Alternative Augmentative Communication (AAC)

An incite into Alternative Augmentative Communication (AAC) and how children use it.

Alternative Augmentative Communication (AAC) is anything we use to help a child represent themselves that isn’t speech. For some children it is necessary in the early years to put something in place that supports them to communicate. AAC supports their communication while speech is coming. Some people can be quite resistant to this idea as they think it might make their child lazy, delay their speech, or prevent them ever talking.

However, research shows that AAC supports talking. It doesn’t replace it. It is very important that children believe themselves to be successful communicators. They need to build their self-esteem by knowing that their communication attempts work. If their talking is very unclear, or they are struggling to learn words it can knock their self-esteem, it can contribute to behavioural difficulties or just make them ‘opt out’ and not want to communicate. By putting AAC in place we support the child to be, and importantly view themselves as, a successful communicator.

Why use AAC?

Language develops through the connection of neural pathways in the brain. The child looks at their dog and you say ‘dog’. Neurons get connected and they learn the words. For some children this happens quickly, while others need lots of repetition to make this happen. If we add visuals into this, it makes learning easier, it is easier to understand. Visual support helps children to learn new words and express themselves. These 2 reasons alone are sufficient to merit putting AAC in place to support your child’s learning and language development when they are young. We often take a ‘watch and see’ approach because we think they might be talking soon or it seems that if we put something alternative in place it’s because we don’t think they will be talking soon. This isn’t the case, it’s just a way of scaffolding or supporting your child to become a successful communicator. If you have a child who is showing frustration because their interaction skills are developing but they can’t express themselves it’s really important to think about ways to help them communicate early on.

Words are symbols.

When we look at a dog and we say the word ‘dog’, those letters, and sounds, and the way we say them, are simply a symbol to represent the object, the dog. Children’s language development relies on children understanding that one thing can represent another. Children go through stages of ‘symbolic’ development so really it’s important not to rush ahead with this.

Visuals (objects, photographs, pictures and line drawings)

You start with objects as they are the easiest representation. If your child isn’t understanding or using any language, using symbols to represent what is going to happen ‘next’ will help them to develop symbolic understanding. Before its time for the bath, you could show your child a bath toy, say a duck, and that duck represents the action of the bath that’s going to happen. They realise that if they see the duck the next thing that will happen is a bath. Or before dinner time, you could show them their bib or cup, or before a trip to the park, their wellies. Choose a closely related object that your child is going to put together with the action and show it just before hand. This is called ‘objective reference’. It teaches the child what to anticipate next. Once the child is recognising objects as indicators of what is going to happen next, you can progress to using photographs of what’s going to happen. You might take pictures of things that the child likes to eat in the fridge so rather than standing at the fridge making sounds the child can chose what they want. If they want milk, they point to the photograph of the milk and you give it to them. You are giving them a step to communicate the message. It is a move on from an ‘ahh ahh ‘and a point. Some children can then move on to symbols. It could be a line or colour drawing. Our world is full of symbols. We use them all the time because we quickly understand visuals. Think about driving down the road and all the symbols that you see and how much information they give you. Symbols are very much part of our life and we just want to use those symbols to support language. Children can be given all the words they would want to use in the representation of a symbol, so they can point to them to make choices of, what they want to drink, or eat, or do, or express their emotions, and all the time you are reinforcing the word by saying it when they point to it.

Natural gestures or signing

Another type of AAC, these can also be used to help get our child’s attention and help them to learn new words and concepts. Starting signing early on is really beneficial. There doesn’t need to be any expectation that the child is going to sign back to you. Instead it is just being used a as a way of supporting those essential neural connections.

PECS (Picture Exchange Communication System)

PECS is a way of children learning to use an exchange to get what they want. It’s a means of helping them learn to request. Before children are able to request they often respond to their hunger by whinging, and mum interprets that, but the child is not actually thinking ‘I’m going to tell my mum I want a drink’, they’re just responding to how they feel. The next stage is they might know that mum is the vehicle to get that drink so they take mums hand and pull her towards the fridge but they don’t do anything more to send the message of what they want. The next stage is to send a message, at first without words, they look at the fridge, they look at mum, they look back at the fridge they’re telling mum ‘I want something out of the fridge’. Even though there are no words used they have sent that message. Then the first words come in and they will look at mum and say ‘milk’. Communication slowly builds up.

PECS intervenes at the level where the child is pulling mum along to the fridge and waiting for milk to appear because ‘if mum is by the fridge I’ll get milk’. PECS puts in another level. If I give you the word milk, I send you that symbol that tells you I want milk. I gave you the word and you give me the milk. But these children who pull you along and stand you in front of the fridge aren’t at that stage of knowing to ask you yet. PECS gives them a symbol, a piece of card, with a picture, or a photograph on it, a symbolic token that they have to give you to get the milk. They are replacing the word milk with the picture. It’s not really about the picture in the early stage it’s about knowing that I have to give my mum something to get the milk, it’s not enough to just stand in front of the fridge because it could be cheese or yoghurt I want. They learn that standing my mum in front of the fridge isn’t getting their message across. They need to do more than that. They need to take the picture and hand it over. It teaches them that an exchange is required. PECS is a structured, stage-based programme which helps children learn to make phrases and sentences about what they see, and observe, and like. It builds up very slowly. PECS is not for children who’ve got that exchange, they’ve got that interaction, they know they need to say something but they just haven’t got the words, or they can’t form the words, or they are too unclear to be understood. For them you would just use symbols in a book. We don’t need to teach these children that exchange, we need to give them the means to tell us what they want as they aren’t able to do that just yet.

Pod book

A pod book is another AAC. It’s worth looking for a family on u-tube called ‘we speak pod’. They have adopted children and they all use pod books. A pod book is a big, thick book, you can probably buy it made or make it through the programme and it has all the symbols your child will ever need in it, in categorised format. It doesn’t follow English word order. It is does it in a slightly different way, so you may select I have something to say, and then you go to the next page and select categories. With each choice, you are refining your message and getting closer and closer to the thing that you want. The idea is it’s like the vocabulary all around children and they find their own pathways through it. This is the benefit of a pod book. It contains all the words any child will ever need. One of the difficult things with using a symbol book is keeping up with producing symbols that are useful for your child as you have to be constantly on top of their developing needs and thinking about ‘what they will need tomorrow’ . The other difference with using a pod book is that you teach it in the way you teach language. So mum, or dad, or grandma would demonstrate how they would send their message and the child would watch them and once confident they can start to use it themselves.

A child who isn’t speaking may be able to use a pod book to produce sentences. Speech, the formation of words and the talking, is separate to language. Language is the concepts, the word knowledge, knowing that words represent objects. Speech is the means to put that together and get it out. When children are not developing their talking it is difficult to know if the concepts are growing in their head. Are they beginning to make all these symbolic representations? Is it just the talking that’s not going well or is it the language and the talking? So a child who isn’t talking but who is able to link 3 word concepts in her head, as their language development is progressing, could use a pod book as a means to get that out.

Electronic devices

i-Pads or communication aids can have symbols imported into an electronic device for children to be able to see, and use, to express words and sentences. This too can be considered. Computer systems can hold categorised, banks of words and a child can open ‘the food page’ or ‘the activities page’ or ‘people page’, with one press they can open a page and make a selection for example the type of food they want.

Incredibly, technological advances have enabled children who have all the concepts in their head but aren’t able to talk, or move their hands well enough to use standard communication aids to use eye gaze technology. These children, whose physical barriers would previously have been impossible to overcome, can now learn to spell, write and access the internet by using eye pointing. Technology has moved forward to such an extent that most children can now communicate at a level that fulfils their potential.

Which to choose?

You can see how symbols can be used in different ways. There are advantages and disadvantages to all these systems and while it’s important to think about which type of AAC will suit your child, using a mixture of approaches can be beneficial. If you think about having to remember something really important the more ways you remind yourself the less likely you are to forget, you might put an alarm on your phone, and put a sticky note on the fridge. Adding lots of visuals is never a bad thing. It’s something we, as adults, do naturally to help ourselves. It’s really important to give our children the same support. It’s how we learn so it stands to reason it’s how they learn. Give your child all these opportunities; don't think ‘should I learn sign language’ or should I use ‘symbols’. It’s absolutely fine to use both.

Signing has advantages, its quick, it’s there, you’d don’t have to look for it, or print it off, you can just use your hands but the disadvantage is that not everyone your child meets will understand it. Symbols on the other hand are difficult to produce, difficult to carry around, it is challenging to keep symbols relevant but the symbols are universal, anyone can look at them and understand them.

Whichever methods you choose, always use the words with them, this is not about replacing the words. Words are the priority! It is about scaffolding the words. You are saying the words over and over again alongside the visuals to make it easier for the child to learn them. The best environment for learning language is a ‘total communication environment’. By using multiple support strategies, we provide an environment that supports our child’s talking all the time, as we go about our everyday lives.

It has to be as easy as possible for them to communicate, it’s all about using whatever means we have to enable them to be successful communicators even if we’re working on the very early stages of getting the ‘to’ and ‘fro’ of language exchange. It’s about creating success however we do that. Ease of use is particularly important to think about for children with physical difficulties. It takes work on behalf of us as adults to break things down and look at the smaller detail but by doing so, you are creating an environment where your child can communicate successfully. That is everything.

That’s not to say all children will be articulate but we can help them not to be stuck in their heads, not be frustrated, and to make those social connections, and express choices and emotions, by being tuned in and creating an environment that allows them to do so. That is the most important thing for us as adults to be doing.