Why should special attention be

paid to the development of literacy

skills in AAC users?
AAC AND LITERACY 1. AAC users pose an interesting question concerning learning
DEVELOPMENT processes involved in learning to read and write.

■ How does the fact that someone does not speak influence the
understanding of phonics.

■ Do we need to learn to sound out words in order to read them?

Ghada Amin
2017 2

2. The development of literacy skills only fairly recently became a

focus in the intervention planning for AAC users. 3. AAC users may use literacy skills as compensatory and
supplemental strategies more often than non-AAC users.
■ All focus was only on face to face communicative interaction.

■ Hence, AAC users may have a greater interest in literacy.

■ Literacy was not in the focus or may not have been
considered a possibility. ■ If you can speak less, you may want to compensate by writing
more.

■ Research and intervention programs need to catch up and

provide effective literacy curricula for AAC users.

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Literacy and AAC use: an interesting
relation ■ E.g. children will learn that a spoken word consists of parts

In typical development: (sounds of spoken words and letters of the written word) and
that a longer word consists of more letters, referring to more
■ Language is acquired through interaction years before literacy
sounds (phonemes).
skills.

■ They will only start communicating in writing till the age of 6

■ Learning to read means the ability to reflect on spoken words
or 7 or even older.
and discover that they can be analysed as sequences of
sounds which can be represented as strings of letters.

■ Learning this skills requires the teaching of phonics.

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In AAC users: Identification of the skills employed

■ Children who are provided with an AAC device at an early age will by an AAC (graphic symbol) user in
encounter graphic symbols at an early age. communication

■ 2-3 year olds will learn to point to pictures to indicate what they ■ Teaching a child to indicate when he/she needs to use the
want.
bathroom involves (a graphic symbol+ a sentence “I need to
use the toilet” beneath it is placed on an SGD.
■ Does the provision of graphic symbols to young AAC users gives
them a developmental advantage regarding reading and writing?

■ Unfortunately, this is not the case, many AAC users demonstrate

delay in acquiring literacy.

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■ A child who is able to use this picture to indicate their need to Three abilities and levels of graphic
go to the toilet indicates that: symbol use
1. The ability to pay attention to specifics of a pictorial representation.
1- The child understood the basic principle of communication
(cause and effect).
2. The ability to understand the referential –pictorial meaning of

graphic symbol.
2- Could be the result of some sort of associative learning. (how
can you make sure that this is not the case?)
3. The ability to insert a pictorial representation in a meaningful way in a
sequence of actions

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The ability to pay attention to

specifics of a pictorial
representation
■ Infants are able to discriminate between objects and pictures
of objects as well as recognize familiar people and objects in
■ When do typical children start paying attention to pictures
photographs.
and their details?

■ These recognition skills are not sufficient for the complex use
■ Are objects with labels different in any way to a child than
required in picture communication.
objects with out labels?

■ Evidence suggest that children notice characteristics of

pictures in their second year of life.
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The ability to understand the The ability to insert a pictorial
referential –pictorial meaning of representation in a meaningful way in
graphic symbol a sequence of actions

■ Understanding a picture for a young child is not easy.
■ Children go through different stages before arriving at the
adult way in understanding a picture.
■ For example, 18 month old children do not get bothered if a
picture is presented upside down.
■ Within AAC the, he use of picture exchange is the best-known
practice to turn the graphic symbol into something that is part
of a real communicative act.
■ The graphic symbol is used as a communicative symbol that
gets you something accomplished through interaction.
■ It includes several stages:

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Can graphic symbols aid word

Stages of PECS
recognition through association

1. How to communicate. ■ When associating the graphic symbol with a printed word
2. Distance and persistence
underneath does the child learn the written word when using
3. Discrimination between symbols
the graphic symbol?
4. Using phrases
5. Answering a direct question
6. Commenting ■ Does printing a sentence underneath the word (e.g. I need the
toilet) help in promoting literacy skills?

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■ Will having the printed word underneath the graphic symbol
allow the user to pickup on principles of orthography?
■ No evidence supporting this hypothesis.
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Literacy activities and a literacy
curriculum for AAC users
Stages that a typical child goes through to establish literacy skills:
Pre-reading stage: unsystematic accumulation of understandings abut
reading between preschool and kindergarten (6months-6years)
Examples: pretending to read, names alphabet, retells story from pictures.
1- Initial reading or decoding stage (age 6-7).
Examples: able to read simple text containing high-frequency words, learns
relationship between letters and sounds and between printed and spoken
words, sounds out new one-syllable words, actual reading level is much
below the language that is understood when heard
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Are the graphic symbols a help
to literacy?
■ Are there specific graphic symbol systems that would allow
more literate preparation than others?
■ Blissymbolics contains a sub-lexical level that is somewhat
similar to the grapheme level of written words.
■ Does this allow the user to employ different strategies than if
a set of graphic symbols would be used?
■ Would the use of minspeak be beneficial for the acquisition of
reading and writing since it requires using a code or rule?
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2- Confirmation, fluency, ungluing from print, automaticity (age 7-8).
Examples:
Reads simple stories with increasing fluency, listening is still more
effective than reading.
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3- Reading for learning (age 9-13).
5- Construction and reconstruction stage (age 18+).
Examples:
■ Examples: reading is used for one's own needs and purposes,
May be responsible for reading independently to learn new ideas,
serves to integrate one's knowledge wit that of others to
gain new knowledge, experience new feelings and attitudes from create new knowledge, it is rapid and efficient, reading is
one viewpoint. more efficient than listening.

4- Multiple viewpoints (age 14-18)

Examples: reading widely from a broad range of complex

materials, able to deal with multiple viewpoints, reading

comprehension is better than listening comprehension

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Different challenges at different

stages
■ Are non speaking children at a disadvantage when it comes
■ Sturm et al., suggest activities with words that have minimal
to recognize sounds and sound patterns?
phonological or orthographic differences are displayed on one
■ Evidence suggests that they CAN perform at normal levels. page of a device and used in a variety of comparative

■ When planning a literacy intervention program for children exercises such as discovering spelling differences and

without functional speech, one needs to find alternatives for similarities instead of sounding out words.

oral analytical skills (i.e. sounding out words and listening to

how they contrast or how they are similar).

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Literacy activities as compensatory Expand the literacy needs.
AAC strategies
Reading and writing needs to become a high priority goal, hence
time and effort must dedicated to follow this (e.g. more pressure
Smith (2005) proposes 3 key goals for intervention for AAC users:
to use and depend on printed information and instructions).
a) Expand the literacy needs.

b) Maximize the opportunities.

c) Minimize barriers to learning.

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Maximize the opportunities.

“analysis of the daily routine and exploration of where additional Minimize barriers to learning.
or existing opportunities can be directed specifically to the needs
Ensuring that the individual can obtain maximum visual access to
of the target individual”.
print (e.g. large print).

In other words, encouraging parents to read more to their

children, suggest that teachers increase the number of literacy
based activities and for youths to provide appealing skills and
activities such as e-mail and text messaging.

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Measuring competencies What about writing?
■ It is a bigger challenge than reading for AAC users.
■ Reading assessment should aim at the following objectives:

■ The production of written text is often slow and poses heavy

1- Developing reading profiles indicating learning strengths
requirements on short term memory.
and weaknesses.

2- Establishing instructional objectives

■ Educators should not neglect this part.
3- Documenting reading growth overtime

■ A writing assessment needs to be conducted.

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■ It includes the evaluation of prewriting skills (e.g. organizing

the ideas to write about), knowledge of spelling rules, editing
and revising, etc.

AAC and intervention

■ Regardless of these challenges there is an impressive with acquired
number of AAC users who are amazing writers.
communication disorders

Ghada Amin

31
 Factors causing in increased
What are the types of
AAC use
1. Improvement of general knowledge about AAC among
acquired disorders that may
professionals. affect communication?
2. Advances in assistive technology  Aphasia

3. More availability and accessibility of AAC  Amyotrophic lateral sclerosis (ALS)

4. Decrease of resistance toward alternative forms of  Parkinson’s disease

communication
 Alzheimer’s disease
5. A growing number of AAC candidates as a result of
 Traumatic brain injury
extended life expectancy and improvements of
 Spinal cord injury
medical care services.
 Head and neck cancer
6. AAC for individuals in the later stages of the life span2 3

is obtaining an increasing importance.  Brainstem impairment (locked in syndrome)

What is the difference

between adults and children
when planning for an AAC?
 For adults it is a matter of finding ways to improve
functional interaction with partners and the social
environment (aiming for independence):
 Children’s need for AAC is often viewed in a
developmental perspective.  A focus on communication

 Pre-symbolic communicator  A focus on strategy

 Beginning communicator  A focus on the type of assistance

 Language based communicator

 Limited lexicon communicator

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 What is the linguistic nature
Nature of the condition of the disorder?
For example: Aphasia affects the internal linguistic system.

 Person will display a some combination of expressive and receptive

language problems.
Cognitive  Severe word finding difficulties

 Apraxia of speech

 And/or syntactic problems

Nature
of  Echolalia
condition
 Word perseveration

 Logorrhea

Motor Linguistic These points must be taken into account when finding AAC solutions. An
AAC that requires a person to construct linguistic messages may not work.
6 7

What is the motor nature of

the disorder?
Another example: ALS  Does the condition limit the range of motor

 Internal language is intact actions for a person?

 Speech and motor executive functions will be  Does this limit voluntary complex actions and

affected motor planning (e.g. Apraxia)?

 AAC solution will include SGD.  What are the alternative access modes (pointing,
touching, eye gaze, etc.) that remain possible and
can be brought under the person’s control?

8 9
What are the cognitive elements Other questions regarding the
affecting the disorder? condition?
 Loss of memory
 Emotional/ social factors
 Word memory limitations

 Word finding problems: a limitation of the internal mental  Progressive nature of the condition.
search function.

 AAC techniques can be of valuable help for individuals with

severe word finding problems.

 This can be done by associating the word with other modalities:

gestures, manual signs, graphic symbols, or SGD.

 Then the person can be taught techniques to self-activate his

neuro-motor patterns required for articulation for the word.
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What are the emotional/social What are the progressive

factors involved both with the characteristics involved?
client and his or her partners?
 One cannot underestimate the impact of a
 Determiners of success of intervention include: motivation, social
progressive disorder such as: multiple sclerosis,
support, and willingness to try and change a person’s condition.
Parkinson’s disease.

 If a new way of expressing a message is introduced then the

partners will need to learn new receptor strategies.
 Partners will need to adjust their expectations especially if they
have been used to the fact that the person has been not
12
communicating for so long.
 A balance is required between using the possibilities
to communicate that are still available and the need
to anticipate a time when less muscular power and
coordination will be possible.
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How natural speech will be
affected

 Aphasia (linguistic disorder)= word finding  AAC intervention for such cases requires a
+syntactic + linguistic comprehension problems. functional approach.

 Dementia: comprehension problems but not

limited to retention and retrieval linguistic
 AAC should improve the quality of life or open
information.
perspective for rehabilitation.
 Acquired motor disorders: limitations in executing
a motor plan due to loss of neuro-motor control.

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Acquired cognitive challenges Alzheimer’s disease

Dementia:
 Characterized by gradual deterioration of memory,
 Umbrella term
awareness, and cognitive functions.
 Includes a variety of causes and symptoms

 Refers to the drop of cognitive executive function.

 Affects people when they are in their sixties.
 Difficulties with the cognitive side of message
generating and understanding process.

 The most common form of dementia is Alzheimer’s

disease.
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Other types of dementia Training individuals with
dementia
 Vascular dementia: results from cerebrovascular
infarcts which causes sudden changes in memory
Keeping memory active through the use of:
and cognitive behaviour.
 Wallets/ books, visualized schedules, and electronic
 mixed dementia organizers.
 Fronto-temporal dementia These individuals can benefit from materials that are visible
 Dementia as part of Huntington’s disease and and tangible.
Parkinson’s disease.  Graphic symbols organized in schedules as reminder of the

 Although language is not the central problem of sequence of activities planned for the day.

dementia, some AAC techniques have been found  SGD can add an auditory component e.g. barcode reader
helpful. 18 for prespoken messages. 19

Acquired linguistic challenges

 SGD offer both visual and auditory reminders.
 SGD can also be used a step by step guide to
remember a sequence of activities.
Aphasiology: refers to the discipline that attempts
to describe and categorize conditions that result from
acquired brain lesions in brain areas that serve
linguistic functions.

 Mobile computing, tablets, and cell phone Aphasia:

technology is offering a range of possibilities.
Impairment of linguistic functions, however it often
How?
can occur with cognitive, motor, and/ or perceptual
difficulties.
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AAC for Aphasia Planning for intervention

Focuses on:  Determine type of communicator

1. Learning and training of new communication  Conduct a needs assessment

strategies by the client.
 Conduct a modality assessment
2. Learning and training of new communication  Conduct a role play
strategies by the client’s communicative partners.
 Topic and vocabulary inventory
3. Improvement of word finding.
 Autobiographical information
4. Help with message construction and narratives.
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Typology for aphasics

2. Controlled-situation communicators:
1. Basic-choice communicator:

 May function well if the information provided is

 Has profound cognitive-linguistic disorder across
modalities.
 May be able to respond to well structured
communicative messages (i.e. choosing between 2
options).
structured through repetition and visualization
(e.g. pen and paper, maps, pictures, objects) to
increase concentration of the interaction.

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 3. Comprehension communicators:

 Can activate speech and language but fail to apply 5. Specific-need communicators:
linguistic control to monitor their own speech
(e.g. production of involuntary irrelevant or
 Have developed reasonable skills that get them
incoherent speech segments).
throughout the day but struggle in specific
situations.
4. Augmented input communicators:  Yes- no questions can be used to solve these issues
 Find it hard to process language that is directed to or previously prepared communication cards.
them without support of additional information.
(key is multimodality)
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Acquired motor impairment Communication solutions for

Amyotrophic lateral sclerosis:
ALS
 Lack of nourishment of the muscles situated at the lateral part of the  Voice amplification
spinal cord leading to hardening of the spinal cord.
 Conversation repair strategies
 Affects upper and lower motor neurons.
 Alphabet supplementation
 Leads to degeneration and loss of motor control.
 Use of SGD (voice banking)
 Individual gradually lose natural speech.
 Current computer electronic measuring and
 Individuals potential to think, understand language, and internally use
recording of human speech acoustics has allowed
language remains intact.
for the creation of digitized speech that includes
 Individuals die within 10 years after onset. all the characteristics of the person’s original
28
voice. 29
 Brainstem dysfunction Locked in syndrome
 Damage to the central nervous system structures  Severe motor impairment in which an individual is
located in the brainstem affects the motor executive conscious but quadriplegic.
functions of speech to a profound extent.  Voluntary movement is limited to eye movements or
 Cause: brainstem stroke leading to disruption of blood eye blinking.
supply to the brainstem by the basilar artery.  Often caused by brainstem stroke but can be cause
 Symptoms: anarthria by severe TBI.

 Most individuals will require a form of AAC at least  Letter by letter partner assistive technique (blinking
initially. code+letter code)

 Most dramatic condition is locked in syndrome.

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Other acquired motor

disorders  Natural speech can be difficult depending on the

Spinal cord injury: level of damage due to the inability to regulate

subglottal air pressure required for natural
 Spinal cord is the gateway for information transfer
speech.
between body and brain as well as a center for neuronal
circuits that integrate and coordinate complex, motor,
and autonomic functions.
 AAC can include, partner dependent strategies
 When injured, body movements and sensations of the (yes/no questions) and devices to which a person
areas that are connected with the spinal cord below has accessibility.
where the injury has occurred become severely limited
or impossible.
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Traumatic brain injury
 Recovery: depends on degree and location of
injury, nature of intervention, cognitive and
linguistic levels of functioning.
 An alteration in brain function, or other evidence
of brain pathology caused by an external force.
 Could lead to permanent disability as well as
speech and communication limitations.
 Can be caused by: physical violence, traffic, or
other accidents.

 AAC can provide an important help in recovering,

 Can occur at all ages but highest prevalence improving, or establishing quality of life.
among late adolescents and early adulthood.
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Head and neck cancer AAC as therapy and

rehabilitation tool
 Cancers of the upper aerodigestive tract.
 AAC can be used as a form of direct communication or as a therapy
 Nasal cavity, pharynx, oral cavity, larynx.
tool.

 Give an example!
 Intervention:

surgical removal of parts of the anatomical structures

 Loncke et al., (2006):
(e.g. laryngectomy) which will severely impact natural
Please read page 145-146 for more information on the experiment.
speech production.

 AAC: esophageal speech, electrolarynx, and SGD. 36 37

Short-term and Long-term
goals
 Appropriate goals must be set.
 Aim should be at improving quality of life.
38
Effects of (partially) device
based strategies
 The use of computer based devices is an excellent
platform to create a wide range of therapeutic
lesson plans and exercises.
 Lingraphica: computer program designed to meet
the communication and language needs of people
suffering from aphasia.
40
Things to consider in planning intervention:
1. Role of the partners:
Partners will often be involved as much as the client
in therapy.
2. The interaction techniques and learning strategies
used to change the patterns of learning and
interaction:
i.e. visualization, use of questions, use of multiple
choice.
39
 Devices can play a role in making sure the clients
will effectively use the skills that have been
acquired in therapy in daily life.
 Please read experiment on page 147.
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Acceptability
 This is a crucial aspect.

 May be psychologically a hard step to take.

 Accepting AAC, learning to use the new ways of
communication and integrating it into a person’s daily
life, is often associated with an acceptance of the
functional status/condition in which a person sees
him/herself presently and in the future.
 Related to self-image, expectations, … etc.
 It is a symbol that the person will have to settle for
less.
 This is also challenging for communication partners and
loved ones as well.

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Self therapy

 An SGD may have the advantage of allowing self

training and has the following advantages:

 Consistent feedback

 Easiness to handle.

 Frequent self exposure.

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