The “Beginner” Augmentative and Alternative Communication (AAC) System Catch 22

It’s ridiculous if you think about it. In schools around the world, children with complex communication needs (CCN) are being asked to prove that they can communicate before they are given access to language. How can students show they have the ability without the words they need? NO ONE can prove he/she can communicate without being given the language to do it. Here…you try it. You can only use this board to answer the question, “What did you have for lunch today?”

Basic communication board
Basic communication board

How did you do? Did anyone have a cookie for lunch? That’s the only way you would be able to answer that question. If you had sushi or a sandwich, well, you’re out of luck. You’ll never be able to demonstrate your skills. People around you will say you must not be intelligent enough. After all, it’s likely that they’ll have the data from your cognitive and language tests to prove it. New people who meet you may not realize that the system is failing you. They’ve been told that you’re “low functioning” and they press their lips together and nod with a silent understanding to “not expect much.”

Let’s consider this because I used the second person pronoun (you) intentionally. At any moment, any one of us could suffer an injury or illness that takes away our ability to speak. What if you knew everything you know right now and had the same beautiful mind, but you couldn’t tell anyone? Everyday, children are in that exact situation. It kind of turns your stomach, doesn’t it?

If someone isn’t given an opportunity to express knowledge, and the words or pre-programmed sentences that are handed to a child aren’t the ones that match what she wants to say, there’s a limited number of times she’s going to tolerate being compliant. These limited systems are compliance-based.  If someone asked “typical” speaking children to say “I want a cookie” and gave them a crumb each time, how many times do you think they would comply? How long do you think it would take for them to walk away…to object and say, “This is stupid.” It’s likely that the many children who are handed limited systems do not have the ability to say “This is stupid.”

Students with CCN often aren’t given an opportunity to explore a comprehensive vocabulary to find the words they have been wanting to say. In many cases, they are given a system to participate in scripted academic programs, but with no room for actual language development or communication.

Speech-language pathologists (SLPs) will say they are working on PECs (Picture Exchange Communication System) and when the student get to a certain level, then maybe they’ll consider using high-tech AAC.  The challenge with PECs is that once students make a basic request, they’ve outgrown that system. Technically, the actual PECs protocol is supposed to be done with two adults, one prompting the child and the other acting as the communication partner. Most of the time, it’s not followed and students are using a communication book with Velcro pictures or symbols. There are some professionals who hold strong to using icon exchange and some who say, “Well, it’s good for some kids.”

But I disagree. Maybe it’s a better-than-nothing system, but it’s not a long term communication solution. Very rarely does a PECs user get beyond, “I want____” (with “I want” being a single icon) and it certainly doesn’t provide a robust vocabulary that includes access to core vocabulary. There is no voice output, so the student doesn’t get the auditory feedback or the experience of having his or her own voice. Pulling icons out of a book, placing them on a sentence strip and handing them to a communication partner doesn’t prepare a student to access a dynamic display device. There are no pre-requisite skills for successful use of a high-tech AAC device.

Proponents of PECs will say that it encourages social engagement and the idea that they have to get someone’s attention. That is also achieved by responding to a child who uses a high tech device with voice output. Children learn language because we assign a shared meaning to words. We communicate with them to teach them communication. So if PECs is “good for some kids,” the kids they’re talking about are assumed to be “low functioning,” uninterested in communication or incapable of using high-tech AAC. They’re the kids that get stuck in the AAC Catch 22.

The Beginner AAC Language System Cath 22
The Beginner AAC Language System Catch 22

Notice that there are only two ways out of that system.

One is that everyone completely gives up on that student’s ability to communicate. The team decides that the student is not interested in communicating. They check it off the list of obligations or write it in the “options considered and rejected” section of the IEP (Individualized Education Program) that they “tried AAC but it didn’t work.”  Unfortunately, I’ve seen that rationale carry on for years and years. Adults who tried AAC 25 years ago are still not using AAC because – back before the internet, cell phones, or plasma televisions – they tried some type of technology that “didn’t work.”

The other way out is through presuming competence and having high expectations that a student will learn to communicate beyond a basic request. Children’s paths can be changed because one person believes in their ability and models across functions of language and topics. (Modeling is evidence-based practice, by the way.) That one person can model with the expectation that the child is learning and absorbing, even when it may not feel like he/she is paying attention. That one person can put the language in a child’s hands that allows the child to say anything, and sends the message that he is competent and capable. That one person can be the difference between a child being the casualty of a limited system or a child with a limitless future. That one person can be you.


Comments

13 responses to “The “Beginner” Augmentative and Alternative Communication (AAC) System Catch 22”

  1. Kristin Lucas Avatar
    Kristin Lucas

    Well-said

  2. Jason Hartung Avatar
    Jason Hartung

    I’m not sure the person who wrote this understands the goal, or how and when to implement PECS. If you had someone who just recently lost speech, but who could still read and/or grasp a vast array of pictures, of course you wouldn’t limit them to four (mostly unrelated) options, and anyone who offers bathroom as an option for “What did you have for lunch” is a sadist. You give them unrelated options only when gauging their responses so that you can better understand them and their abilities.

    1. Jason, I think you may have missed the point entirely. The example was to illustrate that if you have CCN, you can only say the words that are placed in front of you, even when your knowledge is well beyond those choices. If those words are limited to nouns, which often PECs is, the individuals aren’t able to communicate beyond that. So even if the question is “What do you want?” and those 4 options are given, it could be just as ridiculous of a question to that individual if what he really wants is to tell you that his favorite aunt visited the night before. Individuals should be given access to full language and communication and taught to use it because you just don’t know what someone is capable of until you give them the opportunity to show you. PECs are often used for “testing” as you describe so “that you can better understand them and their abilities,” but communication should not be a test. It’s a “lazy” approach to put PECs in front of a child and make them prove that they can use it before giving them access to a comprehensive vocabulary.

      As the author of this article, I can assure you that I am neither a “lazy idiot” nor a “sadist.” As a speech-language pathologist who has spent the last 10 years working with students who have CCN, I do understand PECs very well. Because of that, I also know that many professionals implement a “modified” form of PECs that is not the intended 2:1 approach. Also that communication book often ends up being all the child has if he never had speech and doesn’t play the game to prove himself to someone who may not believe he can read or “grasp a vast array of pictures.”

  3. Rosemary Crossley Avatar
    Rosemary Crossley

    Heidi,
    This is brilliant. Exactly describes our experience as an AAC Centre over the past 30 years. Don’t get me started on the way PECS is used to gag students without functional speech, especially those with ASD.

    Having repeatedly and unavailingly pointed out that assessing children with little or no speech by using tests that require spoken answers is unproductive, we have belatedly started a systematic trial of alternative assessments that require no speech and minimal fine motor skills.
    No-one is given a formal assessment until they demonstrate the prerequisite skills – sitting without too much hassle, functional eye-hand co-ordination, and the ability to select accurately from a minimum of 4 items independently. Students who do not have these skills initially will be taught them with a swag of fun activities that are as age-appropriate as possible. Temple Run, Bitsboard, Zombie Math, Flow Free, Brain Pop, Carpet Board games etc etc.
    The tasks we’re using for formal assessment are the PPVT, Ravens SPM, novel Brain Pop (for comprehension, short term memory and literacy) and King of Math apps. The assessments take place in a familiar setting with familiar people. Parents are welcome to stay in the room sitting behind the student. The assessments are being scored as usual, and are being videoed.
    The parents of the students are being asked to supply their previous assessments for comparison. Typically the students have been assessed as cognitively below the first percentile, which has obviously had a major effect on their educational programs, on measures such as the WISC.
    This is still a work in progress, but horrifyingly NONE of the 15 students with little or no speech assessed this year has tested below the normal range on the PPVT or Ravens. The students are of varying ages and from varying schools and programs, typically those specifically for children with IQ <45. As I said above, most have been assessed as much lower.
    Some students have scored above the 90th percentile on the PPVT. Of course the PPVT and other tasks do not claim to be full scale IQ tests, but one certainly does not expect a child who's been scored as below the 1st percentile on an IQ test to score above the 90th percentile on any test.
    We need to presume that every child has real learning potential and give them access to the communication strategies and hand skills (or alternatives) that will allow them to demonstrate this. The 15 students are using a variety of communication strategies – most are using Touch Chat with Word Power in varying configurations on an iPad or Nova Chat. A child thought to be very low-functioning really got good use out of his Nova Chat (48 locations with keyguard) during a recent bout of chickenpox, when he used it spontaneously PRN to ask his mother to 'Please scratch me on …' followed by a list of itchy bits he couldn't reach. Sadly some of the students are not allowed to use their devices in their schools because 'We only use PECS'.
    Another of the teens with ASD and very limited speech who was assessed as below the 1st percentile has an interesting use for his Touch Chat app. He's become addicted to Brain Pop, which I originally set him as homework. The UK and US apps change topic every day, and he does both after dinner. If he doesn't get 10 out of 10 on the quiz he'll repeat it till he does. If it's particularly interesting he'll use the app to send me an email telling me about it. He was very keen on Einstein. All this is completely independent. His parents speak and write very little english, and cannot assist him. Self-educated by Brain Pop, he scored on the 95th percentile on the PPVT.

  4. Jamie Morgan Avatar
    Jamie Morgan

    YES YES YES YES YES YES YES!!!!!!!!!!!! I have been fighting this battle for 16 years. YES!!!!!!!!!!!!!

  5. Jennifer Avatar
    Jennifer

    Heidi,

    Would it be possible for me to share your above graphic with one of the teams that I work with? I am struggling with this very topic, and really like how it is laid out. The student isn’t using SFY, but they do have an (unused) device.

    Thanks

    1. Of course! Feel free to share it!

  6. Kristin Benjamin Avatar
    Kristin Benjamin

    I just love this. Well done as usual.

    1. Thank you for taking the time to read it!

  7. Gillian McLintock Avatar
    Gillian McLintock

    Hi
    Thanks – this was a very interesting read. I am a parent on a nearly 3 yr old daughter who has recently diagnosed with CCN. Our S&L talks about doing PEC’s and books however were just not sure as even at her age she can recognise different symbols for different apps already therefore I believe she would learn to recognise other symbols to communicate with us on an AAC. She is interested in the iPad therefore not sure if a book is the right avenue to go down. can’t we just go straight to AAC or is she too young?
    Do you have any thought on this?

    1. I would start with high tech voice output unless the students themselves express a preference for light tech (ie communication book). I personally haven’t had that happen. Using high tech, robust AAC gives the child consistent auditory feedback without relying on someone being present to speak what the child point to in a book (or hands to the listener). Having a high tech system allows the child to independently explore and find the words she wants to say. The Babble feature in Speak for Yourself was created for this reason. I would suggest making sure you have an iPad dedicated to communication and locked into the AAC app separate from her entertainment iPad.

  8. Debbie Royer Avatar
    Debbie Royer

    Heidi, Your graphic is perfect in illustrating the issues around AAC provision (or lack of)…would it be okay if I share this as part of an online course I teach for education assistants?

    1. Hi Debbie,
      Thank you! Yes, feel free to share it!

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