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SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003

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In the past, alternative and augmentative
communication was perhaps seen as a rather exclusive
field - but this is changing.
A small number of service users will always need
specialist input using high tech equipment and it is
important that we have therapists who keep up with the
breathtaking pace of improvements in the capacity and
flexibility of technology. At the same time, however, we
have greater awareness of the fundamental importance
of all therapists developing an inclusive and enabling
communication environment for everyone.
Whether high tech, low tech or a combination of
methods, our three contributors demonstrate why the
implementation of AAC needs strategic thinking,
practical skills and a strong focus on the needs of users.
How I
augment
AAC
Read ths
you
coud make more use o AA
nd ads are not used by cents
have dcuty accessng specast
support
Practical points: AAC
1. Respond to long-term and
changing needs
2. Focus on building opportunities for
conversation
3. Take time to reflect
4. Understand why AAC is used - and
why it is not
5. Network to share skills and secure
funding
6. Work from the clients level but
leave room for growth
7. Be as consistent as possible
8. Check that meaning is shared
9. Provide an appropriate range of tools
10. Involve users, families and carers
at every stage.
To find out more about AAC, check out CASC Road Shows. They...
Provide an overview and an update of specialised communication aid technology for use by people
with complex communication needs.
Are sponsored by the UK Trade Association of Communication Aid Suppliers (a sub-group of
Communication Matters)
Include mini-master classes on latest products presented by their manufacturers and suppliers
Have a full day programme including time for browsing, hands-on and discussion, and workshop sessions
They are intended for...
People new to the field of AAC and voice output technology
Professionals specialising in this field who want to keep up-to-date
Everyone with an interest in communication technology
Anyone who works with children or adults with complex communication needs
Presenting companies can include...
Cambridge Adaptive Communication, Don Johnston, Liberator, Prentke Romich International, QED 2000,
Sensory Software International, Sunrise Medical / Dynavox, Crick software and Widgit.
And...
They are FREE.
A list of CASC Road Show dates is at www.communicationmatters.org.uk.
Janet Scott is a speech and language therapist
at SCTCI, Westmarc, Southern General Hospital,
1345 Govan Road, Glasgow G51 4TF,
tel. (0141) 201 2619, e-mail
sctci@sgh.scot.nhs.uk.
Please note:
Janet Scott does not endorse any particular
graphic (or other) symbol system or approach,
and the views expressed are her own.
Sally Millar is a speech and language therapist
at the Communication Aids for Language and
Learning (CALL) Centre, University of
Edinburgh, Holyrood Road, Edinburgh EH8
8AQ, e-mail sally.millar@ed.ac.uk.
Cheryl Davies is a specialist speech and
language therapist at Denewood Centre,
Denewood Crescent, Bilborough, Nottingham
NG4 2FT,
tel. 0115 915 9619,
e-mail cheryl.davies@nottshc.nhs.uk.
simple line drawing. Unless the photograph is
carefully set up with good lighting on a non-dis-
tracting background selected to provide a good
contrast to the target item, the end product may
well pose an interesting figure-ground quandary -
the opposite of what was intended. For others,
three-dimensional, tangible symbols (or objects of
reference) may be more appropriate - perhaps as a
stepping stone to more abstract levels of represen-
tation (Rowland & Schweigert, 1989; 2000).
How genuinely guessable / transparent is
the symbol?
Graphic symbols can be graded along a spectrum
of iconicity (the visual relationship between the
symbol and its referent). At one end are transparent
symbols; at the other, the relationship between the
graphic symbol and the referent is opaque or
arbitrary. Translucent symbols fall somewhere in
the middle - the meaning may not be immediately
apparent but becomes obvious once it is explained.
Most symbols are accompanied by text (the gloss).
For people who can read, this tends to disguise
how opaque even a fairly pictorial symbol actually
is. Test out your friends with a selection of symbols
with the gloss removed. How many can they
understand? How far from the accepted meaning
are they? Even the most pictorial symbol systems
involve a degree of lateral thinking, of metaphor,
of life experience and simply of remembering what
the particular symbol means.
Meaning?
Culture has a huge impact on peoples understand-
ing of what they see and hear. The further away
our clients life experiences are from our own, the
less we should assume that we share a common
meaning. Perception of symbol meanings varies as
a function of culture / ethnicity (Huer, 2000).
However, cultural differences can be very subtle
indeed. Phillips (2001) identified distinct differ-
ences in the understanding of the phrase play
with your child. Life experience is so important in
shaping our understanding. Early in my career I
realised a client thought there were five types of
people: girls and boys, women and men - and
wheelchairs. Given the language he heard around
him every day and his extremely limited life experi-
ence, this was an obvious link to have made: Line
the wheelchairs up at the door, The wheelchairs
go in the bus first, and even Wheelchairs have
their dinner first - they take longer to eat.
3. Flexibility:
Vocabulary?
Shades of meaning can be hard to convey, and mor-
phological and syntactical markers may be lacking
in a graphic communication system. Where the
emphasis is on a functional means of communica-
tion, full grammatical sentences can seem a luxury.
However the use of graphic symbols to represent
higher level linguistic concepts may influence how
language is acquired, understood and produced
(Sutton et al, 2002). One of my clients demonstrated
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SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 (
Figure 1 Comparison of picture producing versus non-picture producing symbols across four different symbol systems
Blissymbol Makaton PCS Rebus
house
tree
happy
under
this
MacDonald (1998) suggests you consider three
main aspects of a graphic symbol system:
1. Construction:
Ease of reproduction?
Computers, scanners, photocopiers have made it
much easier to create good, high quality images
time after time.
Visual abilities?
We need to be aware of our clients visual skills -
their field of vision, their acuity, whether they are
sensitive to contrasting levels of brightness between
different surfaces, their colour vision and so on
(Aitken & Buultjens, 1992). A significant percentage
of people with cerebral palsy have a cognitive visual
impairment; they may also have problems with visual
acuity and motor dysfunction affecting their ability
to coordinate their eye movements. Some of the
more pictorial symbol sets have detail, which may be
distracting for some. We might need to think about
whether colour or black and white symbols would
be easier. It might be helpful to accentuate or high-
light the salient part of the symbol with glitter, a
bright colour or a different texture. We might need
to think about the background for the symbol dis-
play (to make the figure ground contrast more
effective), or the spacing of the symbols, and even
whether to laminate the displays (and if so, whether
to use matt laminate rather than the standard,
cheaper shiny variety).
2. Level of symbolic representation:
Are graphic symbols appropriate?
For some people photographs and other more con-
crete referents will be easier to understand than
even the most pictographic symbol. However for
others they can be more visually confusing than a
Of the confusing number of
graphic symbol systems, how
do you choose which one to
use? The best? The one you
know? Whats been used in the
past? Or, like me, the easy
option (one with a computer
package which creates high quality materials)?
Before computers, I recall hours at the photocopier
then cutting and sticking, and the laborious tracing
or drawing of symbols. I remember scouring mag-
azines and catalogues for pictorial material to
make up communication charts. That still goes
on, but usually it is to supplement a more stan-
dardised symbol set - then it was the symbol set!
Perhaps, though, we actually thought more about
how and why we used graphic symbols? Maybe it
is time to re-evaluate our choices?
Sadly, there is no perfect graphic symbol system;
each has its strengths and weaknesses, each its fer-
vent proponents. Choice of one over another should
be based on the needs and abilities of the client. UK
mainstream graphic symbol systems include
Blissymbols, Makaton, Picture Communication
Symbols and Rebus. Symbol systems associated with
particular high-tech communication aids include
DynaSyms (also known as PicSyms in their low-tech
life), mainly used in the DynaVox family of communi-
cation aids, and Minsymbols (or multi-meaning icons)
used in the Minspeak family of communication aids.
Finally, a number of other graphic symbol systems
have been developed to meet a local need or a spe-
cific client group such as the Bonnington Symbol
System designed to help communication, informa-
tion and access, and a set from Speakability to help
people in the early days of aphasia.
Every symbol system has to be taught to its users,
some are more pictorial than others, some symbols
are fairly easy to guess the meaning of, others are
not. Abstract language is always difficult to convey in
a pictorial way (compare the more concrete mental
image generated by the spoken word house or tree
with the feeling / association of happy and with the
idea / concept of under or this - see figure 1).
Get out there and use it!
There are many things to
think about when choosing
a graphic symbol system.
Janet Scott takes us through
the decision-making process.
Blissymbols are reproduced
from Bliss for Windows -
Export Program, Pub.
Handicom, The Netherlands,
1996.
Makaton symbols are
reproduced from The
Makaton Core Vocabulary
Data Base Pub. Makaton
Vocabulary Development
Project, Camberley, Surrey,
1996.
Rebus Symbols are
reproduced from Symbols for
Windows 2000, Pub. Widgit
Software Ltd., 124 Cambridge
Science Park, Milton Road,
Cambridge, 2003.
PCS are reproduced from
Picture Communication
Symbols, 1981-2002,
Mayer-Johnson Co., PO Box
1579, Solana Beach, CA 92075,
USA.
a cookery session), dinner place mats (for
lunchtime chat), hard backed folding boards, cred-
it card sized symbol wallets, keyring / chain on a
belt clip, stuck inside a plastic lunchbox with carry
handle, on an apron or vest (Goossens & Crain,
1992) or mounted on an eye gaze (ETRAN) frame.
In its most complete form, a communication book
is a full-scale formal communication system, consist-
ing of a large bank of symbols and words, providing
the user with access to a comprehensive vocabulary
covering any and every situation. To produce an
efficient communication book, consider:
1. Design
First consider the basics - size, shape, weight,
style. A4 ring binders are often too unwieldy and
- importantly - uncool. A5 size display folders or
FiloFax style (from office supply catalogues, sta-
tioners and photo shops) are better, with pages in
plastic pockets or laminated.
For people using the Picture Exchange
Communication System (PECS), the communica-
tion book is organised very specifically using
Velcro strips on each page, with each individual
symbol Velcro-backed, so that it can be easily
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003
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A communication book is a
simple, low-tech aid to commu-
nication either on its own or as
part of a range of augmenta-
tive communication methods.
Communication books are on a
continuum.
At one end of the continuum are resources
whose primary purpose is to provide listeners and
potential communication partners with back-
ground and day-to-day information about the
person (which might or might not be accessible to
the client). These include Personal
Communication Passports (Millar, 2003) and home
school / centre diaries.
In the middle ground are resources such as a sym-
bol diary, which provide some element of back-
ground information, and also a shared context for
conversation using text, photos, pictures and sym-
bols. Other examples are:
a scrapbook or Clue Book in which the writer
attaches objects of significance, such as a birthday
candle, shop receipt or cinema ticket, plus a
prompt to launch an appropriate conversation
path (Guess where we went on Saturday).
a more structured Conversation Book which
scripts exact questions for the communication
partner (Ask me where I went at the weekend;
Ask me where I like to go best) alongside the
symbols which will provide the answers.
a photograph album to stimulate conversation.
Captions or accompanying stories can be written
in symbols if that helps. (The easy-to-use new
Talking Photo Album (Liberator, 32) is a cheap
and cheerful way to turn photo albums into
communication aids.)
Towards the other end of the continuum are
resources used more independently for day-to-day
interactive communication. Displays can be of a
limited amount of vocabulary linked to one specific
setting or topic, or a full-scale vocabulary bank.
Symbols can be displayed in all sorts of ways,
including: laminated topic sheets (such as for use in
the importance of not neglecting these grammatical
features when he spontaneously generated this
novel message: Grandpa sore leg get (then he
selected the past participle key) got bandage. I
was so excited to hear this as he had only been pro-
vided with a symbol based electronic communica-
tion aid three months previously, when he was 3;11.
Abbot (2000) provides a useful overview of the
main reasons for using graphic symbols, such as
for accessing information, to support inclusion, to
aid comprehension, to develop literacy skills. It
can be helpful to ask yourself:
Why do I want to use the symbols?
What am I hoping to achieve?
Why am I introducing symbols in the first place?
In addition, you should consider:
What other graphic symbols systems are in use?
Look not just at the clients current school or
resource centre, but also at what is used in the
local environment and wider community.
What support is available?
Symbols become more functional if they are not
the preserve of the therapy cupboard! Look for
computer packages for writing, symbol games,
books with symbol support, using symbols in
email, symbolised websites.
Symbols are becoming more mainstream in our
increasingly visual, pictographic world. Graphic
symbols are on crisp packets, our computer
screens, clothes labels, by the side of roads, at air-
ports. Symbols can make a real difference for the
people we work with (see Walker & Keating
2000a and b; Trapnell & Chapman, 2002).
However, remember that the graphic symbol set
used is the language encoding system for its user -
how they think, how they work out what the world
means. Dont change or introduce a new system with-
out a lot of thought. Try to be consistent across all the
different things the person uses - computer program
for writing, the symbol set in their high-tech aid and
in their low-tech display. Apart from that, dont worry
too much about which symbol system to use. Just
choose one, and get out there and use it!
References
Abbott, C. (ed) (2000) Symbols Now. Widgit
Software Ltd.
Aitken, S. & Buultjens. M. (1992) Vision for Doing:
Assessing Functional Vision of Learners who are
Multiply Disabled. Moray House Publications,
Sensory Series No. 2.
Huer, M.B. (2000) Examining Perceptions of
Graphic Symbols Across Cultures: Preliminary Study
of the Impact of Culture/Ethnicity. Augmentative
and Alternative Communication 16 (3): 180-185.
MacDonald, A. (1998) Symbol Systems, in Wilson,
A. (ed.): Augmentative Communication in
Practice: an Introduction - revised edition. CALL
Centre, University of Edinburgh.
Phillips, J. (2001) The Culture of Community: Do par-
ents and speech and language therapists mean the
same thing when they talk about play? Paper pre-
sented at the XXV IALP World Congress, Montreal.
Rowland, C. & Schweigert, P. (1989) Tangible
Symbols: Symbolic Communication for Individuals
with Multisensory Impairments. Augmentative
and Alternative Communication 16 (2): 61-78.
Rowland, C. & Schweigert, P. (2000) Tangible
Symbols, Tangible Outcomes. Augmentative and
Alternative Communication 5 (4): 226-234.
Sutton, A., Soto, G. & Blockberger, S. (2002)
Grammatical Issues in Graphic Symbol
Communication. Augmentative and Alternative
Communication 18 (3): 192-204.
Trapnell, N. & Chapman, J. (2002) Reading with
Symbols at Frederick Holmes School.
Communication Matters 16 (1): 29-31.
Walker, L. & Keating, F. (2000a) Being Arrested.
Grampian Primary Care NHS Trust (for more infor-
mation contact Lynn Walker, Speech and Language
Therapy Department, Woodlands Hospital,
Craigton Road, Cults, Aberdeen AB15 9PR).
Walker, L. & Keating, F. (2000b) Being a Witness.
Grampian Primary Care NHS Trust (see 2002a).
Resources
Blissymbols (Blissymbolics UK c/o the ACE Centre,
92 Windmill Road, Headington, Oxford OX3 7DR)
Makaton (The Makaton Vocabulary Development
Project, 31 Firwood Drive, Camberley, Surrey GU15 3QD)
Picture Communication Symbols (Mayer-Johnson
Co., Box 1579, Solana Beach, CA92075-1579, USA)
Rebus (Widgit Software Ltd., 124 Cambridge
Science Park, Milton Road, Cambridge CB4 0ZS)
DynaSyms (Sunrise Medical Ltd., AAC Department,
Sunrise Business Park, High Street, Wollaston,
West Midlands DY8 4PS)
Minspeak (Prentke Romich International,
Minerva House, Minerva Business Park,
Lynchwood, Peterborough, Cambs PE2 6FT)
Bonnington Symbol System (Bonnington Resource
Centre, 200 Bonnington Road, Edinburgh EH6 5NL)
Speakability, 1 Royal Street, London SE1 7LL.
Communication - by the book
Sally Millar explains how
different communication
books match different
clients abilities and
situations.
Look, stop, come, like, help
I (me, mine), you/yours, Mum, Dad,
More, not
(I need the) toilet: I feel bad;
Ive finished; more please; I like it; I dont like it; I
want; I need
Whats happening?; When?
Youve got that a bit wrong, Im going to start
again; its something like; opposite; sounds like
(Yes & No unless they can be indicated clearly in
some other, unaided, way.)
I like to mount this frequently used vocabulary
on the inside covers of the book, around the out-
side of the symbol pages that are cut smaller than
the total area of the binder. Another strategy is to
have the core vocabulary on a separate page
attached to the inside cover of the front of the
book that unfolds out to the left hand side, to be
permanently visible and accessible whilst the user
turns to different vocabulary pages of the book to
the right. With smaller books, the actions and sen-
tence starters might be down the left hand side of
each page, with descriptors across the top of the
page, each colour-coded.
3. Symbol books and language development
To develop a users linguistic ability, the book
needs to reflect the users actual level of language
and cognition ability, plus room for growth.
Latham (2003) has developed a prototype com-
munication book design based on her earlier work
at the Redway School (Latham & Miles, 1997) in
which vocabulary is not only divided up into core
and fringe vocabulary but also into developmental
stages 1-5 (matching the bands outlined in the
book). A Stage 1 left-hand core page has a few key
words and phrases, while a Stage 5 core page has
fold-outs with a full set of core chat words,
questions, pronouns, and starters.
It is important, however, not to overlook low
tech, simple options. One of my most successful
AAC solutions consisted of a piece of white paper
with the letters of the alphabet on it (in QWERTY
rather than alphabetic layout, to link with com-
puter use) cut to size and inserted into a clear
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003

detached and exchanged with the communi-


cation partner either on its own or attached
to the sentence strip.
Full-scale communication books can con-
tain photos, pictures, symbols or words, or a
mixture of some or all of these. The layout
has to be both logical and intuitive to navi-
gate around and find the symbol required,
and physically possible for the user to indi-
cate. The organisation, layout, style and cho-
sen size and number of symbols per page has
to take into consideration a range of factors,
including:
Vision and visual perception, visual processing,
visual scanning
Developmental, cognitive and linguistic
levels
Motor planning
Accessing method (direct pointing (range?
accuracy?) or indirect, such as eye pointing,
coding).
However the book is organised, it should
include explicit guidance for communication
partners and helpers about what to do and
what not to do to help the user, what they
should expect the user to do, and ideas for
when and how to use the book. This will
include clear instructions about how the
partner is expected to model book use by
pointing to symbols themselves as they chat
with the user.
It is usually helpful to have an index page,
and coloured dividers and staggered tags
(with colour or symbol on them) to help part-
ner and user alike to locate sections of the
vocabulary quickly. Typical sections for a child
might include home, people, places, activities,
body parts, feelings, food & drink, clothes, ani-
mals, transport, school (weather, colours, num-
bers, money, time, reading book characters.)
On vocabulary pages, colour coding can be
used to make it easier for users to scan
through and visually locate specific symbols.
Unless some other specific colour code is in
operation, I suggest the Fitzgerald Key
scheme (verbs in green, people in yellow, descriptors
in blue, determiners, prepositions etc. in white or
grey, objects, places and other nouns in orange (and
sometimes red), social phrases in pink.) (If coloured
backgrounds are used, symbols may need to be
black and white / transparent, rather than coloured,
to make the page less visually busy overall.)
2. Vocabulary selection and organisation
Selection of vocabulary will be coordinated by
one person, often the speech and language ther-
apist, but input will be sought from everybody
with whom the book user is in contact, especially
parents and family. Once everyone has been
informed about the plan to develop the book, cir-
culate an ordinary exercise book with vocabulary
page headings on it, leaving people to fill in the
words and phrases that they feel are important to
the user in various contexts. This will ensure firstly
that vocabulary is relevant and motivating, and
secondly that family and team members feel
involved and have a sense of ownership, making
them more likely to use the book constructively.
Mechanisms will be put in place to update vocab-
ulary regularly.
We have to ensure that books contain a full
range of communication functions (not just lists
of nouns, I want requests, and one-word
answers to questions). Include vocabulary for
attention grabbers, questions, conversation main-
tenance, interjections, and comments and so on,
and a mixture of different parts of speech.
Once collected, vocabulary will commonly be
divided up into frequently used and highly func-
tional core vocabulary and specific but vital
fringe vocabulary which keeps conversation
going. (Nobody says I had food - they say I had
a ham and tomato toasted sandwich and a coke,
at the Silver Spoon.)
Users may need some of the core vocabulary so
often that it needs to be displayed all the time.
Depending on developmental level, these might
include frequently used key vocabulary, social
phrases, sentence starters, and vocabulary expan-
sion strategies, for example:
Figure 1 Communication Books Continuum
How much involvement does the person have in the communication?
How independent is communication?
not at all little some, with support more even more, most
much wider range
Passport
Varying degrees of
input from person
possible; lots of input
from family.
Diary written in
symbols, Photo
album, Personal
scrapbook, Clue
book, Conversation
book.
Simple topic related
communication
display, eg. topic chart,
daily lunch menu,
storyboard, activity
choice cards.
Input from person is
often prompted. Use
may be modelled by
partner as aided
language stimulation.
Full scale
communication book;
word board, letter
board.
Full vocabulary
available: input from
person is largely
independent but
output is mediated
- sometimes
developed and
expanded, always
spoken out loud and
/ or scribed - by
listener
Voice output aid
Input is fully
independent,
(though introduction
and learning process
may be long).
Traditional
documentation and
records, assessments,
reports etc.
No input from
person.
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diaries, scrapbooks, and so on, which may all be
drawn in at some point in the conversation to fill
an information gap, prevent or untangle misun-
derstandings, or illustrate a point.
The strengths and advantages of low tech com-
munication books are many. A book is cheaper than
a voice output communication aid, though we must
not forget the hidden - and recurring - costs which
include loads of staff time, and also software,
colour printer cartridges, laminator and laminate. A
book is sometimes also simpler and quicker to use,
and is accessible to all sorts of people in the widest
range of day-to-day contexts.
References
Goossens, C. & Crain, S. (1992) Engineering the
preschool environment for interactive symbol
communication. Birmingham Al. SouthEast
Augmentative Communication Conference
Proceedings, available in UK from Cambridge
Adaptive Communication.
Latham, C. & Miles, A. (1997) Assessing
Communication. David Fulton Publishers: ISBN:
1853465038.
Latham, C. (2003) personal communication.
Millar, S. (2003) Personal Communication
Passports: Guidelines to good practice. CALL
Centre, ISBN 1 898042 21 1.
Pound, C. & Hewitt, A. (2003) Conversation
Partners and Communication Access: a roadmap
to inclusion. Presentation at Communication
Matters Symposium, Lancaster, September 2003
Sahian, D. (2002) Fitzgerald Key
www.bbbautism.com/pecs_fitzgerald_key.htm
Resources
ACE Centre North - Developing and Introducing
Communication Books,
www.ace-centre.org.uk/html/resources/Combooks/.
CALL Centre website (Passports Section &
Resources) (also downloadable Clicker grids and
BoardMaker topic charts)
www.callcentrescotland.org.uk.
Cambridge Adaptive Communication (Mayer
Johnson communication folders and symbol
resources books, BoardMaker and Handicom
Symbols for Windows (software)
www.possum.co.uk/Cambridge/Index.htm).
Clicker 4 (software): information from
www.cricksoft.co.uk/uk/clicker_products/.
Liberator Ltd. (talking photo albums)
www.liberator.co.uk.
Mayer Johnson (communication folders and
Speaking Dynamically Pro (software))
www.mayerjohnson.com.
Pyramid Educational Consultants UK Ltd. (PECS
communication books & other materials)
www.pecs.org.uk/.
The Grid (software): information from
www.sensory.com.
Widgit Software (Writing with Symbols 2000,
ideas and resources, link to Symbol World site)
www.widgit.com.
(A fuller version of this article with accompanying
pictures will be on the magazines website
www.speechmag.com from publication of the
Spring 04 issue at the end of February.)
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 ;
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college with a voice output device received limited
support from non-specialist therapists. The aim of
the AAC service was to dovetail with the childrens
service to include young adults with physical dis-
ability and adults with a learning disability who
needed a communication aid. The bid included 0.5
whole time equivalent therapist time for assess-
ment and ongoing support, assistant time and a
budget for communication equipment.
I was appointed with several years experience
working in AAC. One of my first jobs was to review
all the people known to the service. At the back of
my mind was the knowledge that several AAC
users no longer used their device, and I wanted to
get an overview of why this was. Maybe the aid
was no longer suitable? Perhaps insufficient speech
and language therapy support had led to a lessening
of skills? In fact problems included broken devices,
a Minspeak system only used in spell mode plus
the client felt it was too heavy, and expired war-
ranties. Some families had received no training in
AAC or the communication aid, and others were no
longer physically able to use an aid.
I assessed that the adults with learning and / or
physical disabilities population fell into broadly
three groups of clients:
Groups of clients Speech and language
therapy time needed
for
1. Those who have never
used a voice output
communication aid
2. Those who have been
introduced to AAC at
school or college and
have ongoing needs
3. Proficient users
In her Keynote Speech at
Communication Matters 2002,
Dr Pam Enderby stated that peo-
ple with alternative and aug-
mentative communication
needs require long-term speech
and language therapy support
for review of their physical status and to keep up
with evolutions in technology. Specialist AAC speech
and language therapists for adults are nonetheless
thin on the ground. I have had the opportunity to
develop this kind of service in Nottingham and hope
my experience will contribute towards our under-
standing of good practice in this field.
The post of specialist speech and language ther-
apist for AAC to work with adults with learning
and / or physical disabilities was realised in
January 2002 after a five year campaign by Sue
Thurman, the manager for speech and language
therapy services to adults with learning disabili-
ties in Nottingham. She had made a case of need
and submitted bids to the Health Commissioners
for Learning Disabilities. Initially funds became
available for equipment - but Sue declined this
until there was someone in post who knew how
to use it. Prior to this, people leaving school or
A case of need
It took five years for
Nottingham to get a specialist
AAC post for adults.
Cheryl Davies charts the
initiatives, successes and
ongoing challenges of the
first 18 months.

plastic zip pencil case bought in Woolworths for


49p! This could be folded into a pocket or bag and
brought out on any occasion when oral speech
attempts ran into trouble and backup was called for.
Trials have shown that the intelligibility of someone
with indistinct dysarthric speech, such as that of
many people with cerebral palsy, can be massively
increased if the user points out even just the first let-
ter to help listeners decode what they are hearing.
While Passports, diaries, photo albums, conver-
sation books and letter boards may be hand-
made, a computer is necessary to produce an
acceptable-looking full-scale symbol communica-
tion book. Key software will probably be either
BoardMaker (with Mayer Johnson Picture
Communication Symbols (PCS) only, printout
only); or Writing with Symbols 2000 (Widgit
Rebus, PCS, or Makaton symbols, printout and / or
onscreen use). But remember that high tech voice
output communication aid software such as The
Grid, Symbols for Windows, Speaking Dynamically
Pro, Clicker 4 will also offer printout options, so if
your client is using a computer-based voice output
system, you could use the same software for both
the high and the low tech version.
The many different types of communication
book meet different needs (figure 1). In an ideal
environment, people with communication diffi-
culties can use not just one but as many as they
find helpful. Pound & Hewitt (2003) refer to such
resources as communication ramps providing
access to social conversation, and show videos of
people with aphasia sitting with their listeners at
tables covered with several different albums,
familiarisation with
the aid
staff training
training new staff
identifying and
supporting new
environments and
communication needs
updating vocabulary
on the aid
staff training
re-assessment
I set out to establish baselines, to audit and
review, identify equipment needs and liaise with
all parties who would potentially have contact
with the service. I visited speech and language
therapists in hospital and childrens services with
AAC roles, Disabled Persons Act Workers, the
Independent Living Team, the local Further
Education college, Day Services for people with
physical and learning disabilities, SCOPE and
Disabilities services. I also linked with communica-
tion aid services in the region and nationally to
network and gain support for current and good
practice. I was already secretary of the Trent
Region AAC SIG.
I have now been in post for 18 months and
would like to give examples of initiatives, ongo-
ing issues and some successes:
1. User group
I was very keen for all AAC users and their parents /
carers in the area to get together and we have now
met three times. I am supported in this by speech
and language therapy technical instructors. My ini-
tial aims were for the communication aid users to
meet other users, have a social communication
opportunity and have fun. We have generally split
into two groups so that we can:
share experiences of supporting a person using
a communication aid
develop resources that can help new carers
focus on the positive aspects of AAC and
potentially have an advocacy role for AAC services
in the area.
At the last meeting Stuart Meredith, a proficient
communication aid user and excellent role model,
came to talk to the group. The best part has
been seeing the users having conversations.
2. Funding
In AAC this is always a major issue and in all ser-
vices there is no one funding agency that will pay
for equipment. For further information refer to
CAP and ICES websites (see resources). I am taking
part in a pilot study with ACE-North to look at
extending the CAP model into adult services,
which will help raise the issue of the continuing
difficulties in funding for communication aids. A
way forward has to be for funds to be ringfenced
for communication aids.
...resources...resources...resources...
how l...
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 8
The AAC service receives a budget from health
for equipment and resources. This was spent ini-
tially on assessment tools, a device for one client
and equipment for a loan bank. I have also
accessed funds through the Learning and Skills
Council for a student in full-time education,
secured funds from an Further Education college
towards a mounting system and social services
have agreed to part fund one aid using Direct
payments. An ongoing issue will be the replace-
ment of older devices balanced against the needs
of people with no aids. This year we have paid for
warranties and funding or part-funding four aids.
3. The first new communication aid user
My first new communication aid user was Brian
(40). His day centre has provided a high level of
support to help the introduction of the aid. He
has used it to clarify and repair communication
breakdown. Everyone is pleased with that and
there is potential for more skills development.
This was also my first opportunity to co-work with
another speech and language therapist in the
team who had previously provided a communica-
tion book. We have looked closely at our roles
and how to complement each others skills.
4. The speech and language therapy team for
adults with learning disabilities
The team has a high level of expertise in signs and
symbols. They support clients and their communica-
tion environments. My role within the team is clearly
for high tech equipment. We are developing joint
working practices to utilise skills including those of
technical instructors. There are similarities between
the roles - people with high tech needs also need a
communication book and Personal Communication
Passport. I feel it is part of my role to field the frus-
trations of working with technology!
Things that have helped me tackle this new post
effectively include:
Having knowledge of a wide range of
communication aids from Minspeak systems,
Windows based set ups to less complex devices
with digitised speech. (At the last count the
client group use twelve different aids supplied
by six communication aid companies.)
The support of the Communication Aid Suppliers
Consortium (CASC). They have loaned devices to
help me become more familiar with them and are
always available to demonstrate to users and
their families / carers. The phone support is essential.
Communication Matters conference held at
Lancaster University in September each year.
Websites such as The ACE Centre, CALL Centre,
AAC Intervention, Communication Matters (see
resources).
Knowing the geographical area and some of the
resources available.
Apart from the usual joys of working with technology
and not having the time and funds to do as much as
youd like, some of the things I find difficult are:
Working in a community post. It is a real challenge
to support people in a wide range of environments
and to try and meet the training needs of
support staff.
Knowing that best practice is for a multidisciplinary
team approach while working in a fairly
unidisciplinary way. We are working towards
involving other disciplines.
Limited local support for technology and
integrated systems.
Whether its programming an aid, staff training,
helping a user write guidelines for new staff on how
she likes people to communicate with her, liaising
with a counsellor who was working with a client but
had never previously talked to someone using a
communication aid, writing service specifications
and guidelines for budgetary spending or introduc-
ing a new aid to a client, I really enjoy the scope of
my job and the variety of tasks I can undertake.
Resources
Ace Centre (www.ace-centre.org.uk)
Ace Centre-North www.ace-north.org.uk
AAC Intervention (www.aacintervention.com)
Call Centre (www.callcentrescotland.org.uk)
Communication Aids Project (CAP)
(www.becta.org.uk/cap)
Communication Matters
(www.comunicationmatters.org.uk) (also includes
information about CASC - Communication Aids
Suppliers Consortium - roadshows)
Integrating Community Equipment Services
(ICES) (www.icesdoh.org)
Learning and Skills Council (www.lsc.gov.uk)
Minspeak( (www.minspeak.com)
SCOPE (www.scope.org.uk)
Black Sheep Press
New items in the Winter 2003/4 catalogue
from Black Sheep Press are a narrative
assessment Peter & the Cat (see reader
offer), Story Starter pack to complement
existing Narrative packs, concept packs
(Either / Or and All / Except), two sets of
barrier games and, in Phonology Resources,
revised s clusters.
See www.blacksheep-epress.com, or
telephone 01535 631346 for a free catalogue.
Fragile X
Speech and language therapy features in a multi-profes-
sional book about educating children with Fragile X.
Contributors include Jeremy Turk, Kim Cornish , Cathy Taylor
and Vicki Sudhalter, with each chapter suggesting intervention
strategies based on sound educational principles. Members of
the Fragile X Society are entitled to a reduced rate.
Educating Children with Fragile X is published by
RoutledgeFalmer and costs 22.50
(www.routledgefalmer.com).
www.fragilex.org.uk
Group Action
Contact a Family, the national charity
for families with disabled children,
has produced an updated pack for
parents who would like to set up a
local or national support group with
other parents in a similar situation.
For a free Group Action Pack,
freephone 0808 808 3555, e-mail
helpline@cafamily.org.uk, or see
www.cafamily.org.uk.