Augmentative–Alternative Communication

C Mason and K M Chinn, New Mexico State University, Las Cruces, NM, USA
ã 2010 Elsevier Ltd. All rights reserved.

in public settings such as theaters. In the educational setting,

Glossary
a child who is deaf may be provided with an FM unit to
Aided communication – Augmentative or accompany the hearing aid. Cochlear implants are also a
alternative communication approaches that require a choice for individuals who are deaf. The individuals who are
system or device to communicate. blind/visually impaired have Braille, print readers, and
Assistive technology – The use of any item, computers with large computer screens, and large font
system, or equipment that is utilized to improve or choices to aid in reading. Individuals who have cognitive
maintain functional living skills and independence. deficits with communication effects may use more compli-
Digitized speech – Natural speech, which has been cated to simplistic communication boards/switches. Indivi-
recorded and reproduced for use in voice output duals with cerebral palsy generally have communication
communication devices. However, these recordings boards/switches that are programmed to match the indivi-
are limited to recorded words or messages and limit dual’s physical abilities as well as cognitive level. Individuals
the user’s choice of messages. with spinal injury at the level of the cervical vertebrae or
Joint attention – When two or more individuals are advanced neuromuscular disorders such as amyotrophic
focusing or attending to the same activity, object, lateral sclerosis (ALS) may have limited movement, and
topic, or thought process. thus require AAC devices that use eye movement or head
Switch access – When an individual is able to reach, movement to signal letters with which words and sentences
activate, and utilize an external button or switch to can be formed.
create a cause-and-effect reaction. The American Speech-Language-Hearing Association
Synthesized speech – Technologically generated defined AAC as a set of procedures and processes that
speech which uses the linguistic patterns of digitized maximize the individual’s communication skills for func-
speech to create a speech system. This form of tional communication. Separately defined, augmentative
speech provides the user with much more choices communication is any support system in a given situation
and options in creating messages. that allows an individual to communicate independently,
Unaided communication – Nonverbal whereas alternative communication is specifically the use
communication approaches that utilize facial of nonvocal instruments and/or approaches.
expressions and/or body movements, such as The need for AAC spans socioeconomic, racial, ethnic,
gestures, to communicate, for example, American and age groups. According to the American Speech
Sign Language. Hearing and Language Association, the prevalence of
VOCA – The acronym for voice output people with communication impairments severe enough
communication aids, which is a group of devices that to require AAC ranges from 8 to 12 in every 1000. Indi-
provides an alternative voice through recording or viduals that most frequently benefit from AAC include
digitized speech. those who:
 are deaf or hard of hearing;
 have acquired neurological impairments such as TBI,
Augmentative–alternative communication (AAC) provides
cerebral palsy, or aphasia;
individuals special needs with the means to express ideas,
 have progressive neurological disorders such as ALS;
thoughts, concerns, and needs. Thus, the goals for AAC are
 have been diagnosed with an autism spectrum disorder
twofold: (1) to make individuals more functionally indepen-
(ASD);
dent by having the ability to express needs, wants, feelings,
 have motor speech disorders; or
and preferences in a form that others can understand, and
 have been diagnosed with neurogenetic disorders.
(2) to enhance communication skills and language skills,
providing increased independence. Clearly, individuals Two distinct types of users include those with long-
with specific disabilities require AAC devices that provide term need and those with temporary need for AAC.
accessibility specific to their needs. An individual who is Individuals that have suffered a stroke and have devel-
deaf/hard of hearing not only may use a form of manual oped aphasia may need temporary assistance through
communication but may choose to use high-tech devices AAC until spontaneous recovery allows them to regain
such as hearing aids and infrared listening devices available their speech, whereas individuals with ALS, otherwise

544
 Augmentative–Alternative Communication 545

known as Lou Gehrig’s disease, will need continued, long- list of low-tech, aided communication systems might
term AAC support. These individuals may start with include, but might not be limited to,
manual sign language or topic reference pictures to assist
 Eye gaze board – where the individual moves his/her
the listener understand the speaker’s slurred speech more
eyes in the direction of a specific picture or symbol to
clearly. As the disease progresses and independence
indicate a need.
decreases, the individual with ALS will need a more
 Alphabet boards – which provide the individual with
sophisticated system.
the alphabet to spell out simple messages (example
given the end of this article).
Forms of AAC  Writing materials – to communicate wants, needs,
thoughts, and desires.
AAC is found in many forms, from manual communica-  Communication book/dictionary – development of a
tion to low and high technology systems, and are further gesture or communication dictionary provides the
categorized as aided or unaided. Unaided systems, which individual information on what the behaviors look
require no external devices, might include, but are not like, what each gesture means, and how to respond to
limited to, gestures and sign language. Aided AAC devices the message. The creation of the dictionary should
might include picture systems and/or print (which are include the primary caregivers input, and thus provide
considered low tech) and computerized communication consistency in communicative attempts. These can then
devices (which are considered high tech). be paired with more conventional photos, objects, or
symbols to help the individual expand his/her commu-
nication base.
Manual Communication  Picture exchange communication system (PECS) – a
Manual communication systems used for unaided commu- system that was designed to provide opportunities for
nication are the most frequently used form of AAC. Manual individuals, primarily with autism, to begin initiating
communication consists of cued speech, American Indian communication.
Sign Language, American Sign Language, and various  Picture communication symbol systems – other sys-
English signed systems such as Signing Essential English tems, similar to PECS, which provide opportunities
(SEE I), Signing Exact English (SEE II), Language of Visual for communication and scheduling routines.
English (LOVE), and pidgin forms of signed language.  Blissymbolics – another graphic meaning communica-
According to Mitchell (2006), there are approximately tion system originally designed for children who were
11 000 000 individuals who are deaf or hard of hearing in deaf/hard of hearing that was applied to the general
the United States with 1 000 000 Deaf. ASL is the most population.
frequently used version of manual communication as ASL is Higher technological devices, referred to as high tech,
the language of the Deaf culture. Most other forms of are also forms of aided communication and assistive tech-
manual communication, excluding American Indian Sign nology. These devices include different types of hand-
Language, are used in educational settings with children held printers, word processors, and computers. Devices
who are deaf or severely hard of hearing such that it pre- with voice output are referred to as VOCAs – voice
cludes the use of speech and speech reading for communi- output communication aids. These devices are not limited
cation purposes. SEE I, SEE II, and LOVE were specifically to voice output and may instead activate some other rele-
developed to assist deaf and severely hard-of-hearing chil- vant objects in the environment. Examples of VOCAs used
dren in learning English for the purposes of reading and as high-tech-assistive devices may include some, but not
writing. limited to, of the following:
 Switches are various electronically controlled buttons
Describing Low- and High-Level Technology
of various sizes. These buttons are used to activate a
Lower technological devices, often referred to as low tech, device for speech or environmental controls. For exam-
are used with individuals that are unable to produce ple, the push of a button may turn on a television
gestures and manual sign, due to motoric limitations. or personal fan, or it may ring a bell calling for some-
Forms of aided communication such as a communication one’s attention. These switches may be activated with
board, picture schedule, eye gaze board, or other simple various parts of the body from hand pressure to eye
aids are not electronic, but offer a form of assistive tech- blink, depending on the abilities for movement of the
nology. Assistive technology is a broad term which may individual.
include aids for daily living activities, vocational activities,  There are simple VOCA devices, in which, one single
or environmental controls. It may be used to refer to some button activates a single message recorded on the system.
forms of augmentative communication. A more detailed This message is usually recorded by a peer or caregiver.
546 Education of Children with Special Needs

These systems are generally limited in the communica- ability to utilize joint attention with another individual
tion repertoire. This presents difficulties in the use of the must be assessed. Is this individual able to take turns in
system in all other communicative settings or situations. communication and gain the attention of others? Prior to
 More sophisticated VOCA devices offer a variety of choosing an AAC system, the individual’s ability to rec-
opportunities for communication, including keyboard- ognize and understand at an object and photographic
ing, word prediction, and programmed personalized level, line drawing, or written word must be determined,
information for ready-access. The devices may include as AAC devices vary in complexity based on individual
direct selection opportunities, where an individual will abilities. For example, can the individual perform actions
push a single button for a message. This requires strength or use objects? Along with choice of complexity level, the
and the ability to access the buttons. The equipment will number of items presented is also a consideration. Is the
usually have the ability to scan different options with individual able to select one item out of how many
a single switch to hit as the item is highlighted on the choices?
system. These devices may also use recorded speech or Receptive and expressive language skills are part of the
synthesized speech, which is more robotic in nature. determination for an AAC device. The level of communi-
Although great advances have been made to the quality cation is an important factor for choice. What does the
of the speech, we now have a variety of voices to provide client understand? Is the client only able to use limited or
a more appropriate vocal quality dependent upon age telegraphic speech used by his/her communication part-
and gender. ner? The ability to understand extended conversations
and lengthy messages must be determined. Provided
with opportunities through augmentative means, is the
Assessing the Need for AAC individual able to label, identify, or describe? Further,
what types of messages is he/she able to relate? For
Careful and thorough assessment of individuals, their example, can the individual make requests, negate infor-
needs, significant others, and lifestyle is necessary to deter- mation, refuse treatment, gain attention, report informa-
mine the best mode of augmentative communication. Areas tion, clarify messages, seek information, and/or express
of evaluation would include all facets of the individual’s feelings and concerns? The range of physical motion and
medical history, premorbid state, current physical abilities, level of strength/endurance of the individual must be
cognitive abilities, typical communication partners, life- assessed to determine the appropriate type of AAC. The
styles, and living environments. In assessing the individual, ability to move limbs, as well as the range of motion of
careful consideration should include the following: past and limbs, fingers, head, feet, and eyes, are part of this assess-
current medical history; cognitive abilities, including the ment. Further, information regarding the ability to per-
ability to initiate conversation; as well as receptive and form multiple tasks such as the ability to move while
expressive language skills. The individual evaluating a cli- making decisions is important in the choice of AAC
ent in need of an AAC should know the physical limitations devices. Strength such as the ability to apply pressure on
of the individual and how these limitations would affect a switch or button must be determined. Does the individ-
accessing a communication system. Consideration of the ual being assessed for the device fatigue easily? The best
medical prognosis, including a progressive condition, may time of day to utilize maximum strength to communicate
also impact the current and future levels of the individual’s must also be assessed. Some devices may require more
communicative needs. Further, what would be the medical dexterity along with the ability to make choices in a
prognosis of the condition? That is, is the condition a timely manner, as these scanning devices provide a lim-
progressive disease, which may impact the current and ited time frame for item selection. Therefore, speed and
future levels of communicative needs? accuracy may be factors in the selection of a device.
Determination regarding the permanence of the com- Positioning is important to ensure that individuals
municative disorder is important for choosing a device. If have sufficient support to allow them the maximum
the disorder is progressive, how soon is the condition range of motion, provide clear contact with their device,
expected to worsen? As indicated above, if the individual and reduce fatigue during communication opportunities.
has a progressive disease, this assessment process must take An interdisciplinary team effort, including assistance and
future needs into consideration. That is, what will the consultation with OT and/or PT, will provide input
communication needs be at each level of the progression? concerning the client’s physical abilities and equipment
In order to determine which AAC device is most appropri- needs, such as chair mounts, device portability and loca-
ate, cognitive abilities and the ability to initiate communi- tion on the walker or wheelchair, and optimal positioning
cation must be evaluated. The therapist choosing and fitting for the client. Visual and auditory limitations should also
the device must have information regarding the level of be considered in selecting symbols for an AAC device.
awareness of the individual who needs AAC. Further, the Regarding visual impairments, many devices are available
 Augmentative–Alternative Communication 547

and assessment is needed to determine which system(s) the selection of the system will be determined by the
best meets the individual’s needs. In order to determine observations and input from each of the evaluation team
this, the diagnostician must assess how well he/she sees. If members, as well as the evaluation of the individual and
the individual can see print and line drawing, would a interviews with the significant others. Information must be
colored background assist in symbol recognition? How gathered by the diagnostic team; the potential user’s feelings
well can he/she scan multiple pictures for selection? regarding the use of the equipment, such as possible embar-
How many choices can the individual maintain in his/ rassment associated with the device, must be taken into
her line of vision? The size of items on the communicative account. Many of the high-tech devices are extremely
device also must be determined to meet his/her field of expensive and require funding for affordability. If the indi-
vision. vidual does not have a payment source or personal funds,
Since emotional status and level of motivation for selection of a low-tech method may be more acceptable.
communication affects the optimal use of the AAC device, Often, AAC vendors will assist with funding questions and
the following questions must be addressed. Often indivi- paperwork. Along with this service, these individuals may
duals with particular disorders become depressed. Is this also supply a variety of devices for trial and assessment. The
individual on depression medications, which may impact user would have the opportunity to utilize the equipment in
alertness? Does he/she have the desire and motivation to conversational trials to determine the best device, the num-
learn an augmentative communication system? What ber of selections available, and the best mode of access, such
level of communication is important to him/her? Does as scanning or direct selection as discussed above.
he/she desire to carry on conversations, express only basic
wants and needs, or be as independent as possible?
Initiating Communication

Assessing Communication Partners Many times as the individual is trained to utilize the
alternative communication system, they become prompt
Communication partners take on important roles in the life dependent for responses. It is important that the educator
of the individual who requires an AAC device. The follow- or speech-language pathologist avoid prompt-dependent
ing questions must be answered regarding the communi- or cued communication interactions. The system must be
cation partner. Who will be the primary conversation as simple and unencumbered as possible to provide the
partners? Will the communication partner be willing to be easiest access for communication opportunities. The home,
involved in utilizing a new system? Even with the advance- school, and other environments should be engineered for
ment in technology, conversational exchange using an AAC optimum communicative opportunities for the nonverbal
device remains much slower than natural speech, and will individual and his/her communication partners. Vocabu-
detract from the natural social exchange of information. lary and access must be functional for the user and signif-
Will the partner be able to display the patience in waiting icant others. Lack of interest in communication may
for responses? Will the partner be committed to providing indicate that the individual is not being exposed to pre-
multiple communication opportunities for the individual? ferred activities or that the needs of the communicator are
Will the communicative partner be able to understand and not being addressed with access of the system. The use of
help the individual learn and program or change the device, some AAC systems requires a myriad of skills and multi-
dependent upon the situation? Lastly, during the evaluation, tasking abilities. Skills necessary for responding to a sim-
typical communication settings must be addressed. Where ple question posed by the communication partner may
will the individual be communicating most frequently: in require the user to (1) understand the question, (2) turn
the home, school, or community? Will there be extraneous on and focus on the AAC system, (3) attend to symbols
noise or will the setting be quiet? If there is extraneous and perceive them accurately, (4) determine the locations
noise, how loud will it be? To gather the most thorough and sequence to respond, (5) access the system, (6) deter-
and in-depth information in answering the aforementioned mine if the communication partner has understood the
questions and in providing the optimum communication message, and (7) repeat the communicative sequence in
system for an individual, an assessment team should be order to continue the conversation.
organized. This multi-disciplinary assessment team may Early intervention makes a significant impact on the
include: family and/or caregivers who are an integral part of success of an alternative communication system. The
the assessment, an audiologist, an educational specialist(s), earlier the child begins to use an AAC system, the greater
an educational diagnostician, a physician, a psychologist, a the chance of acceptance and regular use. Current research
speech-language pathologist, an occupational therapist, a documents the efficacy of communication services,
physical therapist, a social worker, a rehabilitation engineer, reporting that services should begin before age 2 in children
a vision specialist, and/or a vocational counselor. Clearly, with severe disabilities. The use of AAC systems should be
548 Education of Children with Special Needs

considered as soon as the child demonstrates communicative information as desired by the individual. Most high-tech
needs. Although parents are sometimes concerned that devices may also be programmed with jokes, personal
introduction of AAC may preclude development of speech, stories, and even with speeches an individual may give
numerous studies demonstrate that the opposite affect is during presentations. Along with their cultural style, per-
found; this approach supports such development. sonal information and language preferences, the indivi-
dual’s premorbid state must be taken into consideration
when selecting vocabulary. The factors of educational
Communicating with Partners
status and experiences prior to the onset of the disease
Two different types of communication partners have been or accident are necessary in selecting items for the word
described. A partner-dependent user is one who must rely bank. Based on the individual’s language abilities, what
on another individual to manage the informational parts of speech such as articles, conjunctions, and auxil-
exchange. This situation requires highly familiar contexts. iary verbs should be incorporated into the vocabulary,
The user’s partner may have to scaffold interactions by or would the individual benefit more from telegraphic
offering choices, provide visual input, or restructure the speech such as isolated, simple nouns and verbs?
exchange for easier understanding. The second type of
communication partner is an independent partner, who
has relatively preserved or intact language skills and exec- Using the AAC Device in the Classroom or
utive functions, and may be a candidate for more high-tech Home and Community Settings
devices that will allow communication without the assis-
In order for a system to be effective in an academic
tance of another individual. Teaching advocacy for the
setting, there must be consultation, education, and sup-
individual who uses the AAC device should be the respon-
port for the classroom teacher, students, and the AAC
sibility of the entire evaluation/intervention team. Train-
user. Each setting must have the support and consultative
ing should be shared with family members or caregivers.
opportunities for the system to work. In the home setting,
the parents, siblings, and/or caretakers must be provided
Selecting Vocabulary for the Individual with training in how to utilize the system and must also be
Using AAC instructed in how to access additional information and
resources. Training should be provided in functional set-
Vocabulary selection is imperative for the individual using
tings. Acceptance of and use of an alternative method of
the device. Without appropriate selection of terms, words,
communication is dependent upon all communication
and labels, the individual will not utilize the system effec-
partners accepting and understanding the system. As
tively. Vocabulary selection should focus on: frequently
stated previously, concerns by caregivers and parents
used words, culturally sensitive vocabulary that is used
that an augmentative communication system will deter
with significant others, commonly used names, phrases
the individual from using or developing speech are
and needs, word prediction to make access faster; and
unfounded. The contrary is true. In fact, intervention
personal data information, along with interests and experi-
approaches using AAC are found to facilitate natural
ences so that the individual may share personal information
speech. This information must be clearly stated and
with others. Frequently used words would include those
shared with all parties. It is important that the members
that are frequently found in the individual’s environment
of the AAC team who put a system in place continue to
and in the specific languages. These words are often pre-
constantly monitor the user and communication partners
programmed in the device and are easily accessible through
for changes in the environment and the user’s abilities and
different menus, as well as in word-prediction keyboard
growth. Frequent modification and upkeep of equipment
access.
are also warranted.
The vocabulary selection must be sensitive to cultural
influences. A gesture may produce positive affect in one
culture and an entirely different, perhaps negative mes-
sage in another. There must also be sensitivity to language Conclusion
differences and environments. For example, a child may
be Spanish dominant in the vocabulary utilized at home Augmentative and alternative communication systems
where no English is spoken, and may be English dominant require in-depth assessment, taking many factors into
regarding academic vocabulary spoken in the classroom consideration. The use of a selected system requires
setting. In order for a system to be utilized and effective, acceptance by all individuals working on the diagnostic
it must address concerns across cultures and environ- and intervention teams, along with users, caregivers, and
ments. Personal information would include name, address, significant others. Careful support and maintenance of the
date of birth, physician’s names, current medications, AAC system should be ongoing to meet the changing
names of family members and friends, and other pertinent needs of the individual and his/her environment.
 Augmentative–Alternative Communication 549

A B C D

E F G H

I J K L M N

O P Q R S T

U V W X Y Z

A vowel-based communication chart is a low tech AAC system utilized with individuals
who can spell and are able to communicate answers to yes/no questions with head nods or
eye blinks. The system is used to spell out words by having the communication partner
guess the letters. The communication partner will start determining each letter by asking
for the appropriate vowel in a vertical line and then moving across, horizontally to select
the consonants. Although this process is slow and methodical, it does provide an avenue
when other methods of AAC are not available.
Figure 1

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