AAC Implementation: Where Do I Start?

I’ve been coming across this question frequently, so I’ve decided to outline some of the first things that we do when we are starting to introduce AAC. We don’t have a system that we follow exactly because everyone is different, but there are some things that we do pretty consistently.

 What do I say to the student about AAC?

Tell the student your purpose.

We all like to have some context around an interaction.  If you sat next to a friend to show them an app, you wouldn’t just plop down next to them and start touching the screen.  At the very least, you’d say, “Look at this!” or “Here is the app Jake is going to use to communicate.”  When we sit down to introduce AAC for the first time, we usually start by saying something like, “I know talking is hard. This is to help you tell people what you want and show EVERYONE how smart you are.” If you just read that and thought, “My child/the clients I work with are too low to understand that. They have processing issues and won’t understand complex sentences,” please presume competence and try it anyway. If you’re “right” and the student doesn’t understand the words you’re saying, he will understand two very important things: (a) That you are talking TO him and (b) That your tone is saying something positive. Those two things will likely (and unfortunately) differentiate you from other people in his life. It will make you interesting.

 How should the child be positioned to access the screen?

Make sure the student is in a comfortable position to access the device and give her what she needs to access the device successfully.  Of course, occupational and physical therapists should be consulted if the child receives these therapies.

What you may think is comfortable, may not actually be comfortable for the child. Meet her where she is. If she doesn’t have significant motor involvement or fine motor issues, she may be most comfortable on the floor.  If you are introducing something new to a child, insisting that she sit where you want may cause her discomfort. I have spent a significant amount of time flopping on the floor next to preschoolers or plopping myself into the bean bag chair next to middle school students.  It definitely gets their attention. More importantly, it shows them that you are willing to meet them where they are…physically and at their communication level.

Take notice of which hand she is using and which finger she uses naturally. Of course, the time you spend on access will correlate with the student’s physical limitations. If students have fine motor difficulties, consider trying a key guard. Also, try changing the angle and location of the iPad.  For a child who is having difficulty isolating a finger, I usually move the iPad into a more upright position to decrease the likelihood that stray fingers will accidentally activate buttons and cause mis-hits. If a child is having difficulty reaching the top of the iPad because of range of motion issues in his shoulder, I would move it to a more flat position to allow him to use gravity to his advantage to access the entire screen.  We frequently talk to professionals and parents who believe that children with fine motor difficulties need larger buttons, but over the years when we tried larger buttons with the students, they continued to have mis-hits. The key guards are more effective (in our experience) in increasing a student’s accuracy than the larger button size.

How do I set up the actual language?

Yes, some device logistics would be helpful….Here are some starting points from as basic as one word to a more advanced beginning point. If you’re unsure of whether you should start at a basic, intermediate, or more advanced level, start with intermediate and adjust as needed.

My device logistic examples are going to be on the Speak for Yourself app (because it’s my favorite).  Before I start to work with a child, I ask for some of his/her favorite items and program them into the app. If I am concerned about a child being able to access the iPad, understand cause and effect, or be visually distracted, I start very basic.  Depending on the child, I either start with the actual item name (ball) or the core word that associates most closely (play) and then model the other word quickly (usually as soon as the child is able to say one word independently). For example, if your child used the device to independently say “ball” (of course I would give him/her a ball), and then I would say something like “you PLAY BALL” and model the words in caps.

At the most basic level, I would start with one core word related to something the child loves and turn off the link to the secondary screen. This gives the child the ability to access the word with one touch and get immediate auditory feedback. For the purpose of this post, let’s say our student loves to play ball. I would leave “play” open and close everything else, and then quickly open “ball,” since this might be the word he recognizes.

At an intermediate level, in addition to the thing(s) they love, I usually open “more,” (or “again”), “stop,” “want”, “mine”, “help”, “go” to start and then respond if they touch one of the other buttons. So, if they say “stop”, I’d stop what I was doing and put my hands in front of me. If they say “go”, I might run around a table or turn on or push a toy. I usually turn off the link to the secondary screens for “stop”, “help” and “want” and close most of the vocabulary on the “go” page. Frequently, I move “bathroom” to the “go” page and leave that open, so that if they say that, they are taken to the bathroom. Then they are able to associate that language for potty training. I follow the child’s lead, which sometimes changes the core vocabulary that I introduce, but this is a general vocabulary set.

For students who are more advanced, meaning maybe they are using some type of AAC already or have verbal words, I usually open the words at the intermediate level (in the paragraph above) and vocabulary that they are using in their communication book or even verbally. If they say the words verbally, I don’t prompt them on the device, but I do model the words. The reason for this is that while they may be able to say a word verbally, they may not be able to combine words and use them in intelligible, connected speech verbally….but the device can give them that ability.  Also, there may be times that the child is not able to say the words verbally.  They may be sick or tired or it may be that whatever is limiting their verbal ability in general (apraxia, seizure activity) is stronger at certain times.

Typically, children are using the communication book or saying verbal words to communicate about or request things that they enjoy. They should have the capability to talk about their interests any time they want, just like everyone else. Along these lines, when implementing AAC, make sure that the device is not removed because a student is “stimming” on it (Our thoughts about that are here).  Treat the behavior the same way you would respond if the child verbally repeated the same words, so that he realizes this is his voice and you respect his access to it. In turn, you teach him that he has to respect the rules of the classroom (and in society) that one person speaks at a time. If it’s not your turn, listen quietly.

How do I know what to teach first?

So, now you’re ready to introduce Augmentative and Alternative Communication (AAC) to the child.  Finally!  My first minutes with a child who has never used AAC is all about getting him to care enough about what I have to offer that he is willing to engage and give me his attention. (PrAACtical AAC posted a helpful blog about engagement).

In this series of videos, I’m working with Joshua for the first time.  I started the video about five minutes after I sat down next to him.  He was a little distracted by the camera, as you can see here: Joshuacheese.

Once I have a child engaged, I tend to go in one of two directions (or both, depending on the child). I either attempt to generalize vocabulary that he has learned to a new activity/item or I attempt to teach new words relating to the activity that engaged him. One of the benefits (and curses) of video is that I get to watch my mistakes.

I apologize that it is a little longer than I want it to be, but every time I thought I could cut something out, it seemed disjointed. The beauty of video is that you can watch as much or as little as you would like.  Take a look here!

The mistake that bothered me the most and that was glaringly obvious as soon as I watched the video, is when Joshua is trying to say “quiet” and I think he is saying “great.” Fortunately, he forgave me quickly. I could probably write a separate blog post about other mistakes I made, but the point of this blog is to talk about things we should do.

If you notice in the video, he is comfortable talking about colors. He is confident. He knows he is right, and he can say the words verbally. Now, I want him to feel that way about other words…. Enough other words that he can communicate anything he is thinking.

So, how do I get beyond those first minutes of engaging him and making sure he can access the device and use it with communicative intent?

This is a Building Language “flow chart” I created to give teams a direction and some core vocabulary to plan and target around the child’s interests.

Building Language Where Do I Start

I usually suggest doing a new page for each “love” that they know of for the child, and try to overlap vocabulary so that it is generalized and then add new vocabulary relating to the new item. For example, if you start with “cookies”, you might teach “eat” and “more”.

If the child also loves cars, you can generalize “more” and give him more cars and add “go” to his vocabulary. You can then build language by differentiating whether he wants “More cars,” “more cookies,” or wants you to make the car “go more.” Here’s an example of a completed flow chart for a child who loves cars, like Joshua.

 building language.sample

Like any plan, it should be changed to make sure it works with what is actually happening.  Sometimes, it’s helpful to have a framework so that everyone has common goals, but if there is a teaching opportunity, stray from the framework.  I don’t think anyone on the team will be upset if you teach vocabulary that’s not “on the list” because you followed the child’s lead.

Here is a video once we moved to the floor, where I am targeting “stop” and “go.”

When I watch this video, there are a couple of things I like about it, but first I will say, we are not at optimal positioning. I don’t think there is an occupational or physical therapist there he would say, “Have the child laying on the floor on one of his arms.” Sometimes, real-life conditions are not ideal. Who knows what would have happened if I tried to move him to sit at a table with me? I initially set up the iPads on the table and tried to coax him over, but after 30 seconds – when he was having none of that – I moved to where he was.  If someone has to be flexible, don’t expect it to be the child.

There are a few things that you can see in this video that I try to do as a general rule.

1. When he says something verbally, I model it on the device, but I don’t prompt him to say it again on the device. I want him to know where it is, just in case he gets stuck and can’t verbally say it, but I don’t want him to be redundant.  Communication is difficult enough.

2. I don’t physically take his hand to make him say anything. I have physically prompted students. Some students need help with access because of fine motor involvement, or if they are learning cause and effect and you want them to learn that touching something with THEIR hand, makes something happen. I’ve also had students take my hand to help them find a word.  I try to limit my physical prompts as much as I can. I want whatever they say to truly be what they say, and I don’t want them to become prompt dependent.

3. I spend some time being silent. I’ve shown him where the words are, I’ve used them, and even though it’s not easy, I sit quietly for some time to let him play. I give him some time to initiate…and he does!

Here is a screen shot of Joshua’s main screen when I finished working with him that day:

I’ll let you in on a “secret” that anyone who knows anything about working with students using AAC knows (and probably any therapist, teacher, and parent…having said all of that, it’s more of a reminder than a secret): You are going to make mistakes…a lot of mistakes. Even the most-experienced people in AAC will say that they should have done something differently or they missed something that the child tried to tell them.  As soon as I watched the video of Joshua, I knew he was saying “quiet.”  (In real time, I thought he was saying “great.”) I was relieved that I showed him how to say “quieter” two minutes later, but my real relief is much deeper than that.

My real relief is that children, and people in general, will be patient and work with you if they feel like you are truly trying to understand them. He didn’t toss the device off of his lap because I misunderstood him. He watched me show him how to say “great,” and continued interacting.  He was accepting, interactive, forgiving, and open to learning something new. He focused on the positive parts of the interaction…and so did I.

I know that’s a long answer to “Where do I start?” but if you do everything else wrong, there are three important things that you can do for students who need AAC: respond to anything and everything they say, make them feel positive about using AAC…and start now!