Updated: May 12, 2021
A research report debunked six myths that prevented infants, toddlers and preschoolers from getting augmentative and alternative communication (AAC) systems. Fifteen years later, children are still being denied communication systems because of these myths.
AAC systems help a child communicate when speech is not developing as expected. The myth-busting article (Romski & Sevcik, 2005) was published in the journal Infants and Young Children. Sadly, the authors' call for making research-based decisions when deciding who should be taught to use AAC fell on many deaf ears. Much more research has been published since then, but the myths persist.
AAC is any system other than speech that helps your child express themself, either along with speech or without speech. It can be a system like baby sign language, pointing to pictures or an app that speaks words. Find out more about AAC here.
Today’s post is a summary of what we STILL know about these myths.
SHOULD AAC BE THE LAST RESORT?
Back when I started learning about AAC, the field was in its infancy. Big, clunky speech-generating devices were just starting to be developed. We had a special guest speaker who came to one of my graduate classes to show videotapes of an adult with Down syndrome whose behavior improved after he was taught to use sign language. It was all very cutting edge.
Since it was a new area of practice, recommendations were based on what people thought made sense at the time. For example, researchers at UW-Madison (Miller and Chapman, 1980) recommended that AAC should be considered when speech has not developed by age 8. It was the last resort after all else had failed.
Forty years of experience and research has shown that this “common sense” approach does not make much sense. “In fact,” Romski and Sevcik state, “it is critical that AAC be introduced before communication failure occurs.”
From their earliest interactions, children need to learn how to be effective communicators—both as listeners and speakers. They have ideas they want and need to express. If their efforts are unsuccessful, they lose interest in communication. Without a mode of expression, they don’t get any practice in using words and forming sentences. That delays their language and thinking skills.
If you’ve listened to The Interaction Coach podcast, you’ve heard how children’s language builds through their daily interactions with others. They need to take turns in conversations and use their language for a variety of reasons to get the practice they need for moving on to each level of communication development.
RECOMMENDATION: Introduce AAC at any age when expressive language is delayed or at risk of delay.
DOES USING AAC INTERFERE WITH SPEECH DEVELOPMENT?
The most common misconception about AAC is that a child will become dependent on that mode and lose motivation to use speech. This is another one of those “common sense” assumptions that is not supported by the past 50 years of research and usage.
The opposite is actually true. Recent guidelines from the American Academy of Pediatrics said this about their review of the research: “The use of AAC may help promote social interaction and understanding of the purpose of communication and does not delay onset of speech. Indeed, it may enhance emergence of spoken words by pairing nonverbal and verbal communication.”
Many families teach their child sign language as an early communication tool before their child starts to say words or when their speech is hard to understand. Using signs has been shown to help keep a child’s vocabulary growing at an expected rate. The signs are an effective way to encourage meaningful expression of ideas. As speech emerges or becomes easier to understand, the use of signs fades away.
Using AAC does not mean we quit working on spoken language. Both modes can be developed at the same time. They both require lots of modeling from adults so children learn how and when to use them.
RECOMMENDATION: Use AAC to support the development of communication skills, including speech.
WHEN IS A CHILD READY TO USE AAC?
Another old, common-sense assumption was that children need to reach a certain level of development before they are ready to learn AAC. This was based on the practice of using typical language milestones as a guide to what for target in therapy.
Typical development is a handy reference, but it can’t be our only guide. We must always keep in mind that a challenge in one domain of development has effects in other domains. We can’t assume children don’t have the ability to learn something if we don’t provide them with opportunities to practice skills that are affected by challenges in a domain like vision, hearing or movement.
In The Interaction Coach podcast, I’ve organized milestones that are expected at eight levels of communication development. I put both cognitive and motor skills into the category of Play Skills. That organization emphasizes how both of these domains interact and build each other.
Many examples in the podcast point out how a child’s play and exploration help them develop cognitive skills like object permanent and cause-and-effect. Those cognitive skills help to build language skills.
A child with motor or sensory challenges may not demonstrate the expected level of these cognitive skills. That doesn’t mean the child can’t use these skills when we give them the proper supports and practice.
Likewise, using language helps to develop cognitive skills. If we don’t allow a child to build their expressive communication, we are also slowing their cognitive growth.
We definitely can’t assume that a child with no consistent way to communicate does not have a certain level of cognitive development. How are they supposed to show us what they are thinking?
Sometimes it’s assumed a child must have certain motor or sensory skills before using AAC. For example, they may be expected to point with their index finger or have a certain level of vision. There are, however, a wide range of adaptations available that allow AAC to be used by persons with limited movement or sensory abilities. Part of a comprehensive AAC evaluation by a speech-langue pathologist involves assessing all the child’s abilities and matching them with the features needed in an AAC system. Physical and occupational therapists are able to come up with adaptations for all kinds of movement challenges. Requiring a child to demonstrate a certain level of competence before they are introduced to AAC is a harmful assumption because it delays children’s language, social and cognitive development.
RECOMMENDATION: Do not limit a child’s access to AAC based on any level of “readiness” skills.
WHAT IQ DOES A CHILD NEED FOR USING A SPEECH-GENERATING DEVICE?
A speech generating device (SGD) is an electronic device that gives speech output when the user pushes a button or types a word. Devices usually have a screen, buttons or keyboard where the user enters what they want to say, then the machine says the word or sentence. Some SGDs are called dedicated devices because their only purpose is for communication. There are also iPad apps for SGD, and there is a text-to-speech function available on Mac, Windows, iPhone and Android platforms.
Steven Hawking may be the most famous SGD user. Comedian Lee Ridley, known as Lost Voice Guy on Britain’s Got Talent, is another well-known user (see video below).
In the early days of AAC, SGDs were only recommended for children with an average cognitive (IQ) level. First of all, the high cost of the devices led to a belief that only children who could “benefit the most”—whatever that means—should use them. I would not want to be in a position to say how much benefit is “enough,” or place a value on giving a child a way to express their feelings and thoughts.
Second, the clunky systems were challenging to use and required advanced reasoning skills. The systems coming out in the late 1970’s were not designed with children in mind and tended to assume a well-developed language system. This was a valid reason to rule out users with lower cognitive skills.
Today’s technology is easy to use and much less expensive. There’s no need to consider who might benefit more or less by using an SGD. Systems are available for all levels of cognitive and language development.
RECOMMENDATION: Don’t rule out an SGD based on a child’s cognitive level. Rather, use that information to help match an appropriate system to the student’s needs.
WHAT IS THE RECOMMENDED AGE FOR STARTING AAC?
Often times an AAC approach is rejected for young children. Sometimes this is because of fears AAC will delay the development of speech. Other times a funding source wants to make sure less expensive options have been “exhausted” first. Sometimes it's because the professionals assisting a family don’t have experience using it.
None of these reasons can be supported with research. A review of research on AAC used with infants, toddlers and preschoolers looked at 143 studies published between 1985–2014. Two key findings were:
"The evidence strongly indicates that AAC does not hinder the development of speech at the very beginning stages of language acquisition" (p. 194).
"These reports provide substantial support that early AAC intervention enhances a child's communication and language development, from single sign and symbol vocabulary increases for children 3 years old and under ... to multi-symbol utterances and grammatical development for preschoolers" (p. 193).
There is plenty of documentation that early use of AAC does not hinder speech development, and many times works better than a speech-only approach. You can find short descriptions of some of the research here.
Plenty of online resources are available for parents and professionals to learn how to use AAC with young children. See next week's blog post for some recommendations. A key to introducing AAC is to model its use throughout the day, just as you would do with a speech-only approach.
RECOMMENDATION: Age is not a consideration for introducing AAC.
WHEN SHOULD I USE CONCRETE (REAL) VERSUS ABSTRACT SYMBOLS FOR AAC?
In many AAC systems, the user points to an item on paper or an SGD display to select a word. Back in the day, it was believed that we had to teach children to understand “visual representations” in a sequence from concrete (the actual object) through increasing levels of abstraction (realistic photos, color drawings, black and white line drawings, abstract symbols, written words).
For our youngest learners, it makes sense to start with real objects because that’s what babies do. Before the end of their first year, though, children can recognize pictures. Where did the rest of this teaching sequence come from? Somebody made it up. A behavioral approach to teaching breaks down teaching steps from easiest to hardest. It seemed logical that concrete-to-abstract was a good way to organize the teaching.
After years of research and using AAC with young children, we know that following this sequence wastes valuable teaching time. For example, one study showed that 13- to 18-month old children learned random gestures to represent words as well as 4-year olds did.
Young children who are just learning words don’t care how abstract a gesture or symbol is—it’s all new to them. You show them what it means, and then they know it! Don’t waste time on unnecessary teaching steps.
RECOMMENDATION: Start and continue with one symbol system, such as signs or icons.
There’s no good reason to delay introducing AAC to your child. Age, type of disability, IQ, motor skills—not one of these excuses holds up.
Children need to develop their language by practicing their communication skills. If they don’t have a way to participate, their language development will be hindered.
Introducing AAC doesn’t mean you are giving up on your child’s use of speech. You are giving your child another tool that can boost their development. For many, AAC is a bridge to speech development. For older children who continue using AAC, why would you want to delay them getting started?