Vol. 6, No. 2 March/April 1998	Previous Issues Subscribe to AT Messenger Download PDF Viewer
	PDF Version (for printing) Large Print Version (pdf) Text Version

Ask the AT Experts

This question was answered by Tracy Bombara, a speech/language pathologist with considerable augmentative communication expertise and the new AT Specialist at the Sussex ATRC.

Q: What prerequisite skills must an individual demonstrate in order to be a candidate for an AAC (augmentative & alternative communication) device?

The word "prerequisite" is defined by Webster's 21st Dictionary as "something required beforehand," and often becomes part of discussions relating to whether an AAC system should be implemented with a person who has difficulty communicating verbally. These discussions usually center around whether a person has the "prerequisite" cognitive and/or linguistic abilities to utilize a system that operates on some type of "code" such as pictures or symbols or words. The yardstick used to determine these prerequisite levels is often standardized language test results that report age equivalencies. And if a person's score is less than that of an average two year old, then conventional wisdom leads to the conclusion that the individual would not be able to adapt to using an AAC system.

Armed with the test result information, educated professionals frequently develop arguments that persons with congenital or acquired cognitive limitations may not have the required skills to be able to use an intermediary means to accomplish a function that so many of us take for granted: communication. So, as educated professionals, should we wait for them to demonstrate these skills, or should we try something else?

My answer to this question is grounded in the belief that the major "prerequisite" skill to use some type of AAC is the ability to breathe. My argument centers around the fact that newborn infants are able to communicate a variety of feelings and states, using very limited means of expression, and the adults in their world are able to respond appropriately in the majority of cases. My definition of AAC is "any means that allows a person to communicate more effectively," and is not limited to something that has a price tag above the $2,000 mark.

The primary skill that I look for when considering any type of AAC system is the ability to respond to some type of change in the environment, be it positively or negatively. If a person demonstrates this ability, the positive and negative responses can be used to identify initial vocabulary items. The form or forms that the "AAC system" takes on can be adapted to meet the functional needs of the individual, and do not necessarily have to be housed in a single device or picture board. The "code" used may include simple gestures, basic signs, objects, photographs, symbol drawings, or even sight words.

As educated professionals, we also need to pay attention to the function served by the form we introduce as AAC. Typically, when requests for vocabulary suggestions are made to families, care providers and staff, the top items on the list include "bathroom," favorite foods and drinks, and illness or discomfort. An AAC system should not simply be a tool to meet the needs of those who work with the individual, but also a means of increasing personal expression.

Assessment for AAC must include observation and information-gathering related to the individual's activities in settings that are both familiar and less familiar. The difference in responses to change will provide insight into a place to start for vocabulary development. Positive responses to change will give an indication of vocabulary that may be introduced for requesting or choice making. Negative responses to change may give ideas for teaching the ability to refuse in a more conventionally accepted manner than behavior outbursts.

Does my reasoning indicate that all persons who are non-speaking or who have difficulty communicating should categorically be able to use a communication board or a voice output system? The answer to that question is that I don't feel that any population group will categorically be able to use anything. Not all persons will respond to attempts to increase their communication through adapted means, but my experience has taught me that the cases in which it has not been successful have been complicated by other factors. The expectations of the persons who surround that individual and who provide the basis for communicative interaction must support the use of the aided system. Providing a picture book or an eye gaze system will not make a difference in a world where all needs are anticipated and met without a choice offered, or where the choice expressed has little consequence. It is unrealistic to expect that an individual who has had his or her needs met for a long period of time will suddenly see the value of any communication system and immediately use it without the support and encouragement of those in his or her environment. It is also unrealistic to expect that a few sessions each week with a speech/language pathologist will improve a person's ability to use a system functionally. While the speech/language pathologist is the "expert" on language and communication, he or she is only one member of a team that must be committed to making an AAC system an integral part of the user's life. AAC systems are tools, not cures for decreased verbal communication. Providing legitimate opportunities for use that result in positive outcomes for the individual will determine the success of system implementation.

Returning to the Question of the Month, my answer would be that if we are looking for defined prerequisite skills, we are missing the opportunity to start where the individual is now, and improve the communication skills he or she currently has.

I would encourage you to start simple, and look at the abilities that the individual presents. Use your powers of observation to come up with a plan, and keep the plan moving. A two picture system may be appropriate today, but probably won't be next month. Our own communication needs and skills change frequently, and so should those of our AAC users. Involve the entire "team" from the beginning, using as many natural support opportunities as you can identify. The individuals we work with will let us know when and where the journey should take us.