newly proficient AAC users with older, more experienced users, with the intention of providing positive role models, teaching higher level sociorelational skills, and improving self-confidence and desire to achieve personal, educational, and professional goals. In addition to improving self-confidence and sociorelational skills in the newly proficient AAC user, mentors also benefit from the training experience that prepares them for participation in mentoring programs (Light et al., 2007).
Picture Exchange Communication System (PECS) is a specific, manualized intervention program for individuals with ASD and other developmental disabilities that is intended to shape a child's expressive communication abilities using prompting and reinforcement strategies. PECS training consists of six progressive instructional phases:
PECS requires preparation of pictures on the part of the facilitator and acceptance and ability to transport a communication board or book on the part of the user (Flippin, Reska, & Watson, 2010).
Pragmatic Organization Dynamic Display (PODD) is a system of organizing and selecting words or symbol vocabulary on a low-tech or high-tech AAC system, so that individuals with complex communication needs and their communication partners can communicate more easily. The aim is to provide vocabulary for continuous communication all the time, across a range of different topics, using a variety of messages.
PODD communication books can vary with regard to symbol size, numbers of items on a page, language complexity, access method, and presentation mode (visual or auditory), depending on the specific needs of the individual. Vocabulary organization takes into account communicative function and flow of conversational discourse. Books include symbols for navigation such as "Go to page____"; colored page tabs that match page numbers; and symbols for specific operational commands such as "Turn the page," "Go back to page__," and so forth. The first pages of the PODD book often include words or phrases to support behavioral and environmental regulation and may also include pragmatic starters such as "Something's wrong," "I want something," or "I'm asking a question" to help individuals convey contextual information (Porter & Cafiero, 2009).
Total communication (TC) is a holistic approach to communication that promotes the use of all modes of communication, including sign language, spoken language, gestures, facial expression, and environmental cues such as pictures and sounds. Although TC is most commonly associated with approaches to educating children who are deaf or hard of hearing (Denton, 1976), it has also been used with other populations, such as individuals with ASD (e.g., Nunes, 2008; Wong & Wong, 1991).
Video-based instruction (also called "video modeling") is an observational mode of teaching that uses video recordings to provide a model of the target behavior or skill. Video recordings of desired behaviors are observed and then imitated by the individual. The learner's self-modeling can be videotaped for later review.
Visual prompting strategies use visual cues (e.g., pointing or gesturing) to help individuals with disabilities maintain attention, understand spoken language, sequence events, organize environments, or increase independence with task completion (Hodgdon, 1995). Visual prompts can be general (e.g., gesturing toward the communication system) or specific (e.g., pointing to a specific display location).
Visual prompting strategies can help increase an individual's ability to independently initiate tasks, sustain participation in an activity, perform multistep tasks, and participate in an increased variety of activities.
Use of visual prompting strategies that incorporate the same symbols from an individual's AAC system or that are incorporated into the system itself can help the AAC user understand, anticipate, and communicate about daily routines and can also help decrease challenging behaviors (Drager et al., 2010). Visual prompting strategies can create opportunities to increase aided language input or augmented input.
Visual schedules are a common method of visual prompting. Visual schedules use objects, photographs, drawings, written words, or other symbols to cue or prompt individuals to complete a sequence of tasks or activities. Symbols on the display are presented horizontally or vertically in sequence of occurrence and can represent activities within a day or week (or longer period) or the steps within a particular activity. Visual schedules that initiate or sustain interaction are called scripts. Scripts are often used to promote social interaction but can also be used in a classroom setting to facilitate academic interactions and promote academic engagement (Hart & Whalon, 2008).
Visual schedules can be used to
Language acquisition via AAC is different from language acquisition through typical means. Before acquiring AAC, children likely had (a) reduced means of expression and ability to control communication interactions and (b) fewer opportunities for exploring and interacting with their environment. During the language learning process, AAC users depend on someone else to provide vocabulary and content for their AAC system, and there may be few communicators who can model language using the same form of communication that the child is expected to use (Blockberger & Johnston, 2003; Blockberger & Sutton, 2003).
Acquisition of grammar (both morphology and syntax) can be especially challenging for AAC users who are simultaneously acquiring language, because morphological markers (e.g., tense and plural markers) are difficult to represent via symbols or may be excluded due to space constraints (Sutton, Soto, & Blockberger, 2002).
It is essential to provide support to all beginning communicators as they develop language skills. Children must be able to comprehend and use language to communicate with others in a wide variety of settings and to function effectively in the classroom. For children with disabilities, the skills to support language development very often must be explicitly taught. This includes building both receptive and expressive vocabulary (including both spoken words and AAC symbols). Specific types of vocabulary may need to be targeted (e.g., teaching verbs and adjectives to a child who primarily uses nouns). Once the child has acquired a good number of words and/or AAC symbols, he or she can be taught how to begin combining words to form sentences (Kent-Walsh & Binger, 2009).
Children who are nonverbal or who have complex communication needs often have less exposure to language and literacy due to motor, sensory, cognitive, or other impairments.
Lack of literacy development restricts AAC users to nonorthographic symbols and limits their ability for novel message generation (Millar, Light, & McNaughton, 2004). Nonverbal children may have difficulty acquiring phonemic awareness—an essential skill for literacy development—because they are unable to produce the sounds (Hetzroni, 2004; Millar et al., 2004).
Literacy instruction for AAC users incorporates AAC, assistive technology, and task adaptations that can support literacy learning in children with CCN (Hetzroni, 2004; Light & McNaughton, 2012). Many literacy activities, such as those listed below, can be adapted to meet the needs of AAC users:
Literacy intervention for children who use AAC also includes instruction on how to read for a variety of purposes while drawing on one's own relevant background knowledge and personal experiences (Erickson, Koppenhaver, & Cunningham, 2006).
When working with school-age children who use AAC, clinicians consider the amount of support that the child will need in order to use their AAC system within the school (classroom, lunchroom, hallways, play and leisure activities, etc.) and outside the school setting. Vocabulary selection should give the individual access to the general education curriculum along with access to and use of vocabulary for social communication and functional needs. The SLP is also responsible for IEP documentation.
Possible challenges of AAC intervention in the schools include
These challenges can be overcome or prevented by
According to the Individuals With Disabilities Education Act (IDEA), Section 300.105 on assistive technology,
On a case-by-case basis, the use of school-purchased assistive technology devices in a child's home or in other settings is required if the child's IEP Team determines that the child needs access to those devices in order to receive free and appropriate public education (FAPE; IDEA, 2004).
The transition from adolescence to young adulthood can be challenging for individuals with or without disabilities. The challenges associated with AAC use can present added challenges to success in postsecondary educational or vocational training programs, employment settings, and independent or semi-independent living situations. SLPs are involved in transition planning and may be involved in other support services beyond high school. Support for transitioning individuals who use AAC includes, but is not limited to, transition planning, disability support services, vocational support services, housing assistance, and support for community integration.
See ASHA's Transitioning Youth page for more information.
When working with adults who are using AAC, the SLP considers when the individual started using AAC and, if the individual is using AAC for the first time, his or her skills (e.g., language, cognition, motor) prior to becoming an AAC user. These factors may affect the individual's acceptance of AAC, his or her desire and ability to return to or enter the workforce, any accommodations that will be needed, and the need for communication partner training.
The following should be taken into account when facilitating transition and selecting an appropriate AAC system:
SLPs often assist individuals with reduced or impaired communication when nearing the end of life. The goal of intervention at this stage is to develop communication strategies that will facilitate efficient and effective communication for as long as possible, including connecting with the outside world via social media, e-mail, and texting. The expected outcome of intervention is not to improve abilities but to allow the individual to express wants and needs and to participate in decision making to the best of his or her abilities.
SLPs need to understand the process of dying to understand the emotional and psychological issues faced by individuals and their family members. The wishes of the patient and family are of utmost importance, and the SLP's role extends only as far as the patient and family chooses.
See End-of-Life Issues in Speech-Language Pathology for more information.
The term abandonment is used differently throughout AAC literature. We use abandonment here to mean that an individual has stopped using an AAC device, even though one is still needed.
Abandonment of an AAC system occurs in approximately one third of cases (Zangari & Kangas, 1997), even if the system is well designed and functional (Johnson, Inglebret, Jones, & Ray, 2006).
The following factors may lead to abandonment on the part of the AAC user (Johnson et al., 2006; Light, Stoltz, & McNaughton, 1996; Pape, Kim, & Weiner, 2002):
Abandonment can be reduced if
Expelling common myths surrounding AAC can also lead to improved long-term use and can reduce abandonment.
SLPs who provide AAC services should be familiar with funding options and should have a good understanding of public and private funding sources, including how funding is determined and how advocacy has and will affect funding in the future. SGD vendors often have in-house experts who can help with funding questions.
Low-tech AAC systems are typically created by an SLP and do not require significant amounts of funding, apart from what is typically required for standard SLP interventions. In addition, insurance plans are less likely to cover non–speech-generating devices, although they may cover the therapy sessions. Medicare will not cover non–speech-generating devices.
SGDs are considered durable medical equipment (DME), and funding by third party payers can vary. Medicare covers SGDs for (a) patients ages 65 years and older, (b) patients at any age who are diagnosed with ALS, and (c) patients younger than age 65 years with other qualifying disabilities. Many third party payers apply Medicare requirements when they review funding requests; however, SLPs will need to verify coverage based on their client's specific needs and insurance.
Many device manufacturers provide templates and assistance with funding requests; this does not take the place of a comprehensive AAC evaluation. However, they do include the elements necessary to obtain the device. The SLP must always justify that the device being ordered is medically necessary in order to receive third party funding.
SLPs writing AAC evaluations and completing funding requests must disclose any financial relationships that they have with device manufacturers and must certify that their recommendation for device selection is based on a comprehensive evaluation and preferred practice patterns and are not due to any financial incentive. A payer will often require that an SLP consider at least three SGDs during their evaluation process, and those devices must not be from the same manufacturer or product line.
The Assistive Technology Act (AT Act) of 2004, first enacted as the Technology-Related Assistance for Individuals with Disabilities Act of 1988 (the “Tech Act”) provides every state and territory with federal funding to support efforts to increase access to, and acquisition of, assistive technology devices and services. Key activities include state financing (e.g. the administration of low interest cash loan programs, last resort funds or equipment distribution programs); device reutilization; device demonstrations and device lending. Find your state's AT Act program at the National Assistive Technology Act Technical Assistance and Training (AT3) Center - Program Directory. For more information about the AT Act go to National Assistive Technology Act Technical Assistance and Training (AT3) Center - AT Act Information.
Under current Medicare guidelines, SGDs are covered by Medicare Part B only. Medicare Part A does not provide coverage for SGDs. Patients covered by Medicare Part A (typically those in acute care hospitals or acute rehabilitation hospitals) who do not already have an SGD would not be covered for a personal device during their inpatient hospitalization. The facility is responsible for providing a device while the patient is an inpatient. The only exception to the Medicare Part A coverage is for persons under the Home Health benefit; an SGD can be obtained through Medicare Part B funding while the patient is under a Medicare Part A Home Health Plan of Care.
In April 2015, the Centers for Medicare and Medicaid Services (CMS) proposed changes to the scope of national coverage for SGDs. The proposed changes now include funding for the following:
Internet or phone services—or any modification to a client's home that allows for use of an SGD—are not covered by Medicare because they can be used for nonmedical purposes. Features that are not used by the individual to meet functional speaking needs are not covered (e.g., hardware or software used to create documents, play games or music, videoconferencing).
Medicaid has covered SGDs since the late 1970s. Requirements for funding and documentation for AAC devices paid for through Medicaid vary by state. Medicaid recipients are entitled to coverage for SGDs if they live at home or in nursing facilities. Medicaid managed care organizations must cover SGDs in the same way as traditional Medicaid programs in that state. Refer to the Medicaid Guidelines for your state.
The Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA) of 2010 prohibits disability-based discrimination in insurance policies for essential health benefits, which often includes SGDs. Under the ACA, each state has a benchmark plan, and the scope of coverage for essential health benefits must be at least equal to the scope of coverage in the state's benchmark plan. Several federal employee health benefits programs have complete SGD exclusion or annual dollar limits on SGDs (Golinker, 2015).
Private insurance plans often follow Medicare guidelines regarding funding and documentation. The amount of coverage for an SGD provided by a private insurance company will vary, based on the company and the plan. SLPs working with private insurance should complete a comprehensive AAC evaluation and verify coverage based on the individual's benefits.
Tablets, apps, and computers are considered nondurable, nondedicated devices, and private insurance companies' coverage for these devices varies. SLPs need to verify coverage with the individual's insurance, based on that individual's specific plan and coverage.
Medicaid policies and funding vary from state to state; some states have begun to provide funding for tablets and/or speech-generating software. For example, New York Medicaid will pay for an SGD software program for nondedicated devices (e.g., laptop, tablet) already owned by the beneficiary (New York State Medicaid Speech Generating Device and Related Accessories Guidelines, 2012).
Individuals should check with their state for Medicaid funding policies.
Medicare does not cover the following:
Technology to assist with communication over the phone may be covered by a state's telecommunication equipment distribution program (EDP). Eligibility usually requires low income as well as disability certification and may vary state-to-state. A listing of these programs is available at TEDPA Telecommunications Equipment Distribution Program Association. Currently, many programs include phones useful to AAC users (e.g. hands free phones) as well as coverage of AAC devices, themselves. More and more programs are now adding wireless and/or cellular devices as well.
For individuals who are deaf-blind, the federally-funded I Can Connect program provides eligible individuals with devices necessary for distance-related communication (including computers and software), as well as evaluation and training on the equipment.
Accessories like mounts and those used for access (switches, eye gaze, head mouse) are covered by third party payers as long as medical necessity is established. In April 2015, the U.S. Senate passed the Steve Gleason Act, which clarifies the CMS policy that eye-tracking accessories for SGDs are a Medicare-covered benefit. As of January 1, 2016, eye-tracking accessories for SGDs are covered by CMS.
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
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Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Augmentative and Alternative Communication page.
In addition, ASHA thanks the members of the Steering Committee and Working Groups of the Special Interest Group on Augmentative and Alternative Communication whose work was foundational to the development of this content. Members were Stephen Calculator (chair, document revisions committee, 2001), Doreen Blischak, Amy Finch, Tracy Kovach, Lyle Lloyd, Susan McCloskey, Anne McGann, Cassie Sementelli, Ralf Schlosser, and Rose Sevcik. Alex Johnson, 2000-2002 vice president for professional practices in speech-language pathology, and Celia Hooper, 2003-2005 served as monitoring vice presidents. Michelle Ferketic, Roseanne Clausen, and Susan Karr (ex officios) provided additional support.
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association (n.d.). Augmentative and Alternative Communication (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Professional-Issues/Augmentative-and-Alternative-Communication/.