Web Posted on: February 6, 1998

ONE SIZE DOES NOT FIT ALL: TAILORING AAC TRAINING TO THE USER

Barbara B. Shadden
University of Arkansas Speech and Hearing Clinic
410 Arkansas Avenue
Fayetteville, AR 72701
(501) 575-4917
FAX: (501) 575-4507
Internet: bshadden@uafsysb.uark.edu

Angie Hodges
University of Arkansas
P.O. Box 1194
Fayetteville, AR 72702
(501) 521-0239
Internet: ahodges@comp.uark.edu

Kasey Hodges
(same as above)

Although considerable guidance is available for professionals and users wishing to train/acquire skills for communicating effectively with the Liberator, no predefined program can accommodate the needs and learning styles or strategies of all individual users, particularly young children. Because of the complexity of the Liberator, however, professionals often rely extensively on recommended training approaches without paying sufficient attention to the cues being provided by the user as to his/her preferences and relative learning strengths. This session provides a case example that illustrates the importance of being responsive to user cues. K.H. was barely three years old when she was provided with a Liberator with Word Strategy. The Unity systems were not available at the time of device purchase. Kasey's training began in a rather "traditional" fashion, using approaches outlined by Prentke-Romich. However, over the course of 2 1/2 years of speech-language therapy and home training, the focus of intervention shifted in response to K.H.'s interests and skills and to environmental supports and barriers. In effect, the adults in her life were guided by the incidental learning that K.H. demonstrated over this time period. In particular, acquisition of Minspeak icon codes for vocabulary development received decreased attention and emerging literacy skills and metalinguistic abilities such as phonological awareness and recognition of parts of speech (all in the context of Liberator usage) received increased attention. K.H. now excels in comparison to most "normal" classmates with respect to reading, spelling, writing, and metalinguistic recognition of grammatical forms.

Background

K.H. is a six-year-old child with moderate-to-severe mixed-type cerebral palsy. She has received early intervention services since age six months, and was enrolled in a preschool educational program at age three. At age two, K.H. received a MegaWolf AAC device, which she rejected after several months, probably due to a combination of poor quality synthetic speech and system limitations in terms of communicative expression. At age two-and-a-half, she received a formal augmentative communication evaluation and a Liberator device was purchased shortly after her third birthday. Liberator usage was supplemented by use of PCS symbol boards for specific activities (e.g., participation in story reading and retelling) and environmental engineering. K.H. continued in preschool programming for children with developmental abilities until kindergarten, where she was fully mainstreamed in the public schools. She is now in a regular first grade classroom. Receptive language testing has established average to above average skills on standardized measures.

Assessment of cognitive development also suggests average to above average cognitive skills, even with her motor limitations and speech impairment.

Altering the Treatment Progression Based on User Cues

K.H. became involved in formal AAC therapy during the summer of 1995, just prior to her fourth birthday. Because of her relatively intact receptive language skills and her high level of communicativeness, early therapy activities were developed based on a developmental model of language acquisition (i.e., what types of words come first developmentally, what is the natural configuration of early two-word utterances, etc., etc.). Guidelines provided in the Minspeak/Word Strategy manuals were used to develop therapy objectives and activities. Vocabulary was drawn from developmental guidelines and specific environmental needs and activities. However, our focus on grammatical development, along with other functional communication objectives, was somewhat atypical for AAC approaches at that time. Both Blockberger (1997) and Sutton (1997) have recently highlighted the importance of providing children who are AAC users with grammatical competence and expressive skills.

Throughout the summer and fall of 1995, K.H. made excellent progress with specific targeted objectives. However, it was noted that her retention of Minspeak vocabulary was limited unless icon sequences were used on a regular basis. At times, it seemed that K.H. had begun to plateau in her ability to exploit the Word Strategy features of the Liberator. Such a plateau began to raise questions about whether or not this was the appropriate device for this child. K.H. herself appeared to be increasingly less motivated to work toward learning icon sequences.

During this same time interval, however, K.H. began to acquire pre-literacy and early literacy skills through incidental learning. Experience with written language and with literacy-related skills included: a) exposure to PCS icon board with printed words accompanying icons; b) watching her mother or therapists use the Liberator spell mode to identify icon sequences for specific words; c) asking to "spell" words herself, with the adult providing each letter and identifying its location on the keyboard; d) monitoring of the LED display to determine the accuracy of her selection; and e) exposure to common words through the engineered environment. A shift in therapy focus was finally decided upon when we recognized that K.H. had, on her own, begun to understand that sequences of printed letters correspond with words. This recognition came about rather dramatically when K.H. attempted to spell "pizza" for her clinicians when they did not understand what she was trying to tell them she wanted for dinner. Remarkably, the consonants in the word were accurate.

Based on the slow acquisition of new vocabulary, the gap between the types of communications K.H. desired to produce and her capabilities with Word Strategy, and her obvious interest in and aptitude for written language forms, literacyrelated treatment and home activities were introduced in the spring of 1996. Many of our early literacy-based objectives focused on basic phonics (on soundsymbol associations), with particular emphasis upon the kind of phonological awareness identified by Paul (1997) as critical for children with severe speech and physical impairments. K.H. could identify most common sounds associated with all consonant letters at the beginning of words within about three months. For almost a year and a half, her reading and spelling abilities were targeted, expanding consonant recognition to word final and medial position, introducing basic vowel sounds, and expansion of sight vocabulary. K.H. was encouraged repeatedly to "hear the word in your head" in order to foster phonological awareness. At the same time, she was asked to attempt to spell any vocabulary item for which she did not know the Liberator sequence. This latter strategy encouraged K.H. to take more risks (she does not like to fail), while at the same time exploiting the voice output of the communication device for auditory feedback. For some activities, she was also asked to turn off the Liberator speech output until an entire message had been generated, forcing her to rely on the LED display for feedback about accuracy.

None of the above activities would have been successful had it not been for the unique characteristics of this particular AAC user. Unlike most children, K.H. delighted in any kind of spelling and/or letter recognition task, including those activities that might be considered rote drill by some (for example, using flashcards). Her mother and the professionals working with K.H. believe that her motivation to excel in these activities came from her awareness of the liberating properties of literacy, particularly as it involved messages she could communicate with the Liberator. Although we attempted to continue to increase K.H.'s Minspeak vocabulary during the same time interval, we again became concerned about her lack of a reasonable strategy for searching for icon sequences for new words. Syntactic and morphological development was also beginning to lag behind other skills.

During the summer of 1997 and extending through the fall, it was decided to take a rather unusual approach for a five-year-old child -- an approach justified by her enjoyment of structured performance activities and her lagging Liberator vocabulary development. In effect, we introduced grammatical parts of speech from a highly metalinguistic perspective, explaining the nature of nous, articles, verbs, etc., then requiring K. H. to produce words from selected grammatical categories or identify types of words from word lists. Whenever possible, vocabulary was selected from the Marvin, Beukelman, and Bilyeu (1994) list of frequently occurring home and school words for preschool children. At present, K.H. can identify articles, nouns, pronouns, prepositions, verbs, helping verbs, negative contractions, adjectives, and adverbs, with past, present and future tense forms now available to her. Her ability to identify the type of word has provided her with strategies to determine appropriate icon sequences on the Liberator, thus enhancing her use of Minspeak and Word Strategy. Additional reading vocabulary was introduced weekly, with each week emphasizing a particular sound class ending. Vowel recognition and usage began to improve dramatically.

At the end of the fall 1997 semester of therapy, K.H. could identify icon sequences for 223 out of 300 words used frequently by preschoolers. She consistently identified or produced exemplars of specific grammatical forms with high percent accuracy figures. She now uses the Liberator much more effectively to communicate, mixing Spell Mode and icon sequences to achieve the most efficient message generation. An example of K.H.'s version of The Three Little Pigs follows:

"Once upon a time there was 3 little pigs. The first little pigs house was made out of straw and the second little pigs was made out of bricks. The third little pigs was made out of sticks. The big bad wolf blowed the first little pigs home down. The second little pig drank iced tea with the third little pig and the third little pig fought with the big bad wolf. They at gummy bears all day long. They said I'm sorry. The second little pig played a game.

Candyland. They played Candyland. They went trickier treating. They got candy. They went to a party. They danced and had drinks. The end."

Conclusions

Clearly, K.H. is a remarkable child, with strong cognitive and linguistic skills. She has been fortunate to have a highly supportive home environment and a strong cadre of professionals committed to working with her to maximize her functioning. However, if relatively traditional AAC approaches to functional communication had been maintained in working with K.H., it is doubtful that she would have made the progress she has made in literacy skills development and in Liberator usage. In fact, at one point, we strongly considered backtracking to use of one of the Unity levels, since K.H. appeared to have plateaued in acquisition and use of new Minspeak vocabulary. Fortunately, we chose to take our cue from her obvious strenths and interests. Otherwise, we would never have considered introducing parts of speech to a five-year-old child, or phonics to a four-year-old. K.H.'s example proves -- once again -- the importance of tailoring the AAC intervention to the individual child. Our intense focus on literacy and metalinguistic skills, however, has presented some problems within the public school classroom. These problems will be discussed in this presentation.

References

Blockberger, S. (1997). "Helping the AAC user acquire grammatical morphology" Special Interest Division 12 Newsletter, 6 (4), pp. 5-7.

Paul, R. (1997). "Developing preliteracy skills in children with severe speech and physical impairments: Fostering phonological awareness." Special Interest Division 12 Newsletter, 6 (4), pp. 10-11.

Sutton, A. (1997). "Grammatical development and AAC." Special Interest Division 12 Newsletter, 6 (4), pp. 7-9.