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

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 For more information
Collaborative virtual research center funded by the National Institute on Disability and Rehabilitation Research
Grant #H133E ( )
For more information
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
Identify meaningful social contexts for communication
Develop appropriate AAC systems for the child
Set up the environment to support social interaction
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 Model use of aided AAC
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. Introduction to literacy curriculum
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 www. aac-rerc
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.