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Wendt: Strategies in AAC IN-ABC 2013

1

Evidence-based Strategies in

Augmentative and Alternative

Communication (AAC)

Oliver Wendt, Ph.D.

Department of Speech, Language,

and Hearing Sciences

Purdue University

Indiana Association of Behavioral

Consultants (IN-ABC)

Annual Conference 2013

Program

Prominent AAC Strategies for ASD &

Developmental Disabilities

Manual Signs and Gestures

Picture Exchange Communication System

(PECS)

Speech-Generating Devices (SGDs)

Moving from PECS to SGDs and iPads

Case Examples and Demonstration

Discussion

Autism Spectrum Disorders

(ASD)

Triad of symptoms with

1. Impairments in language and communication

Deficits in language can range from completely

nonverbal to acquiring the ability to speak.

2. Impairments in social interaction

Results in lack of motivation to communicate with

other people – even when these individuals have

acquired some language competence and use.

3. Restricted and repetitive patterns of behavior

Pre-occupation with restricted patterns of interest

can impede social and communicative development.

Proportion of Nonverbal

Children with ASD

Autism includes a “delay in, or lack of the

development of spoken language” (American Psychiatric Association, 2000)

14-25% of children diagnosed with an autism

spectrum disorder (ASD) present with little or no

functional speech (Lord & Bailey, 2002; Lord, Risi, &

Pickles, 2004)

Autistic disorder only: 50% of children are functionally non-verbal

No sufficient natural speech or writing to meet their daily communication needs (Light, Roberts, DiMarco, & Greiner,

1998) Candidates for intervention in augmentative and alternative communication

Other Developmental

Disabilities (DD)

Intellectual Disability: umbrella term for large

range of syndromes and conditions that result in

cognitive impairment

Commonly experience significant difficulty with spoken

communication

Many do not use speech as primary mode of

communication

High incidence of problem behavior

Cerebral Palsy

Unique motor control issues

Up to two thirds also experience intellectual disability

Proportion of Nonverbal

Children with DD

Prevalence of Intellectual Disability is between

1-3% worldwide (WHO, 2001)

ID may be largest proportion of school-age

individuals that require AAC supports

Up to 38% of preschool-age children with ID have

AAC needs (Beukelman & Mirenda, 2013)

AAC is crucial part of service delivery to this

population (National Joint Committee for the

Communication Needs of Persons with Severe

Disabilities, 2003)


2

AAC and Autism

AAC strategies particularly used in ASDs/DDs:

Manual signs and gestures

Pictographic symbols sets/systems

High technology speech generating devices (SGDs) for synthesized and/or digitized speech output

Practitioners face difficult task selecting a suitable approach

Evidence-based practice (EBP):

Using research outcomes as a major basis for clinical and educational decisions (Lloyd, 2001)

MANUAL SIGNS AND

GESTURES

Evidence-based Strategies in AAC

Manual Signs

Manual signs: unaided form of communication; unaided communication does not rely on any aids or devices external to the body and uses only body parts (Lloyd et al., 1997).

One of the first forms of AAC applied to non-speaking individuals with ASD; introduced in the 1970s and used successfully for more than 30 years

Can refer to a natural sign language (e.g., American Sign Language) or to production of manual signs as a code for a spoken language

By the mid-1980s, manual signing was often used in combination with speech, this approach was labeled as “total” or “simultaneous” communication (SC)

Manual Signs (cont.)

Gestures Manual Signs

Why Choose Manual Signs?

Easy to imitate (Sundberg, 1990)

Individuals with ASD may have difficulty controlling

vocal folds but display strengths with imitating

actions

Signs are less transient than words

(Fulwiler & Fouts, 1976)

Less frustrating to learn than vocal speech

May overcome negative history associated

with speech (Sundberg & Partington, 1998)

Manual Signs: Empirical

Evidence

Expressive signing 5 studies including 22 participants concentrated on

teaching manual signs and monitoring sign production as an outcome variable

Across experiments teaching manual signs “highly effective”

Simultaneous communication (SC):

Barrera, Lobato-Barrera, and Sulzer-Azaroff (1980)

taught one participant expressive language skills

using three different instructional methods:

Simultaneous communication superior to sign alone

and oral training


3


Evidence (cont.)

Expressive signing, simultaneous

communication:

Remington and Clarke (1983) compared simultaneous

communication versus sign alone training in two

participants: no difference

Saraydarian (1994), group study: 10 participants exposed

to training program that taught object referents in the form

of simultaneous communication, sign alone instruction

and oral instruction sign alone condition superior,

effect size g = 0.36 indicating moderate effect


Evidence (cont.)

Receptive speech:

Brady and Smouse (1978) compared effects of SC

(Effect Size = 100 %) vs. sign alone (ES = 50 %)

training on receptive speech in one participant.

Carr and Dores (1981) provided SC training to

three participants and measured their correct

responses on a receptive language discrimination

task: Effect sizes were 100 % for each one.


Evidence Summary

Summary: Both groups of experiments, expressive speech and

receptive speech, yield high outcome scores

Evidence suggests it is a viable communication option

Possible explanations for effectiveness: Better choice than vocalization because it is easier to

prompt an action than a vocalization (Sundberg, 1990)

Involves more iconic representation than spoken language (Sundberg)

Motor imitation is an easier behavior to teach because the teacher can make use of physical prompting and fading procedures (Sundberg & Partington, 1998)

Manual Signs Limitations

More and more research studies are revealing motor control problems in ASD Clumsiness

Poor muscle tone

Difficulty with fine and gross motor skills

Seen in about 80% of children with autism, but not part of diagnostic criteria

(Hilton et al., 2012; Isenhower et al., 2012)

Children with ASD often acquire only limited sign vocabulary and signs tend to be poorly articulated

Burden on communication partners: social environment may not be fluent in sign language

Manual Signs Limitations

(cont.)

Intelligibility:

Rotholz et al. (1989): two adolescents with autism were taught to order fast food interacting with staff unfamiliar to them 0-25% of manual sign requests were understood

80-100% of graphic symbol requests were understood

Manual Signs Conclusions

Future research implications: Lack of studies comparing manual signing or gestures

against an aided mode of communication such as graphic symbols More comparative efficacy studies are needed to clarify if learners with autism actually do better and/or have a preference for one communication modality over another

How to use manual signs as part of a multi-modal communication system consisting also of graphic symbols, communication boards, SGDs, and vocalizations (when available) need research into effective strategies for teaching the conditional use of manual signs


4

Gestures

Gestures: body movements or sequences of coordinated body movements to represent an object, idea, action, or relationship without the linguistic features of manual signs

Examples: pointing or yes-no headshakes

One of the earliest developing non-linguistic forms of unaided communication (Loncke & Bos, 1997)

Individuals with autism, however, rarely use gestures as an alternative communication strategy, even if they have difficulty speaking (Loveland, Landry, Hughes, Hall, & McEvoy, 1988)

Why Choose Gestures?

Use of gestures serves as a precursor to later development of language skills (Morford & Goldin-Meadow, 1992)

Gestural behavior also important for establishment and maintenance of social interaction and social reciprocity (Garfin & Lord, 1986; Koegel & Frea, 1993)

Appropriate for early AAC intervention to facilitate symbolic development

Motor demands not as much of an issue as with manual signs

Gestures:

Empirical Evidence

Two studies focused on teaching gestural

communication skills

Buffington, Krantz, McClannahan, and Poulson

(1998) taught gestures in combination with oral

speech, measured frequency of correctly

produced gestural and verbal responses: PND

scores of “highly effective” for all four participants

Carr and Kemp (1989) provided training in

communicative pointing (e.g., to obtain toy),

observed frequency pointing occurred: again PND

scores of “highly effective” for all four participants

Gestures: Empirical

Evidence Summary

Summary:

Appears to be very effective communication

option but limited amount of studies at this time

Compared to manual signs it seems that gestures

are underrepresented and not well researched in

this population

Surprising, because of its correlation with vocal use

and preceding speech development

More research needed to build up the empirical

support for gestural communication

Also need more comparative efficacy studies

EXCHANGE-BASED

GRAPHIC SYMBOL SETS


Picture Exchange

Communication System (PECS)

Structured behavioral intervention program to teach

use of visual-graphic symbols for communication

(Bondy & Frost, 1994)

Teaches to make requests by handing/ exchanging

symbols for desired items


5

Picture Exchange

Communication System (PECS)

Picture Exchange Communication System (PECS) protocol (Bondy & Frost,1994)

Phase I: Physical Exchange

Phase II: Expanding Spontaneity

Phase III: Picture Discrimination

Phase IV: Sentence Structure

Phase V: Responding to “What do you want?”

Phase VI: Responsive and Spontaneous Commenting

Why Choose PECS?

Requires very few prerequisites Only prerequisite individual can clearly indicate wants

and needs

First skill taught in PECS is requesting Often targeted in early instruction of individuals with

developmental disabilities due to motivational considerations (Reichle & Sigafoos, 1991)

Systematically targets spontaneous communication acts, a particular deficit in autism

PECS graphic symbols are highly iconic Can be easily recognized by the learner and are more

recognizable by communicative partners

PECS: Empirical Evidence

Systematic reviews (particularly meta-analyses) are

preferred evidence to document empirical support:

Preston and Carter (2009)

Increase in communication skills in most learners,

effects on problem behavior reduction and increasing

natural speech less clear

Hart and Banda (2010)

Increases in functional communication skills in all but

1 subject

Flippin, Reszka, and Watson (2010)

“Promising but not yet established evidence-based

intervention for facilitating communication in children

with ASD ages 1–11 years”

PECS Summary

Considerable empirical support for using PECS as a

beginning communication strategy

Overall shows strong effectiveness for teaching initial

requesting skills

Some evidence to indicate: more effective than

manual signing in terms of requesting

Effect is less clear for other outcome variables such as

speech production, social or challenging behavior

When treatment goals is speech production no

sufficient evidence to inform practice in favor of PECS

or manual signing

In general, mixed results on this outcome measure

PECS Summary (cont.)

Methodological issues in PECS studies

Often lack investigation of maintenance

Skill generalization sometimes reported, but what

counts as generalization varies greatly

Participant descriptions lack detail

Sparse reports of treatment integrity

PECS appears as a promising intervention

that presents with emerging empirical support,

but critical questions are still to be answered

SPEECH-GENERATING

DEVICES



6

Speech-Generating Devices

(SGDs)

LightWRITER BIGMack

Portable, computerized devices producing synthetic or digitized speech output when activated

Graphic symbols are used to represent messages, activated by finger, switch, head stick, etc., selecting a symbol from the display

SGDs (cont.)

SGDs (cont.)

Fixed Display

Graphic symbols

located in separate

squares of a grid,

organized into rows

and columns

Limited vocabulary

Dynamic Display

• Selection from a

display results in a new

array of graphic

symbols

• Larger vocabulary sets

SGDs (cont.)

Visual Scene Displays

• Language concepts are

embedded into contextual

scenes

• Objects and events within

the photograph are then

used as symbols for

communication

• May be used in a dynamic

display system

Not ideal for learners

with severe autism due

to sensory processing

difficulties

SGDs (cont.)

Example of a child with ASD using an SGD:

http://www.youtube.com/watch?v=s4GAX-

IXE_k&NR=1

Example of synthetic speech output:

http://www2.research.att.com/~ttsweb/tts/demo.ph

p#top

Why Choose SGDs?

Allows composing more detailed messages

Enable user to communicate very precise requests and

prevent communication breakdown

Voice output (aka speech output) may facilitate

acquisition and maintenance of communication

skills

Producing speech can be perceived as more

natural

Better intelligibility

Easier to get attention

Higher likelihood of receiving a listener response

http://www.youtube.com/watch?v=s4GAX-IXE_k&NR=1

http://www2.research.att.com/~ttsweb/tts/demo.php


7

Why Choose SGDs? (cont.)

iPads and other tablet devices are

Lightweight and portable

Cost-efficient compared to dedicated SGDs

Easy to program

Highly motivating to use

Socially appealing

(peer acceptance)

SGDs: Empirical Evidence

Ganz, J. B., Earles-Vollrath, T. L., Heath, A. K., Parker, R. I., Rispoli, M. J., & Duran, J. B. (2012). A meta-analysis of single case research studies onaided augmentative and alternative communicationsystems with individuals with autism spectrumdisorders. Journal of Autism and DevelopmentalDisorders, 42, 60-74.

Van der Meer, L. A. J., & Rispoli, M. (2010). Communication interventions involving speech-generating devices for children with autism: A review of the literature. Developmental Neurorehabilitation, 13, 294-306


Van der Meer, & Rispoli (2010), systematicreview: Found 23 studies with a total of 51 children aged 3-16

years

Positive outcomes reported for 86% of studies, mostcommonly targeting requesting skills

Potentially effective option for teaching communicationskills in ASD

Ganz et al. (2012), meta-analysis: Included 8 studies on SGDs, 9 studies on PECS, 7

other graphic symbols

Effect size estimates were 99% each for SGDs and PECS, 61% for others

SGD or PECS use yields significantly higher effects


(cont.)

Schlosser et al. (2009): “…SGDs represent a viable and effective AAC option for individuals with ASD”

Empirical evidence speaks a clear message, effectiveness of SGDs no longer a question

Wendt and Golinker (2012): “SGDs are one part of the standard of care to improve the functional communication and other outcomes for clients with ASD”

Important when applying for SGD fundingfrom insurance agencies!

MOVING FROM PECS TO

SPEECH-GENERATING

DEVICES


Research Questions

Practitioners/parents: after successful mastery of (initial) PECS

phases, can the child move on to a SGD? (Grether, 2007)

“…research into innovations to the PECS protocol is a

laudable direction and should be continued using rigorous

methodologies” (Schlosser & Wendt, 2008)

Project goals:

- Modify traditional PECS protocol for implementation and

transition to an SGD

- Evaluate the effects of such a modified PECS protocol on

increasing requesting skills, social-communicative behaviors,

and emerging speech

- Evaluate effectiveness of a particular device for such purpose

that is built upon PECS principles


8

Experimental Design Multiple Baseline Design across participants

(Baer, Wolf, & Risley, 1968)

Intervention phase split into PECS phases and SGD

phases, followed by maintenance phase

3 children, 9-11 yrs., severe autism and non-verbal

Dependent measures:

Requesting skills: number of correct requests during

20-trials session

Social-communicative behavior: number of responses

including eye contact, physical orientation towards

comm. partner, positive affect via smiling/laughter

Emerging speech: word vocalizations or word approx.

Materials and Setting

Traditional PECS book with PCS symbols for

desired items

Proxtalker -“sentence strip that actually speaks”:

picture card is put on ProxTalker display speak out the

symbol referent in form of prerecorded digitized speech

- several picture cards can be

combined to speak sentences

- symbols used were identical to

PECS symbols

Departmental Speech Clinic,

3 sessions per week

Modified PECS Protocol

(Preference Assessment)

Phase I: Physical Exchange

Phase II: Expanding Spontaneity

SGD Implementation

Phase III: Picture Discrimination

Phase IV: Sentence Structure

Phase V: Responding to “What do you want?”

Phase VI: Responsive and Spontaneous Commenting

(Original PECS protocol by Bondy & Frost, 1994)

Baseline Video Clip

PECS Phase I Video ClipEnd

PECS Phase II Video ClipEnd


9

ProxTalker Phase II Video ClipBeginning

ProxTalker Phase VEnd

SPEAK all! The purpose is to help teach the process of

constructing sentences

Customizable to each child’s specific needs

Allows the instructor to use recorded audio and custom

images

Seamlessly connects with PECS or ProxTalker intervention

Selection Area on top replaces

PECS book

Sentence Strip at bottom speaks

selected graphic symbols

“Shuffle button" randomly regroups

graphic symbols

DOWNLOADABLE ON ITUNES (free app)

Appstore>Education>Purdue>SPEAKall!

Autism Apps can be Noisy Places

for Those Who Cannot Process It

Moving from Mid-Technology (ProxTalker) to High-

Technology (iPad)

iPad Phase End

Effects on

Requesting

Skills


10

Effects on

Social-

Communi-

cative

Behavior

Effects on

Emerging

Speech

QEEG Brainmap of Neurotypical Individuals Participant on 6/18/11 Participant post-intervention 12/9/11

Further Research on SPEAK all!

Multiple Baseline Design across settings (Baer,

Wolf, & Risley, 1968)

Intervention repeated across clinic, home, and school

environments following PECS instructional phases

iPad with SPEAK all!® replaces ProxTalker,

intervention starts immediately with iPad

Dependent measures:

Requesting skills: number of correct requests during

20-trials session

Emerging speech: word vocalizations or word approx.

iPad and SPEAK all!Participant 3 - Baseline


11

iPad and SPEAK all!Participant 3 – Middle Stages

iPad and SPEAK all!Participant 3 – End

Participant 3 – Requesting

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 smbl

2+ smbl

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Clinic

School

Home

1 attr.

1 attr.

1 attr.

2 attr.

2 attr.

2 attr.

iPad fade out

iPad fade out

iPad fade out

iPad gone

iPad gone

iPad gone

speech only

speech only

speech only

Baseline Ph 3 Ph 4 Ph 5 Maintenance

Participant 3 - Speech

0

10

20

30

40

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

non-int

vocal

wd. appx

1 attr.

Clinic

School

0

10

20

30

40

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Home

2 attr.

1 attr.

2 attr.

1 attr.

2 attr.

iPad fade outiPad gone

speech only

iPad fade out

iPad gone

0

10

20

30

40

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

speech only

iPad fade out

iPad gonespeech only

Baseline MaintenancePh 3 Ph 4 Ph 5

iPad and SPEAK all!Participant 2 - Beginning

iPad and SPEAK all!Participant 2 – End


12

Participant 2 - Requesting

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

1 smbl

2+smbl

HomeHome

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Clinic

School

Baseline Ph 3 Ph 4 Ph 5

1 attr.

1 attr.

1 attr.

Maintenance

Participant 2 – Speech

0

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

0

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

0

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

non-int

vocal

wd. Appx

1 attr.

Home

School

Clinic

1 attr.

1 attr.

Baseline MaintenancePh 3 Ph 4 Ph 5

SPEAK all! Parent TrainingYoung Girl - Baseline

SPEAK all! Parent TrainingYoung Girl - Intervention

SPEAK all! Parent TrainingYoung Girl - Intervention

SPEAK all! Parent TrainingYoung Girl – Maintenance &

Generalization


13

Conclusions

Findings provide support that AAC can have

facilitative effect on natural speech development

There may be a particular role for shaping echolalic

utterances

Refute myth that AAC prevents speech

Confirm augmented input may enhance

expressive and receptive communication

development

Confirm PECS principles (behavioral) hold true

regardless of modality

Conclusions (cont.)

• All participants mastered iPad intervention, but

varied in ability to complete later protocol

phases; effects are replicable across settings

• Gains in speech production most notable for

echolalic child able to request in spoken

sentences after fading out iPad

• Other participants varied in effects on natural

speech production

• Pre-treatment speech skills and degree of

cognitive impairment likely moderator variables

Conclusions (cont.)

• Results underscore the potential of including parents for maximizing benefits of AAC intervention in autism

• Clinicians should recognize the value of joint parent-professional partnerships, and develop expertise for parent training

Acknowledgements Aforementioned projects were supported by

Project Development Team within the ICTSI

NIH/NCRR Grant Number RR025761

Technology Development Grant from the

Innovation and Commercialization Center –

Information Technology

Research Fellowship from Purdue Center for

Families

Purdue Research Foundation International Travel

Grant

Acknowledgements (cont.)

Thanks to ProxTalker.com, LLC for providing

devices!

Thanks to Purdue EPICS Team!

Thanks to the families who agreed to

participate in our research!

Acknowledgements (cont.)

Thanks to the following individuals for their

help with data collection and reliability

analyses:

Colleen Coleman

Zhihua Dong

Casey Hobbs

Kim LeCleir

Minghua Tan


14

Further Information on

SPEAK all! / SPEAK now! Apps

• Download on iTunes (free app)

Appstore>Education>Purdue>SPEAKall!

http://itunes.apple.com/gb/app/speakall!/id478863940?mt=8I

• Instructional Videos:

http://youtu.be/h2hWMQc8IUg

• Support Site:

http://epics.ecn.purdue.edu/ipaac/#speakall

Contact

Oliver Wendt, Ph.D.

Department of Speech, Language, and Hearing Sciences

HEAV 202D, Purdue University

West Lafayette, IN 47907-2038, USA

E-mail: [email protected]

Web: http://www.speakmod.com

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http://youtu.be/h2hWMQc8IUg

http://epics.ecn.purdue.edu/ipaac/#speakall


15

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Preston, D., & Carter, M. (2009). A review of the efficacy of the Picture

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16

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