Augmentative Communication:
Applications and Practical Strategies for Children who have Rett Syndrome

Linda J. Burkhart

Why use Augmentative Communication with Children who have Rett Syndrome?

• Means of expressive language
  
• Means of improving receptive language skills (makes language visible)
  
• 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 processing
  
• 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 regulate behavior
  
• Provides a vehicle for developing social skills, turn taking and interacting with peers
  
• Provides support for emerging literacy and mathematical concepts
  
  

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 joint attention
  
• 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 Stimulation
  
• 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", etc.)
  
• 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.
  

Requesting Recurrence

• Signal for "more" of a playful activity, rough house etc.
  
• Add simple voice-output, picture symbol or sign language for "more"
  

Calling and Initiating Communication:

• 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- "look Mommy"
  
• Vary the call message using Step-by-Step to expand language and increase interest, while still keeping the same communicative function.
  

Where do you begin? 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.)

• 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 or more.
  

Follow the child's direction or lead: empowering the child and giving her the control.

• Child directed activities keep the child's interest and receptivity high.
  
• 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 to request)
  
• Set up scenarios that encourage initiation. (phone play, bubbles, songs)
  
  

Provide Simple Choices

• 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 the object
  

Utilize eye-gaze as a communication strategy:

• 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, picture symbol)
  
• 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 talking"
  

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 initiation
  
  

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, hugs, etc.)
  

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 frames)
  
• 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 the activity.
  

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 social interaction
  
• Sequential message device for a series of communicative turns
  
• Great way to develop pragmatic skills of turn taking and conversational flow
  
• 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?, I’ll give you a hint..., what do you think?)
  
• Allow the child to initiate, don’t 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, what’s up?” or “How’s 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 voice-output device)
  
• 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 of language
  
• 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 indoor/outdoor carpet)
  
• 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 child)

• 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, computer
  
• 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 some more!"
  
• Blocks / moving toy (need to ask "build them up.")
  
  

"Show" Stage

• Send battery toy to adult and then request "me" to have it come back.
  
• Carry something with toy (like a cookie on a plate on the bike)
  
• Use language: "look at this," "hello," "good-bye," and "come here"
  

Turn Taking

• 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 ball"
  
• 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," etc.
  
• Make choices of toys and activities not visible (picture symbols or signs)
  
• 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 on.
  
• 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
  
• gestures
  
• picture/symbol systems
  
• voice-output devices
  
• facial expressions
  
• verbal approximations and vocal tonality
  
• eye-gaze
  
  

Sign Language

• 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 hearing children
  
• 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 draw
  
• 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 and Elder)
  
• 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
  

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Linda J. Burkhart, linda@Lburkhart.com, http://www.Lburkhart.com