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Evidence-based AAC Interventions for Infants, Toddlers, and Preschoolers Janice Light and Kathryn Drager Penn State University Seminar presented at ASHA.

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Presentation on theme: "Evidence-based AAC Interventions for Infants, Toddlers, and Preschoolers Janice Light and Kathryn Drager Penn State University Seminar presented at ASHA."— Presentation transcript:

1 Evidence-based AAC Interventions for Infants, Toddlers, and Preschoolers Janice Light and Kathryn Drager Penn State University Seminar presented at ASHA 2007, Boston

2 The Penn State Team Emily Angert Julia Birmingham Jacky Cammiso Jen Curran Elizabeth Hayes Melissa Ihrig Lauren Karg Line Kristiansen Wendy Lewis Ashley Marzzacco Jen May Holly May Ashley Maurer Rebecca Page Elizabeth Panek Sarah Pendergast Kate Shapiro Nicole Sherman Kristin Stoltzfus Melissa Witte

3 The challenge How do we provide access to the magic and the power of language and communication for young children with complex communication needs who require AAC?

4 What did I learn watching my kids learn language? Young children –Start learning communication & language at birth –Learn language during daily activities in their environment, especially play –Learn language in the context of social interactions with familiar partners –Communicate not just to express needs and wants, but also to build social closeness and share information Social interactions are prime times to build language –Depend on context to learn language “First words” are context-bound

5 What did I learn watching my kids learn language? Young children –Receive scaffolding support from their parents to help them learn language Parents provide opportunities for communication & language learning Parents adjust language input to children’s understanding Parents respond to children’s communicative attempts –Receive 100,000s of models of language use Parents say words to children before they “know” the words –Learn language rapidly –Have fun learning language

6 Principles to guide AAC intervention with young children Start as early as possible –Intervene with infants, toddlers, preschoolers who are at risk Intervene in natural environment during daily activities –Maximize functionality, familiarity, meaningfulness Focus on sustained social interactions with familiar partners –NOT just expressing needs and wants, –but also building social closeness & sharing information in sustained social interactions

7 Principles to guide AAC intervention with young children Provide contextual support to help children learn language –Use context to support comprehension & expression –Infuse familiar experiences /contexts into AAC systems Show parents how to provide appropriate scaffolding support –Provide frequent opportunities for communication –Provide appropriate language input –Respond to child’s communicative attempts

8 Principles to guide AAC intervention with young children Provide models of AAC & speech –Use AAC & speech when talking to child Sign & speech Aided AAC & speech –Expand on child’s messages using AAC & speech Ensure that AAC systems are dynamic –Support language learning –Regularly introduce/ add new concepts for child –Model their use

9 Principles to guide AAC intervention with young children Ensure that intervention is FUN!! –Integrate communication & play –Enhance motivation of child and family –Ensure that AAC systems are appealing and fun! –Ensure that AAC systems are easy to learn and use!

10 Goals of the presentation Share the results of a research study that developed, implemented, & evaluated the effects of AAC interventions on the language and communication skills of young children with complex communication needs –Multiple baseline across participants Share case examples to illustrate AAC intervention and outcomes

11 AAC-RERC Project is part of the AAC-RERC II –Collaborative virtual research center funded by the National Institute on Disability and Rehabilitation Research –Grant #H133E ( ) For more information –http://www.aac-rerc.com to access the webcast or –Janice Light

12 Participants Single subject multiple baseline design 9 participants to date –6-40 months old upon referral –Significant communication disabilities –All nonsymbolic or minimally symbolic at baseline 0-25 symbols expressively Evaluated impact of AAC intervention –Collected longitudinal data to track language development Pragmatic, semantic, syntactic development

13 Goals of AAC Interventions The overall goal is to build social interaction between young children & familiar partners Maximize child’s functional communication Enhance child’s language development –Increase participation /turn taking –Express range of communicative functions –Develop breadth of semantic concepts –Build greater complexity of language structure to support more complex communication –Build phonological awareness skills /foundations for literacy development

14 AAC Interventions Scheduled for 1 hour per week In natural environment –Typically at home –Sometimes at preschool Within play and other activities of daily living Involved parents and other primary facilitators

15 Departure from typical AAC intervention Focus on sustained social interaction –Don’t just focus on needs and wants Redesign AAC to better meet young child’s needs and skills –Provide contextual support to support language learning Encourage language learning through AAC –Don’t require language learning prior to AAC

16 Components of effective evidence- based AAC intervention 1.Identify meaningful social contexts for communication 2.Develop appropriate AAC systems for the child 3.Set up the environment to support social interaction 4.Use appropriate strategies to support child’s communication Meaningful opportunities for communication Appropriate supports to ensure successful communication

17 Case #1 AAC intervention with infants - Initial intervention Goals –To increase active participation in social interactions with familiar adults –To increase communicative turns /social bids –To introduce range of communication purposes

18 Identify meaningful contexts for social interaction Meet with parents; observe child Select contexts that are –Interactive Rich in opportunities for participation –Reciprocal –Easy to sustain over multiple turns –Motivating to the child –Meaningful / familiar for the parents and child –Frequently occurring –Valued by the family –Fun!!

19 Identify meaningful contexts for social interaction Focus on contexts that provide –Sustained social interaction Offer multiple opportunities for participation /communication –Not just expression of needs and wants Single opportunity for communication e.g., snack Initially choose contexts that –Involve only the infant and the partner (and AAC) Minimize the joint attention demands –Have predictable structure

20 Identify meaningful contexts for social interaction Social games –E.g., Peek-a-boo, So Big Songs (line by line) –E.g., Itsy Bitsy Spider Musical instruments & toys –E.g., Winnie the Pooh, crib toy / mobile Books –E.g., Brown Bear, Who’s hiding?, Baby Faces

21 Develop appropriate AAC systems Communication is multimodal Identify modes that are used currently by child Vocalizations Facial expressions Introduce additional modes to augment /enhance communication Signs Light tech symbols Speech generating device (SGD)

22 Introducing AAC to parents AAC intervention results in significant gains in –Functional communication –Language development Will AAC inhibit speech development? Meta-analysis (Millar, Light & Schlosser, 2006) –0% demonstrated decreases in speech production –11% showed no change –89% demonstrated gains in speech Gains observed were modest ones +20 spoken words or less –Ceiling effects in many cases –AAC does NOT inhibit speech development

23 Develop appropriate aided AAC systems AAC systems should –Be fun –Be easy for infants to understand and use –Be dynamic

24 AAC systems should be fun (from Light, Drager, & Nemser, 2004; Light, Curran, Page, & Pitkin, in press) AAC systems should appeal to infant –Multiple bright primary colors –Familiar motivating content Preferred people and activities –Fun interactive play activities –Engaging characters Expressive faces –Engaging speech output, songs, musical instruments, sound effects, laughter –Child’s preferences

25 AAC systems should be easy to use AAC systems should be easy for infants to understand & use –Use touch screen for selection if possible Immediate cause and effect / direct relationship Selection upon activation not release –Provide scaffolding support to assist with navigation Set up menus / arrows for future navigation Model use, but do not require use –Use visual contextual scene displays to provide meaningful interactive contexts to promote social interaction

26 Traditional grid layout Vocabulary represented by separate AAC symbols in “boxes” –Language is taken out of context –“Decontextualized” Concepts are presented separately –Visual-spatial relationships are not preserved –Contextual relationships are not preserved Imposes greater cognitive /linguistic demands

27 Visual scene display layout “Graphic metaphor” (Shane, 1998) Vocabulary embedded under “hot spot” in visual scene display (VSD) –Digital photo of child’s experiences –Scanned image of familiar book Vocabulary presented in meaningful context –Concepts related visually and conceptually as in life

28 Develop appropriate VSDs Develop visual contextual scene displays that represent the selected interactive contexts to expand the child’s communication –VSDs are designed to provide a high level of contextual support –VSDs provide a context to support the communication of young children and their partners VSDs can be implemented –On dynamic display speech generating devices (SGDs) –As low tech systems Choose appropriate representations for VSDs E.g., digital photos, scanned images

29 What makes a “good” VSD? Visual scene displays for young children should –Be meaningful and relevant –Represent motivating contexts /activities –Portray interactive social experiences –Provide a rich context for communication –Reflect the child’s perspective on the event /experience –Reflect the child’s conceptual development /understanding –Be appealing

30 Develop appropriate VSDs Adapt VSD as required to accommodate –Visual skills Reduce complexity for very young children, Remove background to increase contrast for children with visual impairments –Motor skills Number of hotspots Size of hotspots –Cognitive/ Language skills Amount of vocabulary Type of vocabulary provided

31 Select appropriate vocabulary For each interactive context, select appropriate vocabulary to expand the child’s communication Individualized Motivating / fun Functional Developmentally appropriate Kids should sound like kids! Culturally appropriate Supportive of language learning Include a range of developmentally appropriate & functional concepts people, actions, objects, places, social words, relational concepts, questions, etc. Support participation in social interaction not just expressing wants Young children can only learn language if we provide access

32 Select appropriate vocabulary Identify appropriate “hot spots” in the VSD for vocabulary related to the context –Be sure hot spots are an appropriate size accommodate child’s motor & sensory perceptual skills –Consider child’s language and cognitive development when adding vocabulary Initially beginning communicators may only have a single hotspot in a VSD Gradually add more hotspots / vocabulary concepts –Observe child’s interests in VSD If child selects same area of the VSD, add vocabulary to this area of interest to reflect the child’s intent / meaning

33 Develop appropriate VSDs VSDs can be very simple or more complex depending on the needs and skills of the child –Single image with a single hotspot –Single image with a few hotspots –Single or multiple images with multiple hotspots –Hybrid displays including a visual scene as well as additional vocabulary items organized outside the scene in a grid –Traditional grid displays with symbols displayed in rows and columns

34 Introduce appropriate AAC systems Light tech symbols –Meaningful & appealing representations of concepts Digital photos, scanned images, color line drawings Covered in contact paper & backed with Velcro Taught in meaningful contexts; paired with the referents

35 AAC systems should be dynamic –Start with systems that provide potential access to 1,000 of concepts Do not let AAC systems limit language development –Gradually build language

36 AAC systems should be dynamic Young children experience qualitative & quantitative changes in development AAC systems must reflect these changes –Introduce new activities regularly Respond to child’s preferences –Introduce new concepts regularly ***Provide access to range of language concepts Model their use in meaningful contexts Don’t wait for child to “prove” comprehension –Introduce more hotspots as motor skills develop Embed more language

37 Set up the environment to support social interaction Ensure appropriate positioning to maximize attention and participation –Accommodate motor skills & cognitive skills Minimize joint attention demands and maximize the child’s attention to partner and AAC system –Sit directly in front of the child at eye level –Hold the AAC system directly in front of the child, just below the partner’s face

38 Use appropriate strategies to support child’s communication Have FUN!! Engage in social interaction using appropriate strategies to ensure Meaningful opportunities for communication Appropriate supports to ensure successful communication

39 Initiate the context / identify opportunities for communication Initiate the interactive context / start the activity Locate the appropriate display for the child –Initially do not expect the child to navigate independently –As the child develops competence, model navigation to the appropriate display Identify numerous opportunities for the child to participate within the context –Initially context may be repetitive –As child develops competence, build in numerous varied opportunities for interaction

40 Mark opportunities for child to communicate Clearly mark each opportunity for the child to communicate Use expectant delay Focus attention on child; maintain eye contact Use expectant body posture Wait and allow the child time to communicate

41 Respond to the child If the child attempts to communicate, respond immediately Fulfill the intent Repeat or expand on the child’s message Model AAC + speech Continue the activity Continue to provide meaningful opportunities for child to communicate Repeat over successive turns Introduce new context as required Watch for loss of interest

42 If the child does not attempt to communicate, Model an appropriate turn use AAC + speech Use a third party model to demonstrate if available Parent, sibling, or aide demonstrates for the child what to do Present the opportunity again

43 Model AAC + speech When talking to child, always model AAC Speech + sign/ gestures Speech + aided symbols Speech + SGD Model AAC use to Support child’s comprehension Show the child how to communicate Provide opportunities for child to learn new language concepts & new structures Make note of gaps in available vocabulary; add required concepts

44 Work with parents to enhance participation Identify opportunities for communication Infuse into familiar, meaningful, motivating, social activities Opportunities to sustain social interaction Model use of AAC plus speech Demonstrate how to use AAC to communicate Provide scaffolding support in AAC use Locate appropriate light tech symbols to offer choices Help locate appropriate pages in VOCA Recognize and respond to child’s communicative attempts Fulfill communicative intent Expand and model more complex messages using aided AAC Have fun!

45 Intervention Stage 2 Developing semantic concepts Goals –To continue active involvement in social interactions with familiar adults –To expand expressive vocabulary to communicate more diverse meaning –To teach questions gradually to provide control over vocabulary acquisition /language learning

46 Work with parents Continue to –Set up numerous opportunities for communication –Recognize and respond to child’s communicative attempts Model use of aided AAC –Model known concepts as well as new ones –Expand on child’s messages Teach new concepts –Link new symbol to the concept directly –Demonstrate concept –Model use

47 Provide scaffolding support in AAC use –Help locate appropriate pages in VOCA as required –Teach organizational system Organize vocabulary according to meaningful events Use appropriate menu symbols

48 Intervention - Stage 3 Learning syntax and morphology Goals –To continue active involvement in social interactions with familiar adults –To take turns with peers with adult scaffolding –To continue to expand expressive vocabulary e.g., question words, etc Read, read, read –To encourage communication of more complex, novel meanings by combining symbols –To introduce early morphological structures to specify meaning

49 Developing the foundations for social interactions with peers Important to develop the foundations for peer interactions –opportunities to develop friendships –“testing ground” for communication skills Develop repertoire of activities as contexts for interactions with peers –books –songs –games –play activities

50 Learning the form of language Begin to introduce more complex forms of language Model AAC + speech –Build up sentences –Break down sentences –Use message bar with VOCA to provide visual /auditory feedback Teach in context; demonstrate appropriate use –Explain rules as appropriate Expect use only in contexts where obligated –E.g., “writing” activities / publishing books

51 Gradually introduce expression of morphology/ syntax –e.g., present progressive, plurals, past tense, auxiliary Challenges –How do we represent grammatical parts of speech?

52 Intervention Stage 4 Phonological awareness / literacy Goal –To continue active involvement in social interactions with familiar adults –To interact socially with peers –To continue to expand expressive vocabulary –To continue to develop syntax and morphology –To teach phonological awareness skills and literacy skills

53 AAC systems –Introduction of alphabet board – light tech –Access to alphabet on high tech system Speech output letter sounds not names Introduction to literacy curriculum –Letter-sound correspondences –Phonological awareness skills Sound blending Initial phoneme segmentation –Early decoding & shared reading –Early writing activities

54 Ongoing literacy instruction Ongoing reading of books, talking about stories Teaching reading skills Decoding of more complex words Sight word recognition skills Reading simple stories Building comprehension Teaching writing skills Writing stories

55 Summary of results to date All children have demonstrated significant increases in their rate of turn taking –All children sustain interactions with others for significantly longer All children participate in interactions that involve –Social routines –Play activities –Not just expression of needs and wants

56 Children use their AAC systems independently for play & learning as well Children use their systems as contexts to interact with peers –Shared books –Shared singing –Play All children have demonstrated significant increases in their expressive vocabularies All children have acquired a range of semantic concepts

57 Children are combining concepts to communicate more complex meanings All children have been able to use VSDs on initial introduction once use is modeled –seem to be more interested & motivated when scene displays are used to integrate AAC & play, book reading, music Children have learned to use other displays –Hybrid displays –Grid displays

58 All children started with adult scaffolding support to find appropriate pages in aided systems –Children have learned some navigational tools Menu Forward and back arrows to change pages –Some children navigate independently Some children are developing phonological awareness and literacy skills

59 Early AAC intervention supports language development and communication –Increase participation and build social interaction –Develop breadth of semantic concepts /vocabulary to support more diverse communication & conceptual development –Build greater complexity of language structure to support more complex communication –Build phonological awareness skills and foundations for literacy development

60 The art and science of AAC intervention The science of AAC intervention –Implementation of evidence-based intervention procedures Research is available to guide in planning and implementing AAC intervention with young children –Monitoring effectiveness with individual child –Evaluating outcomes

61 The art of AAC intervention The belief and the commitment to the right of all individuals to express themselves fully and seek their full potential

62 For further information, Visit for the webcast on young children who require AAC or This research is part of the AAC-RERC II and is funded by the National Institute on Disability and Rehabilitation Research of the U.S. Department of Education, under grant # H133E ( ). The opinions contained in this presentation are those of the grantee and do not necessarily reflect those of the U.S. Department of Education.


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