AUGMENTATIVE AND ALTERNATIVE COMMUNICATION

Children who have physical, cognitive, and developmental disabilities and are as young as 2 years arrive for medical and therapy appointments as already competent users of their parents' smart phones and tablets for leisure/ entertainment and with early learning apps. Five-year olds with visual, visual-motor, and fine motor planning disorders can be introduced to keyboarding as a possibly more functional alternative to handwriting—but may need to be retrained from swiping on smart phones and tablets as an access method before they learn to point and touch keys.

All children, whether disabled or not, utilize a complex communication system that integrates spoken, written, and pragmatic social language skills. AAC includes low- and high-technology devices that supplement these skills and facilitate language learning. Augmentative communication options are appropriate for any child whose natural speech and writing does not enable him or her to express himself or herself to all listeners in all environments and for all pragmatic communication purposes. In addition, AAC devices should be considered when natural speech and writing does not sufficiently support continued speech, language, and academic learning and success. Rather than slowing down the development of more competent oral speech and articulation skills, using an AAC system to support expressive language (vocabulary, syntax, and pragmatic) learning and teach a child the interpersonal power of "spoken language" can help support speech development and provide more competent language skills when oral speech capabilities catch up.

The communication impairments of children with complex communication needs may be caused by motor speech disorder (such as dysarthria or dyspraxia); a cognitive and language disorder (such as global developmental delay); a pervasive developmental disorder or autism spectrum disorder; a chromosomal abnormality (including Down syndrome); mental retardation; a brain injury; cerebral palsy; or a neuromuscular disorder (such as muscular dystrophy or SCI). Many children from age two through adolescence who can benefit from AAC have a multiplicity of complex diagnoses that may include hypotonia, spasticity, attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD), and/or cortical visual impairment.

Communication behaviors develop spontaneously in all children, regardless of the severity and multiplicity of their disabilities. Nonverbal communication behaviors may manifest as vocalizations for satisfaction and dissatisfaction; eye gaze and eye contact; looking away from a person, place, or thing; idiosyncratic gestures; and physically leading adults to desired objects and places. Even when such communication behaviors are more "reflexive" or self-directed than intentionally interactive, parents, caregivers, and familiar listeners typically learn to recognize communicative information from their children's behaviors.

One goal of AAC intervention includes introducing communication strategies that help a child develop systematic language and communication behaviors. Systematic communication helps listeners to more readily understand a child's communicative intent, helps to reduce the "20 questions" guesses that parents and caregivers typically engage in, and helps the child and his or her listeners form a communication dyad. With regard to the psychosocial development of children and adolescents with disabilities, the use of a speech-generating device may enable them to shift social and communication control of interactions from parents, teachers, and caregivers to the child—just as happens with typically developing children as they develop independence and interdependence within the social interactions that occur throughout their home, school/day care, and community experiences.

Not all augmentative communication devices need to be speech-generating. Low-tech aids can include communication notebooks, communication boards, and Picture Exchange Communication System (PECS) displays. They may be even simpler, including low-tech systems, such as refrigerator magnets or homemade picture magnets displayed on the refrigerator or on a cookie sheet for portability.

It is important that all people utilize their residual speech whenever functional, although many children and adolescents may benefit from an AAC device to augment that speech. Natural speech may be used primarily for initiation and getting attention, with a supplementary device used to communicate specific or complex information (eg, "I want + go + grandma + house" rather than just "go" or "grandma"). Unaided natural speech may be one's primary communication technique, but supplemented by a speech amplifier or a speech-generating device in noisy environments.

AUGMENTATIVE AND ALTERNATIVE COMMUNICATION (AAC) DEVICES

Today's AAC devices typically are hosted by Windows tablet computers, iPad tablets, or Android tablets; some apps are available for smart phones as well. AAC devices should be thought of as having features that support their users' achievement of success across their home, school, community, and leisure (and eventually work) environments. Like all technologies, neither the features themselves nor the functions that open the doors to success can be seen as static. A 2012 holiday gift giving guide about cameras referred to considering "which cameras use their newfound Wi-Fi capabilities." Within a year, it was noted that "new models can back up straight to cloud services or networked computers as well as connect directly to a mobile device, so you can view, transfer, and edit shots, and then upload to sharing sites over your devices mobile broadband. Some models use Wi-Fi to remotely control the camera, too, using your mobile device's display as a view-finder." The same rapid shift is true—and will continue to be true—of features and capabilities in AAC devices.

The most important features of AAC devices can be thought of as (a) access options; (b) vocabulary and syntax organization; (c) pragmatic language function supports; and (d) language output. Consequently, the most important team members to determine an effective match of an AAC device to an individual are often a speech-language pathologist and an occupational therapist, often in conjunction with a seating specialist for individuals who have positioning and wheelchair needs. Parents as well as adolescents and younger children and other team members (whenever possible) should be active participants in decision making regarding a specific AAC system for an individual. At the very least, determination of a child's need for and development of a recommendation for a specific AAC device should include a detailed parent and team member education process so that they can help make informed decisions about a device and a treatment plan for implementation of that device in a child's natural environments.

Most AAC devices currently use dynamic display technology in order to provide efficient access to expressive language. Dynamic display technology changes its display of vocabulary keys (that contain letters, words, pictures, commands, etc.) according to what has been selected before. The most common version of this is the word prediction displays that smart phones and tablet computers use to make typing e-mails and text messages easier for those who are not efficient users of their small keyboards. A less familiar version of dynamic display language organization includes syntactical prediction of vocabulary so that selection of the verb "go" automatically links to a page of vocabulary that represents different places (perhaps with its own link to a page of "People" since many of us are more likely to talk about going to grandma's house for dinner than to a fast food restaurant).

As modes of communication have been changing throughout society, the modes of communication that AAC devices support also have needed to change—and will need to continually change. High schools and junior high schools are providing access to curriculum materials online and allowing students to submit homework through e-mail. This makes access to written output and electronic communication through the same language system a person uses for face-to-face communication more important to children with disabilities who are even partially included in inclusive education settings. Text messages frequently are the most common way that adolescents socialize, plan, and even schedule school-centered work group meetings. Adolescents who use AAC devices need to have access to receive and send text messages through their "communication devices" to fully participate in activities with their peers. As electronic health records are more universally used among health care providers and networks, more patients have easier access through secure patient portals to their health information, communication with their health care team members, scheduling appointments, and so on. This can provide adolescent AAC users with more independent and private communication with their health care team members, without being constantly dependent on their parents for communicating their physical statuses, experiences, and feelings with doctors, nurses, and other health care providers.

 
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