Sparking Early ConnectionsHigh Tech AAC in Early

Intervention Teletherapy

Sarah Walker, M.A. CCC-SLP Maddie Reinlein, M.S. CCC-SLP

Sarah Walker, M.A. CCC-SLPDisclosures

Financial: Salaried full-time employee of Control Bionics

Non financial: No non financial disclosures to report

Maddie Reinlein, M.S. CCC-SLPDisclosures

Financial: Salaried full-time employee of Circle of Care Pediatric Home Health

Non financial: No non financial disclosures to report

Agenda

-Overview of of Early Intervention

-AAC in Early Intervention

-Teletherapy Techniques for High Tech AAC in Early Intervention

-Teletherapy + Parent Coaching

-Conclusion

Learning Objectives

1- At the end of this presentation, the learner will be able to correctly identify four roles of AAC in Early Intervention.

2- At the end of this presentation, the learner will be able to accurately discuss at least two key points regarding use of high tech AAC with the Early Intervention population.

3- At the end of this presentation, the learner will be able to identify at least 4 AAC teletherapy strategies to utilize with the Early Intervention population.

Overview of Early Intervention

What is Early Intervention?● Therapy for children ages birth to 3 and their families● Critical to the development of at-risk children and a federal mandate for

those who qualify in every state● Addresses the following areas:

○ Communication skills ○ Cognitive skills ○ Gross Motor skills ○ Fine Motor skills○ Social-Emotional skills ○ Self-Help skills ○ Oral motor skills

● SLP Role: cognitive skills, communication, sensory skills, social-emotional/play skills, and adaptive/self-help skills, such as feeding and swallowing and oral motor skills.

AAC in Early Intervention

What is AAC?• ASHA defines augmentative and alternative communication (AAC) as an area of clinical practice that addresses the needs of individuals with significant and complex communication disorders characterized by impairments in speech-language production and/or comprehension, including spoken and written modes of communication• AAC uses a variety of techniques and tools – including picture communication boards, line drawings, speech-generating devices (SGDs), tangible objects, manual signs, and gestures– to help the individual express thoughts, wants and needs, feelings, and ideas• AAC is augmentative when used to supplement existing speech, and alternative when used in place of speech that is absent or not functional• AAC may be temporary, as when used by patients postoperatively in intensive care, or permanent, as when used by an individual who will require the use of some form of AAC throughout their lifetime

AAC in Early Intervention: Myths● AAC is a “last resort” in speech-language intervention.● AAC hinders or stops further speech development.● Children must have a certain set of skills and intact cognition to be able to

benefit from AAC● Children have to be a certain age to be able to benefit from AAC● There is a representational hierarchy of symbols from objects to written

words (traditional orthography)

Research Findings● AAC should be introduced as soon as it is apparent that a child’s

communication is difficult to understand or interpret. There is no evidence AAC will impede a child’s ability to be verbal in the future

● It is better to strengthen the communication intent, rather than waiting for failure

● Children with cognitive deficits can use AAC, and AAC can be critical in cognitive gains

● There is no minimum age for AAC ● It does not matter if a child uses abstract symbols or icons because they

all function the same to the child

Lack of AAC in Early Intervention● AAC is underused in early intervention● 2006 study (Dugan, et al.,2006)

○ Early-intervention providers focused on teaching “skill development” (such as vocalizing or signing) with 12-24 month age group

■ Did not introduce any low tech or high tech AAC○ When working with toddlers over 2 years

■ More than a third of providers focused on skill development■ 55% low-tech devices ■ 8% high-tech devices

● 2014 study (Hustad et al.,2014)

○ 2-year-olds with CP were less likely to use AAC than were children who were non-verbal■ bias against using AAC with children who have any speech, regardless of intelligiblity

4 Key Roles of AAC in Early Intervention

1. Augmenting existing natural speech2. Providing a primary output mode for communication3. Providing an input and output mode for language and communication4. Serving as a language intervention strategy

● Depending on the child’s needs, abilities and diagnosis, these roles will look differently with each case

○ Example: CP case scenario vs ASD case scenario

High-Tech AAC in Early Intervention● AAC devices must be customized to the individual needs of the infant or

toddler. High tech devices provide many options for customization and can “grow” with the patient vs. low tech options

● For infants and toddlers with complex communication needs, AAC devices and strategies are tools to help develop communication, language, literacy, play and cognitive abilities

○ Flexible AAC■ Evolving communication grid systems

● SuperCore Learning● SnapCore First

■ Multimodal Access● Access needs may change throughout course of development

Teletherapy Techniques for High Tech AAC in Early Intervention

Why do children communicate?Behavior Regulation Joint Attention• Requesting objects • Commenting• Requesting actions • Requesting information (asking questions)• Protesting • Answering questions

• Initiating or maintaining a topic• Clarification

Social Interaction• Requesting social routines• Showing off/telling jokes• Greeting/closing• Calling• Telling/retelling stories• Acknowledgement• Requesting permission (Wetherby et al.,1988)

How to introduce high-tech AAC in the birth-3 population1. Identify Environments• Identify where SGD will be used• Introduce during familiar routines that provide opportunities for frequent communicative attempts (e.g., circle time, snack, recreation, community)• Need to be generally positive opportunities• Allow child to use multiple communication modes (e.g., speaking, gestures, signing) in addition to SGD• Elicit natural response from communication partner

2. Engineer the Environment• Create communication opportunities thoughtfully and deliberately• Identify what is motivating to the child• Raise expectations• Situation should require AAC user to communicate to participate in an activity, find an object, or correct a problem (“environmental sabotage”)

(Soto & Zangari, 2009)

How to introduce high-tech AAC in the birth-3 population3. Identify Vocabulary• Need vocabulary appropriate for the child and environment• Teach core words while supporting activity-specific and environment-based vocabulary• Words and phrases are age and developmentally appropriate• Words and phrases are meaningful and motivating to child• Words and phrases serve an identifiable communicative function (e.g., requesting, greeting, protesting, commenting, asking)

4. Model! Model! Model!• Identify and train potential communication partners• Remember to use peers• Develop competence with your high-tech communication system• Copy pages and make low-tech book to use when high-tech device is not available or not working properly

(Soto & Zangari, 2009)

Core vs Fringe Vocabulary● Core- make up 80% of what we say from a bank of 400-500 words

○ Highly functional and/or common words and phrases (e.g., me/you, want, stop, more)○ Items related to basic needs or short social messages (e.g., help, no, hi/bye)

● Fringe- make up 20% of what we say from a bank of thousands of words○ Words are specific to the content of a lesson or activity or related to a specific topic○ May be specific to particular individuals

Children birth-3 are Emergent Communicators• No reliable method of symbolic expression yet• Uses facial expressions, body language, gestures, vocalizations, or other nonsymbolic modes of communication• Need simple concrete pictures• Need to be very motivating• Core word examples: more, stop, go, help, I, you, eat, drink

Grid Size and Layout● Many people struggle with this step as each individual’s needs and abilities are different● We often underestimate a user’s potential● AAC users don't need to prove themselves by first showing they can use a few buttons per page● The real power of AAC is being able to expand language and communication● Fewer buttons = fewer communication opportunities● If you start with a smaller grid size and gradually increase, button locations will change. Each

time we change the grid size, the child will need to re-learn where the words are● In most cases, it is best to start with a larger grid size and “hide” buttons rather than start with a

smaller grid size● Hiding buttons allows you to slowly introduce new vocabulary and pathways, while building

muscle memory and motor planning skills of existing vocabulary● Pairing a consistent motor movement with consistent auditory feedback and a natural response

while using a high-tech device is what develops effective communication skills

Proloquo- 45 button page set, reduced to 9 buttons by ‘hiding’

Cause and Effect● AAC can be used to teach cause and effect as well as communication at

the same time○ Child presses Cheerio button, receives Cheerio○ Child presses Baby Shark button, hears Baby Shark song

● Be consistent with outcomes● Teletherapy Cause and Effect Strategies

○ Green Screen Games○ Pause and Play Music/Videos○ Book Reading with Symbols

Remote Editing● Several communication systems have a remote editing feature● This can be very helpful for SLPs who are unable to see their patients in

person at this time● SLPs can create custom grids for activities that will be used in teletherapy

each week● SLPs can also create a few starter grids while parents are still learning

how to use the device

Make it Motivating!● Allow room for exploring and learning● Meaningful interactions are the most motivating● Take time to determine what they want to communicate● Use photos of family, pets, friends, favorite toys● Use in natural contexts throughout the day ● Model, model, model● Caregiver/Parent coaching/carryover is crucial

Teletherapy + Parent Coaching

Coaching is Crucial in Teletherapy● Parents/families/caregivers are an essential part of any therapy team● While teletherapy is nothing new to our field, COVID-19 has brought it to

the forefront of service delivery options● Now more than ever, parent coaching is a key component of successful

early intervention, especially with high-tech AAC● It is important for families to take ownership of the AAC device and feel

comfortable in their role in facilitating therapy at home under the guidance of an SLP

Create a Communication Environment● Set up your environment to set up your child for success● Set up cause/effect situations● Create grids that match social routines, books, play schemes● Allow child to make their own selections and acknowledge selections,

even if you think the child made an error● Aided Language Modeling

○ multiple communication modes: talking, signing and pointing to photos on an AAC device while interacting in fun and meaningful ways with children

Narrating Play and Modeling Key Words● Self Talk- Talk about what YOU are doing● Parallel Talk- Talk about what your CHILD is doing● Model key words on the AAC device while narrating● No Expectations and no pressure

“Wow, you are building a big block tower! Yay, you found a blue block! That block is small. You put the blue block on top of the tower. Your tower is getting so tall! Oh no, you knocked over the block tower! All the

blocks fell down. Thank you for cleaning up the blocks”

8 exposures to fringe word “block”

“Wow, you are building a big block tower! Yay, you found a blue block! That block is small. You put the blue block on top of the tower. Your tower is getting so tall! Oh no, you knocked over the block tower! All the

blocks fell down. Thank you for cleaning up the blocks.”

12 exposures to core words

Repeat, Repeat, Repeat● Repetition is okay and even encouraged!● The more exposure your child has to a word, the more likely that they will

develop an understanding of the word and add it to their vocabulary● If you are playing with bubbles, you might feel like a broken record saying and

modeling “bubble” each and every time you blow a bubble, but it’s so helpful for your child.

● For example: “Oh look, bubble! Pop the bubble! Wow bubble! Big bubble. Little bubble. Bye bye bubble!” Even with one round of blowing bubbles through the wand, that maybe lasts 30 seconds, you could squeeze at least 3 repetitions of the word “bubble” in. If you play bubbles for just 5 minutes, your little one could have the word “bubble” modeled 30 times!

Eliminate Distractions● Manipulate your physical environment to eliminate distractions as much

as possible and create more opportunities for focus on communication.○ Phone, tv, computer, toys within reach, background noise

● Remember, this doesn’t only mean distractions for your child, but also

distractions for YOU!

● Set aside time each day to eliminate distractions, sit with your child face-to-face, and communicate

Stop Anticipating, Start Expectant Waiting● Anticipating your child’s every need does not leave much room for

communication● Don’t be afraid to wait!● Expectant waiting is a research based technique that encourages little

ones to communicate by letting them know that it’s their turn and that a response is expected1. WAIT! Pause and give your child time to respond2. Create motivation by waiting expectantly3. Guide a response4. Model

Communication Temptations● A communication temptation is purposely creating a communication

opportunity for your child that is highly motivating or rewarding. ● When a child is motivated to communicate in a positive environment,

it greatly increases the likelihood that they will do it again.● Use environmental ‘sabotage’

Natural Conversation Model● In natural conversation there is a balance of comments, opinions,

questions, and answers● No one can hold an enjoyable conversation by only asking questions● Never want to “quiz”● 3:1 ratio rule of comments and modeling to asking questions

Comments Question

1. I found a shopping cart 1. What color is the banana?2. We need to buy bananas3. These bananas look so yummy

Communication Frustration● Frustration will happen- when you don’t yet have all the skills needed to successfully

communicate what you are thinking or feeling, it’s hard!● Frustration vs Failure- A little frustration is okay and cannot be completely avoided,

but we never want to make a child feel like they are failing○ Failure: Withholding your child’s juice box until they select the word “juice”, even though ‘juice’ is a

new vocabulary word and they have never used it independently before. Your child points and cries to no avail, and the juice box is left on the counter. Your child feels upset and defeated.

○ Frustration: Withholding your child’s juice box instead of immediately giving it to them when they point. Your child gets frustrated and starts to whine. You say “oh, it looks like you want juice” while modeling “juice” on the device. Your child imitates you by selecting “juice” , and you hand over the juice box. Feelings of pride replace the frustration because their effort was rewarded

● Maintain a fun, optimistic attitude● Place reasonable expectations● Wait, but then model as needed● Reward any effort, even if it’s not perfect

Consistent Expectations● The communication expectations for your child should remain the same

across all environments, all situations, all people, at all times of day

● In order to be successful, your child needs to know what is consistently expected of them at all times. This provides equal opportunity for communication each and every time

Resources for Parents and SLPs

● Local AAC company representatives● https://praacticalaac.org● https://www.speechandlanguagekids.com/aacpage/ ● Green Screen Speech Therapy (Distance Learning) Facebook Group● https://www.playsparktoys.com/ ● https://www.teacherspayteachers.com/

Conclusion

-What is Early Intervention

-What is AAC

- Introducing AAC in Early Intervention

-Teletherapy Techniques for High Tech AAC in Early Intervention

-Teletherapy + Parent Coaching Strategies

ReferencesAlant, Erna. (2017). Augmentative and alternative communication: Engagement and participation. San Diego: Plural Publishing

AssistiveWare (2020). Choosing an AAC Grid Size. www.assistiveware.com

Branson, Diane., & Demchak, Maryann Branson, (2009) The Use of Augmentative and Alternative Communication Methods with Infants and Toddlers with Disabilities: A Research Review, Augmentative and Alternative Communication, 25:4, 274-286, DOI: 10.3109/07434610903384529

Davidsoff, Beth. AAC with Energy. ASHA Leader: January 2017- Volume 1.

Dugan LM, Campbell PH, Wilcox MJ. Making Decisions About Assistive Technology With Infants and Toddlers. Topics in Early Childhood Special Education. 2006;26(1):25-32. doi:10.1177/02711214060260010301 Robinson, N. B., & Solomon-Rice, P. L. (2009), Supporting collaborative teams and families inAAC. In G. Soto & C. Zangari (Eds.), Practically speaking: Language, literacy, and academicdevelopment for students with AAC needs (pp. 289–312). Baltimore: Paul H. BrookesPublishing.

Romski, MaryAnn PhD, CCC-SLP; Sevcik, Rose A. PhD Augmentative Communication and Early Intervention: Myths and Realities, Infants & Young Children: July-September 2005 - Volume 18 - Issue 3 - p 174-185

Wetherby, A., Cain, D., Yonklas, D., & Walker, V. (1988). Analysis of intentional communicationof normal children from the prelinguistic to the multiword stage. Journal of Speech, Language,and Hearing Research, 31, 240–252.

Thank You!