Augmentative and Alternative Communication (AAC) can seem like the answer to all your prayers when you are working with or caring for an individual with special needs.
Unfortunately, AAC can also seem extremely overwhelming when you have a client or a loved one who presents with severe physical, and/or visual limitations.
I have met parents and therapists who have been working with or caring for people who are severely limited in their ability to use their bodies often leading others to believe that these people have no understanding of what is happening around them and therefore, no need for a way to communicate.
AAC provides us with an answer to these struggles; however, if there is not someone to help them discover these capabilities, they can live a life without the vital communication they deserve.
One of my core beliefs as an SLP and AAC Specialist is that everyone deserves a way to communicate and everyone has the capability to communicate, they just require the right access. I want to provide hope to all out there that believe there is no communication options for their client or loved one with severe physical and/or visual limitations.
The AAC evaluation is a long and complex process, this is something I tell all my clients when they walk into my office for their first evaluation. No matter the client, the insurance, the limitations, or even the simplicity, it is never a cut and dry process.
Most types of therapy evaluations have standardized tests that can be followed. It is provided in 1-2 sessions with perfectly written out instructions, a way to score the test and determine the needs of the client. You will find this in Speech/Language evaluations, PT, OT, educational testing, and even psychological testing; however, when we are talking about AAC, it is never that simple.
There are some standardized tests to help in determining the level of the client, but these tests will never point you to the exact device you should select, and it certainly does not help you to determine the type of access this client requires.
The question remains, how does one evaluate and identify the correct device and identify the most effective access if there are no standardized methods?
The first and most important answer is you must find an experienced Speech-Language Pathologist who has extensive experience in AAC.
When doing an evaluation for someone with physical limitations, it is also important to have an Occupational Therapist on your team as they are experts in how the body moves and works. It is important that this OT is also knowledgeable in AAC, alternative access, and mounting systems.
A team of an experienced SLP and OT will help to ensure that the correct setup of the device and that the mounting and access method comes together correctly.
Another important factor in AAC evaluations is that the client has a strong support system. If evaluators take note that there is not strong support system, they will then note that this system will not work. For any AAC user, there must be people who are willing to setup the device, learn the device and work with the client using the device daily.
During an evaluation for someone with physical limitations, our first goal is to identify multiple types of access that would be viable for this client. In order to identify what they understand, we must first have a way for them to access things such as switches.
It is always preferable to be able to utilize direct select if possible. Direct select is defined as “a method of accessing an AAC system where an individual selects a specific target with a body part or accessory.” (https://www.communicationcommunity.com, AAC Direct Selection (Access Methods)).
If it is clear that this client cannot touch a screen with their finger, we will then evaluate their vision in terms of visual tracking and ability to move the eyes. We also request a vision assessment be provided ahead of time if possible. Eye gaze is a popular type of access but is very difficult for clients to utilize and they must exhibit good vision and tracking skills.
If this is not an option, we then consider using a head mouse, head tracking or choices of styluses. A stylus can be attached to equipment such as hand braces or be used as a head pointer. There are some companies that have begun exploring different shapes and grips for styluses to make them more accessible. All of these direct select methods should be considered and tried (if possible) before moving on to indirect access options.
Indirect selection is defined as “a method of accessing an AAC system where the individual selects a specific target given a set of choices.” (https://www.communicationcommunity.com, AAC Indirect Selection (Access Methods)).
Indirect selection is primarily used when a client has physical limitations and/or visual impairment to the point where they would be unable to see the screen to make a direct selection.
Indirect selection has many different options that can be explored. Many clinicians and evaluators do not have tons of experience in this area and therefore go with the easiest option and that is often the option that is preset when you select scanning options (scanning is how we access indirect selection options).
Many devices will be setup on autoscan which will highlight one button at a time at the push of a button and when you push the button a second time it will select the button you landed on. Autoscan can also be done with block scanning or column/row; these methods allow multiple buttons to be highlighted at one time and you can select within these blocks. A person must have good vision and know the device well to use block or column/row scanning.
A lesser-known scanning method is called step scanning. You can use one switch (button) or two switches when using this method. Step scanning allows the user to have more control over the device, they move the scanner from one place to the next. Step scanning is often the easier option, especially for a new user who has difficulty with making their selection in the time frame given on the autoscan.
If a client uses indirect scanning methods, the evaluators often spend a lot of time assessing the body and movements that would be viable for switch access.
For instance, does this client have enough head control to push a button or perhaps they have better movement at their elbow or foot. No body part should be counted out, but of course we always want to start with the use of the hands as this is the easiest and most accessible way to make selections. Thankfully, there are many different switch options for our clients to select from, we can try a standard button or perhaps a very small or very large button.
They also make switches that are flat, sensitive, wobble switches, joysticks, twitch switches and so many other options. This allows the client to have many options but also may in some instances take longer to identify what is right as many options may need to be explored before identifying the most accessible option for this particular client.
In this blog, I quickly mentioned most access options and loosely how we evaluate. A true evaluation of a complex client can never fully be put into words. The fact that it cannot be put into words does not make it unrealistic to have these clients evaluated. A knowledgeable SLP and OT will always find a way for your client or loved one to communicate.
AAC is a tool that is meant for anyone who has complex communication needs regardless of their cognitive status or physical, visual, or hearing limitations.
People who work with and care for these complex individuals must remember that while we can always find AAC to meet their needs, they may not ever have the ability to join in conversation or write a book but everyone has the ability to tell us their most basic wants/needs and when you are working with or caring for someone who has no access to a method of doing at least that, they are missing out on the right to express themselves.
Having realistic expectations of these clients is important, we don’t want to overestimate or underestimate their capabilities.
Communication brings a freedom like no other, without it we are stripped of our most basic rights and leaving others to make assumptions about a person’s needs, likes or dislikes is unfair, but we do it often because we believe we know this person so well that we can read their minds and their actions to determine exactly what they want.
I can tell you from experience that once these people gain a voice, we quickly learn that much of what we did was make assumptions because it is the best we were able to do when they are unable to tell us.
If you are working with or caring for a client who currently has no source of communication, find an SLP who is experienced in AAC and request an evaluation.
Never wait, never believe they are too young, too old, or not capable.
Allow a professional to determine what is right for them with the help of others on the team (parents, teachers, nurses, therapists, etc.).
If a child is not talking and over the age of 3, do not wait and hold out hope that they will eventually begin talking. Instead, give them the tools now to communicate and allow their verbal skills to continue to grow while also having a means of communication.
I hope to see a world where AAC is no longer a stigma and/or a final option, I also hope to see a world where we stop underestimating the capabilities of people with severe impairments. Everyone deserves to have a voice!
Elyse Goldshein, M.S., CCC-SLP has been a practicing SLP for almost 18 years with experience in all age groups from early intervention through end of life. She has been working with clients with severe special needs for her entire career and has been involved with AAC for the past 17 years. For the past 6 years, her sole focus has been AAC evaluations and trainings. Elyse has taught graduate courses in AAC as well as been a supervisor for countless students. Her goals in her professional career is to provide as many deserving clients with AAC as possible as well as to educate the loved ones, care givers, educators and general population about the importance of AAC.