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9/9/2018

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Beyond Basic Requests: Building Language Skills with

Children who need AAC

Cathy Binger, Ph.D., CCC-SLP

University of New Mexico

(c) Cathy Binger 2018

Disclosures

• I have received funding from the National Institutes of Health to support this work (R01DC016321).

• I am being compensated for serving as your speaker today.


Current Project: Actively Recruiting!

(c) Cathy Binger 2018 3

Families must come to UNM for visits

Families receive a $20 gift card for each visit

Length of study = ~ 5 months/child

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Overview

• Early language development model & AAC

• Applying a Developmental Model: AAC Case study

• Integrating Approaches: Challenges and Opportunities

• AAC as a Tool

• Language Goals for Children who use AAC

• Dynamic Assessment

• Intervention techniques to Improve Expressive Communication


Communication Silos

Even AAC specialists fall into the trap of aligning themselves with particular approaches for preliterate AAC communication


“This district is really focused AAC iPad apps”

“I think activity displays provide

the best supports for students”

“We use PECS with all of our students

with autism”

“Approach X is great for most children who

need AAC”“I would never use

Approach Y”


• The evidence does not support any of these kinds of statements• No “one size fits all”

• We do have lots of evidence about how children learn language

How many of you have heard some version of this?

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We still have a long way to go!

• We must stop arguing with each other over which approach is “better”• Each approach has something to offer

• We must objectively – and dispassionately – examine each approach to see what the strengths and weaknesses are

• Every approach has strengths

• Every approach has weaknesses

• Then – and only then – can we move the field forward, toward more cohesive approaches to building language skills via aided AAC


https://www.socialana.com/face-your-weaknesses-to-find-your-strength/

Model of Typical (Early) Language Development


Why Use a Typical Language Development Model for Children who are not Typical?• All children deserve the opportunity to achieve their maximum

linguistic potential

• This provides us with a way to examine• How well each AAC approach promotes full language development

• Where the weaknesses lie• All AAC approaches have areas of weakness

• What gaps we need to fill in with additional approaches

• We must strive, as a field, to develop new, integrated approaches that better mimic typical language development


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Language Domains

Semantics

SyntaxMorphology


Pragmatics

• Communicative functions


Commenting

• We need lemons/boiled eggs/etc.

• It’s very cold

• Daddy, I got some muffins

Asking questions • Can I carry pretzels?

Commanding • Let’s go!

Directing Attention • Dad!

(Requesting) • (Can I have X?)

(Rejecting) • (I don’t want pineapples)

Pragmatics

Consider what his communication would be like without • Core vocab (Marvin et al., 1994)

• Fringe vocab


• Lemon, milk, spaghetti, cereal, peanuts, basket, etc.Nouns

• We, I, you, your, itPronouns

• Got, get, go, like, see, need, carryVerbs

• Cold, boiled, circle (cheese)Adjectives

• VeryAdverbs

• A, the, someArticles/ Determiners

• In (your basket)Prepositions

• Oops-a-daisy! Whoa!Interjections

Semantics

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Simple subject-verb-object statements

We need lemons

Embeddings

Put it in the shopping cart

Questions using intonation

Got some spaghetti?

Questions with inverted auxiliary

verbs

Can I carry cereal?

Imperatives/ commands

Let’s go

Put it in the shopping cart


Syntax

Grammatical Markers

• Plurals

• Blueberries, pretzels, eggs

• Prepositions• In

• Likely present or emerging• -ing (19 mo.)

• Possessive ’s (26 mo)

• -ed (26 mo.; boiled)

Contractions

• Let’s

• It’s

• Here’s

• I’ll


Morphology

What’s the Point?

• Even a child as young as two has AMAZING language skills!

• Within all language domains

• Our job is to maximize gains in all areas

• We can use our knowledge of normal language development to ensure that our objectives are supporting all domains


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Applying a Developmental Model: Case Study


Henry: Five-Year-Old with Autism

• Attends preschool 5 days/week

• Receives SLP services at school• Is using a PRC device

• Receives additional SLP services in a private clinic

• Speech is highly unintelligible• Single word intelligibility with context = 3%

• Language sample with repeated listening = 32%

• MacArthur CDI: 109 words expressively• Almost certainly affected by speech intelligibility


Henry’s Test ResultsTest Percentile Age Eqiv.

PPVT-IV 53 5;2

TACL-3VocabularyGrammatical Morphemes

Elaborated Phrases & Sentences

39377516

4;9

Leiter-R (non-verbal IQ) 70

Vineland: Communication 10

Mullen: Receptive Language 37 4;1

Mullen: Expressive Language

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Receptive Language Age of 4;9

This tells us that Henry…


…needs access to far MORE language than

Beckett!

What Language Expectations Should We Have for Each Domain?

Semantics

SyntaxMorphology


Pragmatics

Pragmatics


• Reject

• Request

• Make choices

• Show affection

• Greet people

• Offer & share

• Direct attention

• Answer yes/no questions

• Ask questions

• Name things/people

• Make comments (Communication Matrix)


Typical 2-year-olds are doing all of these

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Semantics


• >2,000 word expressive vocabulary

• All parts of speech & subcategories (e.g., all types

of pronouns)


Age 3 = ~1,000 wordsAge 4 = ~1,500 wordsAge 5 = ~2,100 words

Syntax


• Grammatically complete sentences• All semantic-syntactic relations

• Compound sentences• Complex sentences

• Use of auxiliary verbs in statements and questions

• Clausal conjoining and embedding


Brown’s Stage = Post V

Morphology


• -ing

• plural –s

• possessive ’s

• in, on

• determiners

• regular past tense

• irregular past tense

• third person singular –s

• auxiliary verbs

• Etc.


Brown’s Morphemes = ALL

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School-Based ApproachUnity/Core Vocab

• Vocab is frequently used & highly flexible

• “Unity 60 Sequenced”• Multiple selections required to

access each word• Allows for access to wide range of

vocab• Selected to promote long-term

language growth• Can hide icons so he’s not

overwhelmed


(Another Example of Core Vocab)


Current Functioning: Unity 60 Sequenced on an “Accent”• Has had device for ~ 1 year

• Can locate ~40 words independently (mostly core); can learn more but supports are limited

• Readily learns how to access some fringe (animals, food)• Understands the taxonomic categories

• Uses single-word utterances; gets frustrated when asked to do more

• Seldom seeks out device when communication breakdowns occur (says it’s “Too hard”)


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Private SLP’s Approach Activity Displays

• In keeping with WHO-ICF

• Activity-based; focused on what’s motivating

• Can readily locate ~35 symbols on a display

• Many parts of speech available + grammatical morphemes


Current Functioning: Activity Displays• Just started using these with new private SLP

• ~8-10 displays, each one used for a motivating, preferred activity• Ex: playing with vehicles, reading favorite stories

• Started putting 2- and 3-word sentences together in a single session

• If he doesn’t remember what a symbol is for, he simple selects it

• Obviously happy during sessions

• Readily initiating and imitating sentence productions


Activity Display Core/ Unity

Use Today • Range of functions • Range of functions• Difficulty locating items to make

choices

Build for Tomorrow

• Full range of functions; can be modified to grow with thelearner

• Full range of functions; can grow with the learner without modifications


Contrast with PECS

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Use Today • Wide array of vocabulary available on each display

• Easy to locate/ access

• Vocab to build grammar available

• Easy to access motivating vocabulary

• Wide array of vocabulary available on device

• Challenging to locate/ access

• Vocab to build grammar available

• Difficulty to access motivating vocabulary

Build for Tomorrow

• Storing thousands of words is challenging

• Limited # of words per display

• Thousands of words already stored

• Essentially unlimited vocab


Contrast with PECS


Use Today • Easy to create grammatically complete messages

• Can include many semantic relations on one display for easy sentence-building

• Can create compound & complex sentences

• Challenging to create grammatically complete messages initially

• Challenging to access wide range of semantic relations for sentence-building

• Challenging to create compound & complex sentences

Build for Tomorrow

• Challenging to produce novel, decontextualized sentences

• Designed to support productions of novel, decontextualized sentences



Use Today • If included, grammatical morphology and other early morphemes are easy to access

• Not available on Sequenced 45• Easy to access with more

complex arrays: Sequenced 60 & 84

Build for Tomorrow

• Challenging to include all grammatical morphology on a single display

• Grammatical morphology will remain in same location over time


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So…What Does This Mean for Henry?

• Neither approach is fully meeting Henry’s language needs

• Combined, these two approaches provide a solid approach for face-to-face communication

• All language domains for today• All language domains for tomorrow

• Major missing piece is LITERACY• Must look at other solutions for this!• This is Henry’s path to full,

independent communication


Full Language System

Literacy-based

solutions

Unity: Core + Fringe

Activity Displays

Integrating Approaches: Challenges and Opportunities


Other Learners = Different Solutions“Henry” was just an example…



NOVA Chat 10:

On-screen keyboard

NOVA Chat 10: Core +

Taxonomic

NOVA Chat 10: Activity Displays


Manual Signs

PODD for Low Tech

WordPower: Taxonomic +

Literacy

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Other Learners = Different Solutions


Maximal Language Potential

Visual Scene

Displays

iPad app: Comments,

Asking Questions

PECS

Maximal Language Potential

Literacy Solutions

Language in all Domains for TOMORROW

Language in all Domains for TODAY

Challenges & Opportunities

• Each person who uses AAC is unique

• We have varying levels of support for some approaches • All focus on particular domains and particular points in development

• No evidence supports the use of any single approach that• Cohesively, simultaneously builds language in all domains

• Meets learners’ need for both today and tomorrow


Challenges & Opportunities

• We need new, better integrated approaches

• Until children who need AAC are communicating in like Beckett, we’re not there yet


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In the Meantime….

• We must use language development to guide us• Ensure supports in all language domains today

• Ensure supports in all language domains tomorrow

All learners deserve the opportunity to reach their full language potential


AAC as a Tool, Not a Goal



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AAC as a Tool

◦ Augment = to supplement

◦ Alternative = to replace

◦ AAC = Using ANYTHING other than speech to communicate


Facial expressions

Gestures

Manual signs

Objects (whole or partial)

Miniature objects

Remnants

Graphic symbols (line drawings, photos)

Electronic devices (high end and low end)

AAC is a TOOL, Not a Goal

◦ GOAL◦ Improved daily life communication

◦ TOOL◦ AAC

◦GOAL ≠ AAC

AAC is about COMMUNICATION


What are the Outcomes?

Increase/Improve

Participation

Academic/ employment

outcomes

Social skills

Language skills


AAC use is never an outcome in and of itself

Devices cannot accomplish anything in and of themselves◦ Nothing magical about

using AAC◦ “What app is that?” is not

the central question

Devices are TOOLS to reach the same goals as clients who rely on speech

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Language Goals for Children using AAC


Focus, Goals, & Context of Communication

• Improving daily life communication Focus

• Very similar to non-AAC clients; e.g.,

• Improve spoken syntax

• Expand expressive vocabulary, etc. Goals

• We will discuss AAC devices within the context of communication

• NOT the features of each device in isolationContext


AAC is much less intimidating when viewed this way!

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Language Goals for Children who use AAC

Pragmatics

• Turn-taking, commenting, asking questions

• NOT just requesting!

Semantics

• Vocabulary size & diversity

Morphology

• Grammatical morphemes

Syntax

• Message length and complexity

• Early language rules


Differences between the Videos

• What are the differences between the first video compared with the last two?

• What questions do you have about this child’s abilities that can assist with goal-setting?

• What are some viable goals we might set for this child?


Example Goals

• José will indicate that he needs to use the restroom using an appropriate mode of communication at least once per day during a 3-day period

Severe disabilities

• Jasper will take at least three commenting turns with his peers during free play time using an appropriate communication mode (e.g., using pre-programmed phrases such as “That car is fast”)

Preschool

• Margarite will use grammatical morpheme markers appropriately when preparing & giving oral presentations in science class (core curriculum)

Elementary school


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Background on Children who use AAC


Risks to Development for Children who use AAC

• All aspects of language (e.g., Binger & Light, 2008)


Pragmatic Semantic SyntacticMorpho-

logical Narrative

Historically more focus on improving pragmatics and early semantics

More focus recently on other areas

Contributing Factors

Intrinsic factors

• e.g., cognitive/ motor/ motor-speech/ language impairments

Extrinsic factors

• e.g., lack of communication opportunities, lack of access to appropriate AAC solutions


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Extrinsic Factors

• We have more control over the extrinsicfactors

• Can help children make rapid progress when we tackle extrinsic factors

• Main focus of today’s talk

• Can help compensate for some intrinsic factors, too

• Expectant delay: increases processing time


Characteristics: Children who use AAC

• Communication Characteristics of many Children who use AAC (e.g., Light, Collier, & Parnes, 1985):


Are passive communicators

Exhibit challenging behaviors

Initiate few interactions

Respond infrequently

Produce a limited number of

communicative functions

Use restricted linguistic forms

Characteristics: Communication Partners

• Communication Characteristics of many

Communication Partners (e.g., Light, Collier, & Parnes, 1985):


Take the majority of conversational

turns

Provide few opportunities for communication

Ask predominantly Yes/No questions

Interrupt individuals using

AAC

Focus on the technology, instead

of the individual

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Receptive vs. Expressive Language Gaps & Receptive Language vs. Speech Gaps

Often, we still misdiagnose children with expressive language disorders when they have severe speech impairments Poor speech masks underlying expressive

language competence

Children with large gaps (Tend to) make rapid progress with expressive

language

May have a WIDE range of disabilities

Have severe motor-speech disorders

Lack the tools to communication linguistically

NOT THE ABILITY!(c) Cathy Binger 2018

Language

Cognitive

Gross motor

Fine motor

58

Gaps & Testing: General Considerations

• Test receptive language formally whenever possible• May need to make adaptations for physical limitations

• New evidence from our lab (unpublished pilot data) that receptive language strongly predicts expressive potential


Gaps & TestingStandardized Testing

• Use standardized, normed tests that require NO verbal output from child; e.g.,

• PPVT

• TACL (Test of Auditory Language Comprehension)

• CASL (Comprehensive Ax of Spoken Lang)

• CELF-P (some sections)

• TOLD-P (Test of Language Devp – Primary)

• (Some tests contain items that require spoken output)• (PLS, Mullen Scales of Early Behavior)


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Gaps & Testing: Parent Report Instruments

• Vineland Adaptive Behavior Scales• Communication subtest

• Receptive language scores significantly correlated with early AAC sentence-building outcomes in our most recent work

• Additional subtests• Daily Living, Social Communication, Motor Skills,

and Maladaptive Behavior

• MacArthur-Bates Communication Development Inventory

• Parent checklists• Translated into over 90 languages• Determine MLU3 (when appropriate)

• Have parents write down the 3 longest utterances they’ve ever heard the child say

• For children with some speech, this is an indicator of expressive potential


Gaps & Testing: Age Equivalent Scores

• Determine age-equivalent score on standardized tests

• Use this as an expressive aim. Example: • Child’s age = 5;0

• Receptive age = 3;0

• Expressive expectations = ???

• What are your expressive language expectations for language for a child who is 3 years old?


Relationship between Gaps & Expectations

• We frequently underestimate expressive capability

• Many children simply lack

• The tools to do more expressively

• The expectation that they can do

more expressively

• There are (many) exceptions, of course

• Low level symbolism; pre-symbolic communicators


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Intervention Techniques to Improve Expressive Communication


Intervention Techniques to Improve Expressive Communication (e.g., Binger, Kent-Walsh et al., 2008, 2010, 2017; Binger & Light, 2007; Tonsing et al., 2014)

Prompts

• Aided AAC Modeling

• Expectant Delay

• Open-Ended Question Asking

• Direct Verbal Prompting

• (Physical prompting)

Responses

• Contingent responses

• Imitations

• Recasts

• Can be spoken and aided (or unaided)


Sample Communication Board: Locatives and Attributes


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Sample Communication Board: Possessives and Agent-Action-Object


Intervention Sessions: 3-Symbol Locatives • Note in the videos:

• Motivating contexts for communication• Adequate time allowed for responses• Aided models of targets• Grammatically complete spoken models• Corrective feedback• Encouraging correction of errors

• Ix Play Session 1




Intervention Sessions: Grammatically Complete Locatives • Note in the videos:

• How much FUN this can be!• Same techniques as original videos• Encouraging use of grammatical markers• Speed of learning to use the markers• Impossibility of producing such sentences without AAC

• Ix Play Session 1a with markers

• Ix Play Session 1b with markers

• Ix Play Session 2 with markers


1 ChildH_Loc_Ix1_CP1_7-23-13.mp42 ChildH_Loc_Ix2_CP2_7-25-13.mp43 ChildH_Loc_Ix3_CP3_7-30-13.m2ts4 ChildH_Loc_markers_Ix1_Play1_10-1-13.mp45 ChildH_Loc_markers_Ix1_Play1_10-1-13 5 word production.mp46 ChildH_Loc_markers_Ix2_Play2_10-3-13.m2ts

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Challenge your Clients

• Provide them with the communication solutions they need

• Motivating contexts

• Appropriate vocabulary

• Expectation for success

• Expect them to keep improving

• Increase expectations every time they improve


Summary

Remember that we are SLPs: Focus on the Language!

AAC is a TOOL, not a goal

Goals for children using AAC should be very similar as those for children who do not use AAC

Children using AAC tend to be passive; it’s up to us to provide opportunities for communication

Dynamic assessment can be used to help set reasonable SHORT-TERM expectations

Intervention techniques for children who require AAC are the same as for children who rely on speech


Questions?

Contact info: [email protected]


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References: Various AAC Approaches

• Low Language Expectations• Hustad, K. C., Keppner, K., Schanz, A., & Berg, A. (2008). Augmentative and alternative communication for preschool

children: Intervention goals and use of technology. Seminars in Speech and Language, 29, 83–91. http://doi.org/10.1055/s-2008-1080754

• Building Evidence-Based Practice in AAC Display Design for Young Children• http://www.tandfonline.com/doi/abs/10.3109/07434618.2015.1035798

• Activity displays• Binger & Kent-Walsh intervention research; e.g.,

• http://journals.sagepub.com/doi/abs/10.1177/1525740116655804

• http://ajslp.pubs.asha.org/article.aspx?articleid=2109135

• Full articles available here: https://www.researchgate.net/profile/Cathy_Binger/publications

• AAC Intervention Meta-analyses• AAC & Autism (including PECS, iPads, SGDs):

• http://www.aaiddjournals.org/doi/abs/10.1352/1944-7558-119.6.516?code=aamr-site

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5036660/

• http://www.tandfonline.com/doi/abs/10.3109/07434618.2015.1047532

• iPads & Autism: https://link.springer.com/article/10.1007/s40489-014-0018-5

• Core vocab (Note: I could not locate any peer-reviewed intervention research)• http://praacticalaac.org/strategy/teaching-core-vocabulary/

• http://praacticalaac.org/praactical/5-misconceptions-about-core-vocabulary-in-aac/


Key References of Our WorkBinger, C., Kent-Walsh, J., Berens, J., Del Campo, S., & Rivera, D. (2008). Teaching Latino parents to support the

multi-symbol message productions of their children who require AAC. Augmentative and Alternative Communication, 24(323-338).

Binger, C., Kent-Walsh, J., Ewing, C., & Taylor, S. (2010). Teaching educational assistants to facilitate the multi-symbol message productions of young students who require AAC. American Journal of Speech-Language Pathology, 19, 108-120.

Binger, C., Kent-Walsh, J., & King, M. (2017). Dynamic assessment for three- and four-year old children who use augmentative and alternative communication: Evaluating expressive syntax. Journal of Speech, Language, and Hearing Research, 60, 1946-1958.

Binger, C., Kent-Walsh, J., King, M., & Mansfield, L. (2017). Early sentence productions of three-and four-year-old children who use augmentative and alternative communication. Journal of Speech, Language, and Hearing Research, 60, 1930-1945.

Binger, C., Maguire-Marshall, M., & Kent-Walsh, J. (2011). Using aided AAC models, recasts, and contrastive targets to teach grammatical morphemes to children with developmental delays who use AAC. Journal of Speech, Language, and Hearing Research, 54, 160-176.

Kent-Walsh, J., Binger, C., & Malani, M. (2010; invited). Teaching partners to support the communication skills of young children who use AAC: Lessons from the ImPAACT Program. Early Childhood Services, 4 (3), 155-170.

Kent-Walsh, J., & McNaughton, D. (2005). Communication partner instruction in AAC: Present practices and future directions. Augmentative and Alternative Communication, 21, 195-204.

King, M., Binger, C., & Kent-Walsh, J. (2015). Using dynamic assessment to evaluate the expressive syntax of five-year-old children who use augmentative and alternative communication. Augmentative and Alternative Communication, 31, 1-15. DOI: 10.3109/07434618.2014.995779

(c) Cathy Binger

201874
http://www.tandfonline.com/doi/abs/10.3109/07434618.2015.1035798http://journals.sagepub.com/doi/abs/10.1177/1525740116655804http://ajslp.pubs.asha.org/article.aspx?articleid=2109135https://www.researchgate.net/profile/Cathy_Binger/publicationshttp://www.aaiddjournals.org/doi/abs/10.1352/1944-7558-119.6.516?code=aamr-sitehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5036660/http://www.tandfonline.com/doi/abs/10.3109/07434618.2015.1047532https://link.springer.com/article/10.1007/s40489-014-0018-5http://praacticalaac.org/strategy/teaching-core-vocabulary/http://praacticalaac.org/praactical/5-misconceptions-about-core-vocabulary-in-aac/

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