Applications and Practical Strategies for Children who have Rett Syndrome
Linda J. Burkhart
Why use Augmentative Communication with Children who have
- Means of expressive language
- Means of improving receptive language skills (makes
- Improves self-concept and self esteem - which in
turn, improves a child's ability to learn
- Multi-sensory representation of language concepts
provides richer information about the concepts for the child to process
- Allows students to learn through visual strengths
while providing associated information to weaker areas such as auditory
- Makes language more concrete and less fleeting
- Increases motivation
- Increases participation
- Facilitates learning by making learning interactive
- Reduces Frustration and behavior problems
- Provides a means for the child to self-talk and self
- Provides a vehicle for developing social skills, turn taking
and interacting with peers
- Provides support for emerging literacy and mathematical
Key Components for the Success with Augmentative Communication
1. Receptive before Expressive: Language must go in before it can come out
Joint Attention and Shared Interaction
- Use visual supports, and exaggerated gestures to increase
- Tapping object, and flashlight cueing
- Objective is shared enjoyment - make up simple games based
on the child's pleasure
- Use a motivating toy as focus of attention and interaction
- Much is learned receptively at this developmental level
through modeling language and play, but this natural function only works
if the child is interested and attending
Natural Aided Language Stimulation:
- Vocabulary is first introduced receptively
- Multi-Modal Language Stimulation - information needs to
go in before it comes back out
- Carol Goossens' - filling a cup analogy for Aided Language
- Engineering the Environment for Aided Language Stimulation
(Goossens', Crain and Elder)
- Language is not learned by straight imitation, it is learned
through broad experiences that provide multiple repetitions of concepts,
vocabulary and conventions. This provides a scaffold from which children
can construct language.
- A wide variety of communicative functions need to be represented
(comments, questions, requests, humor, teasing, protesting, rejecting,
- Use conversational language ("You like that, don't
you" "Your car is crashing", "That's big one",
- Avoid asking too many questions, use more comments and social
expressions ("that's silly", "uh oh!". "we need
to clean it up.")
- When asking a question, provide a concrete way for student
to respond ("Do you want chocolate or regular milk" - showing
both containers or pictures for child to select from)
2. The Use of Active Learning is much more effective than Passive Learning
- Problem of learned helplessness
- Student's interest and ability to learn will be increased
with active participation
- Everyone has a basic need for control in their lives within
the context of general societal controls
- Children need a balance of familiar repeated information
and new or different interesting information.
- A feeling of "I can do this," "I want to
try it myself," or "I know how to do it!" goes a lot farther
than hand over hand participation or passive compliance.
- If the child sees a reason or purpose to participate, he/she
will be much more likely to be actively involved. Provide a purpose in
a manner that makes sense to the child.
- The challenge is to find some method or adaptation for the
student to have active participation and a feeling of control and choice
in every activity.
Calling and Initiating Communication:
- Signal for "more" of a playful activity, rough
- Add simple voice-output, picture symbol or sign language
Where do you begin?
- Call Mom/teacher for "peek-a-boo" or "finger
play" or to sing a favorite song.
- Later, child calls mom as emotional need to touch base-
- Vary the call message using Step-by-Step to expand language
and increase interest, while still keeping the same communicative function.
Figure out what the child really likes or
would most likely want to do and start with that activity (ex; tickle, bounce,
juice, swing, bubbles, Mommy's song, silly noises, etc.)
Follow the child's direction or lead: empowering the child and giving
her the control.
- Balance novel with known to create a feeling of familiarity
and comfort with curiosity and intrigue.
- Move from requesting one activity to choosing between two
- Child directed activities keep the child's interest and
- Don't get into a battle of wills (example of snack - teacher
directed: show me cookie vs. what do you want? or just providing the opportunity
- Set up scenarios that encourage initiation. (phone play,
Provide Simple Choices
Utilize eye-gaze as a communication strategy:
- Create and provide multiple opportunities for choices throughout
the day and represent these choices visually
- Provide choices with multiple modes: two hands, objects,
pictures, eye gaze, light pointer, talking switches, environmentally placed
talking switches, head activated talking switches
- Try requesting actions on objects instead of just requesting
- PVC pipe stand
- baseball card album page with center cut out
- flashlight cueing
- talking picture frames for auditory feedback
- model eyegaze as you communicate to the child
Respond with Natural Consequences:
- Respond to all attempts to communicate regardless of form (voice, sign,
- Respond with natural communicative response (provide item requested,
"oh you want some popcorn - here you go")
- Avoid artificial rewards for talking such as unrelated treats or "good
Keep questions and extraneous language to a minimum
- This may feel unnatural.
- Put verbal patter in your head and a look of expectation and interest
on your face.
- Avoid using What is this? and yes/no questions
- Use natural prompts, facial expressions, look of interest, attend to
another child (doll or puppet), feigned disinterest, or pauses to encourage
Expect delayed processing time
- Use anticipatory pauses.
- Don't distract the child from his thought processes.
- Use environmental prompts instead of physical prompts.
- Allow the child to control the sensory experience (request swinging,
Reduce motor demands
- Use eye-gaze frame and vest.
- Try a light pointer.
- Experiment with a flip chart. (Let me know when you see/ hear the one
that you want)
Minimize random activations
- Reduce activation size and space between choices to require closer attention.
(If both switches are large and close together, the child may easily hit
both or one randomly without close attention)
- Increase distance between selections at first. (Radio Shack picture
- Have child move to selection in his environment.
- Wait for child to focus on selection before moving it within reach.
- Ask for confirmation with eye point strategies if you are not sure what
the child looked at.
- Successively eliminate choices. (verses in a song, building parts)
Allow the child to withdraw and center and then continue at his
own pace, kids learn in short spurts.
- Go with distraction and then entice the child back.
- Provide the child with a means to communicate about distractions.
Self directed repetition (difference between getting bored with something
and assimilating something)
- Adult directed: habituation, boredom, anger,frustration, feeling of
powerlessness. (low motivation)
- Child directed: as needed to assimilate concepts, to practice new skills,
to feel a sense of "I can do it" and show someone else their
accomplishments (share the joy) (high motivation)
Provide child with natural multiple opportunities by responding
with small amounts of what was requested or actions of short duration.
- Offer small bites at snack.
- Try actions on toys. (make it go some more)
- Communicate multiple times within the activity instead of just choosing
Social Scripts (Caroline Musselwhite)
- Reduce the motor requirement for accessing a device - while providing
opportunities to practice using a single switch within the context of
- Sequential message device for a series of communicative turns
- Great way to develop pragmatic skills of turn taking and conversational
- Create script with the child - giving her choices of what to record
throughout the script (Its helpful to write the script with the child
first and then record it on the device with the child watching.)
- Begin with attention getters
- Use a variety of communicative functions: humor, teasing, transfer of
information, asking questions, commenting, turn transfer (Guess what?,
Do you want to know where I went?, Ill give you a hint..., what
do you think?)
- Allow the child to initiate, dont say press your switch
Approach the child with a look of interest on your face and wait. You
can try a natural verbal prompt if necessary such as So, whats
up? or Hows it going?
Additional strategies for Motivation to Communicate:
- Challenge is to find a need to communicate
- Use environmental and time associated prompts instead of physical and
verbal prompts when possible
- Expect Delayed Response
- Sabotage and place toys or needed pieces out of reach or out of sight
to require child to ask a person to get an item
- Physical play "turn me upside down", "spin me around!"
- Follow the leader in gross motor activities (child directs action with
- Toys that are difficult to manipulate, but result in action "help"
or "put it on
3. Children most effectively learn to use augmentative communication
through the same methods that they learn to use verbal communication - through
modeling in natural and functional contexts.
- Drill and practice, rote learning is not very effective
- Learning in functional situations facilitates generalization
- Anything that has some intrinsic motivation for the child is more likely
to be practiced in different settings and used by the child.
- Modeling and a simulated immersion environment are powerful
- Use multi-modality aided language stimulation to model appropriate use
- Concept of an immersion environment
- Theme based learning provides multiple experiences with a concentrated
set of vocabulary and concepts without being monotonous.
Integrate communication with play
- Use battery toys to cause something to happen that gives the child control
and provides topic of communication. (roll a ball, knock over blocks)
- Adapt battery toys to fit pretend play. (puppet on bump'n go toy)
- Stabilize toys for more independent play. (Velcro® playboards with
- Use adapted spinners and generic game boards to play games.
- Use toys that require assistance to operate. (helicopter)
Early Interaction (sharing play/toy with an adult or other
- Telephone: "Hello," "good-bye," ringing sound and
later add more language - places child in control of initiating and terminating
- Follow the leader - language master, simple scanning, voice-output,
- Balloons - directing action (blow it up, let it go! make it squeak!)
- Bubbles (two step toy so there is a need to ask: "dip it in, get
- Blocks / moving toy (need to ask "build them up.")
- Send battery toy to adult and then request "me" to have it
- Carry something with toy (like a cookie on a plate on the bike)
- Use language: "look at this," "hello," "good-bye,"
and "come here"
- Expanding contingency understanding - how my actions effect others actions
- Two switches two kids on software that only allows one switch to work
at a time
- Play ball (penguin toy) "throw me the ball" or "get the
- Modeling with peers in a small group
- Adapting simple games
Expanding Language and Concepts
- Request actions and toys: "throw ball," "bounce ball,"
"bounce baby," "baby dance," " baby sleep,"
- Make choices of toys and activities not visible (picture symbols or
- Choose which song or which verse
- Combine concepts on a computer to observe results (IntelliPics)
Pretend and symbolic play
- Model pretend play receptively before expecting it to be used independently
- Imitation of "Mommy or Daddy things" (household tasks) Provide
adapted toy and proximity to simulate whatever adult activity is going
- Doll house playboard (noun/verb and noun/adjective)
- Vehicle playboard (in, out, car noises: beep, brmmm brmmm - using voice-output)
- Pretend cooking (battery dino eating)
- Dollhouse play: directing action (Speaking Dynamically)
- Adapted art activities
- Dress up - choices and comments
- Simulation on computers
4. The use of multiple communication systems is vastly more effective than
use of a single system.
- sign language
- picture/symbol systems
- voice-output devices
- facial expressions
- verbal approximations and vocal tonality
- Positive features and limitations
- Spontaneity and portability
- Effect on how language is presented receptively - slower speed, more
emphasis, multi-sensory, increased attention, more use of facial expression
and body gestures
- Impact on auditory processing
- Potential for closely paralleling verbal language
- Limited audience of communicative partners, so need for multiple options
- What type of signs? - Use Baby Signs and Signed English, not ASL: with
- Baby Signs research
- Start early to develop child's understanding of how language works to
establish a good foundation for later communication
- Expressive use for student who are unable to sign - used for drawings
of abstract concepts for picture communication systems
- Start with signs for people, favorite events and activities, daily routines
Selecting Picture Symbols for Beginners
- Use of Photos for people and some favorite toys that are difficult to
- Enhancing photos by cutting out the shape and mounting on a plain background
- Line drawings for wider communicative functions
- Hi-lighted backgrounds - used receptively at first (Goosens, Crain
- Voice-output to increase cognitive connection
- Environmental placement
- Photo albums / language books to talk about present, past and future
Designing Communication Boards and Overlays for Voice-output Devices
- Activity based vs. mega boards
- Left to right organization
- Phrase based boards for social comments and more bang for the
buck. Word based boards for generating more novel utterances when
child is linguistically ready and has good motor access
- Provide both sides of the conversation on the communication board
Linda J. Burkhart, linda@Lburkhart.com, http://www.Lburkhart.com