Augmentative-Alternative Communication (AAC) and Autism: A Case Study

Augmentative-Alternative Communication (AAC) and Autism: A Case Study
This case study profiles one non-speaking client with a diagnosis of autism spectrum disorder (ASD). I will describe two different augmentative-alternative communication (AAC) strategies used with this client. The rational for teaching both AAC strategies is provided along with AAC objectives, directions for implementation, feedback for correct and incorrect responses, list of needed materials, when strategies should be implemented and by whom. The information provided in this case study was used to help train parents and school professionals to implement AAC strategies for a specific client.

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1. Client Profile:
Shelly is an adorable, 5-year-old, non-speaking, female with a diagnosis of autism spectrum disorder (ASD). Shelly presents with severe ASD to the degree in which her symptoms impact her learning and independence skills. She is enrolled in a full day preschool program which uses an educational curriculum designed for children ages 2.5 to 5 years of age who have been diagnosed with ASD. The preschool curriculum is loosely based on a combination of Dr. Stanley Greenspan’s DIR/Floor Time Model and TEACCH.
Cognitively, Shelly demonstrates skills in the areas of cause-effect relationships, means-end causality and emerging joint attention skills. She is beginning to sort by color with some assistance and requires physical prompting to use an object schedule to transition between classroom activities. Shelly's attention fluctuates based on her mood. On a good day she may attend to non preferred activities for up to 2 minutes given a highly preferred reinforcer upon completion of each task.
Shelly communicates primarily through facial expressions, leading adults by the hand to what she wants, crying, laughing, and vocalizations that often reflect her mood or feelings. Shelly will seek attention by taking an adult's hand or by establishing eye contact. Shelly uses a Go Talk 9+ voice output communication aide (VOCA) and/or the Picture Exchange Communication System (PECS) to make requests from a field of four photographs but occasionally requires gestural prompts. Shelly is able to consistently follow a few basic one step commands (e.g., "stop" and "come here"). Shelly often walks with a wide base gait and has some difficulty with balance. She has many sensory issues including hyper-sensitivity to pain (e.g., pain of constipation or an ear infection). Shelly seeks oral stimulation and therefore uses a chewy on a regular basis; she would bite her hand prior to having a chewy. She self calms herself by going to a beanbag chair in the library area of the classroom. Shelly is learning to use a VOCA to express her anger more appropriately than biting her hand and to excuse her from activities to go to her beanbag chair if necessary.


2. Strategy 1:

A. General description: Picture Exchange Communication System (PECS).

PECS was developed by Lori Frost, M.S., CCC-SLP and Dr. Andrew Body approximately 20 years ago as a communication system designed specifically for children with ASD. One of the hallmark deficits of ASD is poor joint attention and thus, impaired pragmatic skills. Frost and Bondy developed a communication system that is designed to compensate for these deficit areas by having children physically hand their message to their communication partner. As a result of poor joint attention skills, many children with ASD have difficulty using gestures and pointing. This makes using communication point boards and VOCAs difficult for many students with ASD. Even children who are able to point don’t always look to make sure there is a communication partner receiving their message.

PECS requires a child to find a communication partner and physically give them their message. This system helps to make an abstract concept such as “exchanging thoughts and ideas” more concrete for children with ASD. Children first learn to exchange either a picture symbol, photograph or object (depending on the level of representation they understand) to receive a highly desired item or action (i.e., bubbles or tickles). When children are first learning to communicate using the picture exchange system they often require an extended, open hand cue from their communication partner. They also may require hand-over-hand assistance provided by another adult positioned behind the child to hand the symbol to their communication partner. It is important to fade physical prompts as soon as possible and fade the open hand prompt soon there after.

When the child can independently hand an adult a communication symbol, begin working on distancing yourself from the child and the child from the communication symbol. The goal is for the child to independently seek out his communication symbol and then find a communication partner to give it to. After this skill has been established, the child should learn to discriminate between two different symbols. Give the child two symbols, one to represent a highly preferred item or action and the other to represent a neutral or non-desired item (i.e., a sock or clothespin).

B. Rationale:
Shelly uses a simple single message VOCA (i.e., Big Mac) to make requests during certain classroom activities. Her classroom is engineered with several PECS books containing both photographs and picture symbols for various items in each area of the room. Thus, Shelly uses a combination of the VOCA and PECS to communicate throughout her day. It is important to have a “no-tech” backup communication system for VOCA users because when their device breaks they still need a way to communicate. I want Shelly to have plenty of opportunities to communicate throughout her day and I want to keep her “no-tech” communication aide skills sharp.

C. AAC Objective:
Teach Shelly to discriminate between 4-6 different photographs to request desired items. This will increase expressive language skills in the area of requesting and increase her independence level.

D. Materials:
Communication book with highly preferred items represented with photographs. You must have highly preferred items readily accessible to immediately reinforce Shelly when she makes a request (e.g., fruit, cookies).

E. Directions for Implementation:

i. How to Implement This Strategy
Allow Shelly to have access to her communication book at all times. You may decide to leave it in one central location in your house so she can always find it when she needs it. If she prefers to carry it with her, great! This means she is taking ownership of her communication system.
Shelly has several photographs of highly desired items in her communication book. For structured teaching times (e.g., meal time) stick 4-6 photographs onto the Velcro on the front cover of the book to allow her to choose from these items. This is narrowing her choices and may help her to discriminate between the different photographs. First, show her the desired item and tempt her with it (e.g., if the item is food pretend to eat it and tell her how good it is) to get her interest.

1. Feedback for Correct Responses:
If Shelly hands you the correct photograph for the item, immediately reinforce her with the desired item, hold the photo up by your mouth and say, “Oh, you want (desired item)!” If she is requesting food, give her very small pieces of food so she has more opportunities to make requests and will not satiate on the food too quickly. If she is requesting a puzzle give her one or two pieces so she has to ask several times to complete the puzzle. During these teaching moments we want to get in a lot of practice! As she becomes more accurate in discriminating between photographs we won’t have her make as many requests as we are now.

2. Feedback for Incorrect Responses


Scenario A:
If Shelly reaches for the desired item instead of a photo in her book point to her book or tap it to remind her to use her pictures. If she still does not use her pictures have a second adult seated behind her help her place the photograph in your open hand. Shelly should not need this much prompting but on occasion she may need a reminder to use her pictures.

Scenario B:
If Shelly hands you a different photograph immediately reinforce this by giving her the item represented in the photograph even if you know she doesn’t want that item. Show her the photograph she chose and say, “Oh, you want the (item in the photo)!” You are teaching her that the photos have meaning and she must look at the photos and choose carefully or she will not get what she wants.

ii. Who Should Implement This Strategy
Anyone can implement this strategy if they understand these implementation strategies. Make sure that all people implementing this strategy fully understand how to communicate with Shelly using her PECS so she is taught in a consistent manner.

iii. When to Implement This Strategy
The structured teaching times can be implemented when ever there are opportunities for Shelly to make a request for a desired item or action. For example, have her PECS book available during meals so she can tell you when she wants more juice or fruit. Take her PECS book outside so she can ask for a push on the swing or a bounce on the trampoline. It is important that she have access to her PECS book at all times so she can communicate at all times. If she has difficulty carrying it with her, consider carrying it for her or leaving it in central location in your house where she can always find it.


3. Strategy 2:

A. General description: Voice Output Communication Aide (VOCA)
A VOCA is a powerful communication aide because it gets people’s attention by giving a non-speaking individual a voice. Voice output provides an additional benefit in that the user hears the verbal model every time they select the picture representation of what they want. The user’s peers may also pay closer attention to their messages because they can hear them. Typical peers are often interested in how VOCAs work and they enjoy helping their disabled peers improve their communication skills by helping them to learn to use their communication devices.

B. Rationale:
The Go Talk 9+ voice output device has 9 cells and 4 levels. Shelly is currently using 4 cells on 3 different levels. Different levels represent different vocabulary topics. For example, the first level has snack choices, the second has song choices for circle time and the third level has toy choices. On each level, the bottom right hand cell is programmed for her to express: “I’m mad!” Shelly frequently expresses anger and frustration inappropriately by biting her hand. She is learning to use the Go Talk 9+ to make requests and to appropriately express her anger and frustration. The Go Talk 9+ was selected after Shelly demonstrated a clear understanding of the PECS to make requests and was able to use a Big Mac voice output device to express her anger given gestural prompts. Shelly’s strengths include: appropriate use of eye contact and her ability to initiate interaction with adults, looking at her communication partner and pointing skills.

C. AAC Objective:
Teach Shelly to replace inappropriate behaviors such as biting her hands and screaming with using her Go Talk 9+ VOCA to more appropriately express her anger and frustration.


D. Materials:
Go Talk Voice Output Device, bean bag chair, cause-effect music toy.

E. Directions for Implementation:

i. How to Implement This Strategy
Encourage Shelly to carry her Go Talk 9+ with her at all times. She must have access to her device at all times so when she feels angry she can tell you appropriately without biting herself. It is important for her to learn to take responsibility for her communication system and carry it with her all the time.

Shelly has several photographs of highly desired items on her Go Talk 9+, but each overlay also has a spot for “I’m mad!” in the bottom right corner. I have placed it in the same spot on every overlay to help Shelly remember where it is located. When she is angry it is very easy for her to bite to let you know how she feels. To replace this behavior we have to make it as easy as possible for her to get her point across in a more appropriate way. At school she often calms herself down by taking a minute to lie in a bean bag chair and suck her thumb or listen to music. She typically needs only a few minutes to calm down.

When you notice that Shelly is beginning to become agitated (i.e., she starts to scream) help her activate the message on her Go Talk 9+ that says, “I’m mad!” Then tell her, “I know, you’re mad!” and immediately offer her, her bean bag chair and/or music toy. It is important to have her activate her device and offer her a break before her behaviors escalate.

1. Feedback for Correct Responses:
If Shelly allows you to help her activate her Go Talk 9+ with physical assistance, immediately offer her, her bean bag chair and/or music toy and say, “I know you’re mad!” She will typically look at you and calm down within a few minutes.


2. Feedback for Incorrect Responses
If Shelly is so upset that she does not allow you to help her activate her device, wait for her to calm down and then try again. Hand-over-hand assistance does not typically upset Shelly; however, if her behaviors have escalated she may need time to calm herself before she is attending to what you telling her.

ii. Who Should Implement This Strategy
Anyone can implement this strategy if they understand these implementation strategies. Make sure that all people implementing this strategy fully understand how to communicate with Shelly using her Go Talk 9+ so she is taught in a consistent manner.

iii. When to Implement This Strategy
It is important that Shelly have access to her Go Talk 9+ at all times so when she becomes angry or frustrated she can express herself appropriately. Encourage her to carry her device with her so she will always have access to it.

References
1. Beck, A.; Stoner, J.; Bock, S.; Parton, T. (2008). Comparison of PECS and the Use of VOCA: A Replication. Education and Training in Developmental Disabilities, 43 (2) 198-216.
2. Cafiero, J. A., Acheson, M., & Zins, J. E. (2007). Autism spectrum disorders and augmentative and alternative communication: From research to practice. Perspectives on Augmentative and Alternative Communication, 16, 3-8.
3. Chiang, H., & Lin, Y. (2008). Expressive communication of children with autism. Journal of Autism & Developmental Disorders, 38(3), 538-545.

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