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Augmenting Speech
Rosemary Crossley, A.M., Ph.D
Individuals are described as having a severe communication impairment (SCI) or complex communication needs (CCN) when their speech and handwriting are insufficient to meet their communication needs. The terms are usually used in relation to people with no speech, or with very little intelligible speech, but they may also be applied appropriately to people whose speech, while clear and fluent, is still not meaningful or representative of their real thoughts.
Impaired speech may be replaced or augmented by gesture and body language, hand signs, spelling, and specially developed communication aids. These strategies may all be described as augmentative communication, or AAC (which stands for Augmentative and Alternative Communication—‘augmentative’ communication is added on to speech, ‘alternative’ is used instead of speech).
Augmentative strategies should be introduced as soon as it becomes apparent that speech is likely to be significantly delayed, to ensure that the child doesn’t miss out on social and learning experiences requiring speech. Every child who has very limited intelligible speech after the age of two should have a professional assessment by a speech pathologist with experience in augmentative communication as well as traditional speech therapy. For children with diagnoses associated with a high probability of speech impairment, such as autism, cerebral palsy, Down syndrome and Rett syndrome, intervention should start earlier. The aim of therapy should be to help the child communicate as fluently as possible, using any strategies which work for that child.
Often parents are anxious that early use of non-speech communication will prevent a child talking. In fact, every indication is that the reverse is true. For example, in the Helsinki signing study, children with Down syndrome who started using manual sign at the age of 6 months talked significantly earlier and more fluently than children who did not use sign.
Unfortunately it is not easy to replace speech. Manual sign is as portable as speech (like your tongue, your hands go everywhere with you) but only people who know sign will understand you. A communication book containing lots of pictures and words will be understood by more people but is a nuisance to carry round and can't be used in the swimming pool, or to talk to a number of people at the same time. An electronic voice is great for talking to a number of people, but the batteries go flat. And so on.
Every non-speech communication strategy has pros and cons. In selecting augmentative communication strategies, account has to be taken of these, in addition to the physical and sensory skills of the users, their academic skills and their communication needs. It is rare for any user's overall communication needs to be met by one device or one strategy, partly because most people with severe speech impairments also find hand-writing difficult. The need for specialist training of communication partners must also be considered.
Strategies for augmenting speech
Gesture and body language are used to some extent by almost everyone. Some formalized gestures, such as nodding the head for ‘yes’ and shaking for ‘no’, are powerful, but there are intrinsic limits on the sophistication of communication obtainable by gesture and body language alone. While a person may respond to questions or make basic needs understood with gestures, carrying on a conversation is virtually impossible.
Sign Language—hand signs are often taught to children with delayed speech. They are useful, but require good hand skills. Unfortunately many people with SCI have difficulty reproducing the sequences of fine movements necessary for signing (and handwriting). As a result, they often end up able to recognize many more signs than they can produce. And, of course, hand signs are only useful if everyone the child interacts with recognizes the signs.
The Picture Elicited Communication System (PECS) is a strategy aimed at encouraging children who find speech difficult, particularly children with autism, to initiate communication by taking a card with a picture or symbol of a wanted item to an adult. PECS is a useful strategy for getting basic needs met and avoiding frustration, but by itself it allows only limited communication, due to the obvious vocabulary limitations.
Communication aids are devices specifically developed or adapted for use by people with severe communication impairments. Because these people have very varied skills, needs and problems, there are many communication aids, ranging from simple communication boards to lap-top computers which speak. Some communication aids require literacy, but many do not.
Communication boards or books represent language in words, pictures or specially drawn symbols. There are many symbol systems (Blissymbols, Picyms, Compic, etc) but they all share the same limitation—a communication board user can only say what the person who assembled the board thought was necessary or suitable. It is impossible to provide enough symbols or phrases to cover all situations, and the larger the number of items the harder the system is to use.
VOCAS or voice output communication aids are electronic communication aids which talk, either in synthetic speech or in digitized human speech. There are many of these, ranging from single-utterance devices (e.g. BIGmack) to aids which contain thousands of utterances (e.g. Dynamite) and text-to-speech devices which say anything which is typed (e.g. Link).
Spelling gives people without fluent speech access to an unlimited vocabulary understood by most of the people with whom they come in contact. Spelt communication loses the inflection of speech and sign, but it is nonetheless the most empowering non-speech communication strategy. People who can spell but cannot write can use keyboards or alphabet cards.
Visual strategies include calendars, schedules, choiceboards and menus, transition/travel helpers, task organizers and so on. Providing information in a clear visual form may help some people with SCI to be sure about what is happening and what they are expected to do. Visual strategies foster the development of both literacy and independence skills, but they serve primarily an input role, providing information rather than being a means of expression, and should be used in conjunction with individualized expressive communication programs.
Communication aid access
‘Access’ is a specialized term when used in augmentative communication. It refers to HOW communication aid users activate their communication aids. Most people who need to augment their speech have difficulties using their hands. These may be due to obvious problems such as paralysis or severe tremor or due to less obvious problems such as impulsivity or perseveration. Whatever the difficulty, there are ways around it. This is where a specialist augmentaive communication therapist or team has an important role – in establishing why potential communication aid users have difficulty in using their hands, and what the best alternative access strategies are.
Ironically, it is easier to help potential communication aid users who also use wheelchairs, because alternative access may require devices that are more easily set up on a wheelchair than carried around. Some common accommodations are:
• Putting a keyguard on a standard communication device to stop two keys being activated at once
• Attaching an enlarged keyboard such as Intellikeys to a lap-top computer or other aid
• Using a headpointer – a stick attached to a headband – or an optical headmouse to make selections
• Using eye-gaze – that involves a large communication display placed so that a communication partner can read what item the user wants from the direction of his/her gaze
• Scanning – either partner-assisted or electronic. However complex a scanning system is, it basically presents one choice at a time, and the user accepts or rejects it. The choices may be pictures, written words, spoken words or letters. There are many ways of setting up scanning systems, and many different switch alternatives for electronic systems. Scanning systems can help people with the most severe physical impairments to access communication aids and computers.
Where does facilitation come in?
Facilitated communication training is a strategy for teaching people who need to use AAC to use communication aids with their hands. It is particularly appropriate for people who can move their hands and arms freely but who have other difficulties with other aspects of hand function such as eye-hand co-ordination, scanning displays, and index-finger isolation. Most of these people walk, and cannot use the access adaptations listed above for practical reasons.
In facilitated communication training (FCT) a communication partner (facilitator) helps a communication aid user overcome difficulties in hand use and develop functional movement patterns. The immediate aim is to allow the aid user to make choices and to communicate in a way that has been impossible previously. Practice using a communication aid such as a picture board, speech synthesizer, or keyboard in a functional manner is encouraged, to increase the user’s physical skills and self-confidence. As the student’s skills and confidence increase the amount of facilitation is reduced. The ultimate goal is for students to be able to use the augmentative communication strategies of their choice independently.
Facilitation is an access strategy which is used to enable some people with hand function impairments to make use of communication aids. Like other access strategies, such as eye-pointing, expanded keyboards and single-switch scanning, it is an accommodation to physical problems designed to allow more individuals with SCI to make use of AAC. Every effort should be made to provide people who generally use facilitation with the skills to access aids containing a limited range of options, such as YES/NO boards and multiple-choice boards independently.
Some Communication Aids
There are many different communication aids, all of which fit someone’s needs in some situations and none of which fit everyone’s needs or even one person’s needs all the time.
Here’s a list of some communication aids I find useful. This is a small selection from a very large field.
Low tech:
YES/NO cards
Picture cards to be exchanged for desired items
Opinion and multiple-choice boards
White boards for offering written choices
Communication folders of words and sentences, with or without associated graphics
Spelling boards
Diary containing personal information and conversation starters
Limited utterance high tech:
Speaking devices on which utterances are recorded by a speaking person
Talk Trak wrist band—4 digitized utterances
Message Mates with keyguards—limited vocabulary, digitized speech
Dynamo, MiniMo—small aids with dynamic displays
Cheaptalks—many versions—limited vocab., digitized speech
Macaw—sophisticated aid with digitized speech
Laptop with Speaking Dynamically Pro software, etc. etc.
Babar—hand held bar code reader
Unlimited utterance high tech:
Devices which say what the user types.
Lightwriter or Allora
MT4 — sophisticated aid with dynamic displays
Polyana—pocket computer with voice
Laptop with Words + software
Vanguard, etc. etc.
N.B. Only literate users can create unlimited utterances using these devices, though sophisticated users of Minspeak symbols can come very close using devices such as the Pathfinder.
Handwriting replacement
Neo keyboard—a mini-laptop with optional keyguard and word prediction
Laptop computer, possibly with word prediction (e.g. Co-writer) or text-to-speech software (e.g. Intellitalk)
Desktop computer, possibly with word prediction or text-to-speech software
An enlarged programmable keyboard (e.g. Intellikeys) may be used with a computer or compatible aid
Ph. (61-3) 9509 6324
Fax. (61-3) 9386 0761
e-mail: dealcc@vicnet.net.au
Autism/ASD, Cerebral Palsy, Down Syndrome, Intellectual Impairment, Learning Disability, Fragile X Syndrome, Rett Syndrome, Stroke/CVA,
Persistent/Permanent Vegetative State, Acquired Brain Damage,
Motor Neurone Disease/ALS, and Huntington's Disease.
DEAL has been able to help people with all of these diagnoses to communicate.