The ability to speak is a blessing which is taken for granted many a time. Meaningful speech is a learned behaviour which involves information processing and generating a motor response. Majority of the children on the spectrum have processing difficulties and co occurring motor difficulties like apraxia/dyspraxia, low tone etc. Their motor system takes time to develop and does not always follow the timelines / milestones of typically developing children. This impacts the ability to produce speech because speech is a pure motor act involving the synergistic functioning of a number of muscles.

But as discussed in some previous blogs on Communication by @prashanthivankamamidi Read it here Speech is not the only means to communicate and non speaking doesn’t mean non thinking and non speaking doesn’t also necessarily have to be non communicative .

On similar grounds, speech may also not always be communicative for people on the spectrum. Using an AAC system does not mean we are giving up on speech. In children with sensory processing disorder and motor speech difficulties like dyspraxia and dysrathria, appropriate sensory integration strategies, whole body and motor speech work need to be incorporated into the child’s program to see gains in speech. At the same time since we want the child’s language to grow along with the child, we need to explore alternative methods to stimulate language and foster communication. As parents, I believe it is our duty to make the process of communication easy for our children because communication is the essence of human relationship. Language adds meaning and expression to human interactions. So AAC is an attempt to support a developing motor system to communicate and develop language .

Alternative and Augmentative Communication includes both low tech and high tech forms. Low tech includes gestures, writing, sign language, communication boards ,pictures, PECS etc where as high tech includes a speech generation device which uses softwares like Avaz, Proloqu2Go, Tobii Dynavox, Saltillo, LAMP words for life and many more. I have been using Avaz as well as communication boards with my son. So lets jump into the strategies.
For any AAC system to be successfully implemented , we need to consider many variables. Each of the headings below is a topic in itself and this is just an overview of the strategies which I found useful.

• To begin with , PRESUME COMPETENCE. Every child can communicate if we teach them the way to do so and provide them with ample opportunities for the same. First of all, we need to get rid of limiting beliefs. When we think of only limitations like the child has difficulty in visual discrimination, scanning, fine motor issues etc as an excuse not to use AAC , we are giving up even before we begin.There is a way to work around these issues and trained professionals can guide you regarding the same. These days there are eye gaze systems available which can be successfully used for communication even by children who have significant motor difficulties.

SETTING UP THE SYSTEM: This is an essential part and one of the first steps in an AAC intervention where in we decide and make a list of all the possible words which we use on a daily basis, the words which are important to the child. This is mostly child and family centric.

For eg: A child may love ‘ Dosa’ or a family might visit a particular relative every weekend and so on. So there must be symbols in the system to cater to this kind of conversation. That is why AAC systems need to be customised keeping the user in mind. Once the list is decided these are carefully laid out in a particular order and at various levels so that navigation is easy for the child. At this stage we decide on the grid size (number of pictures per screen), size of the symbols, levels of folders etc depending on the child. An AAC trained professional can guide in this processs taking into account, the individual child’s visual and motor abilities. Nevertheless it is always a good idea to have more symbols than a restrictive set of symbols which are just need based because unless we have those symbols we will not model those. It is essential to use a robust system with access to a rich vocabulary. I know this may sound counterintuitive, because we are told that children on the spectrum have significant processing difficulties and hence should be exposed to a limited number of words initially. But most of the time what happens is that when we have less number of words on our system we restrict the language that we are modelling to just those many words that we have on our systems. So we will get stuck at need based communication simply because we are not exposing our children to richer language. So more words being modelled results in richer receptive language. This doesn’t mean that we are going to model all these words in a day or two. It is done gradually and systematically. But we should have it in our AAC system so that when the appropriate situation arises we can model the same. This is one of the biggest advantages of hi tech systems because any word with its picture symbol, can be added at the click of a button. Also the auditory feed back that a hitech system provides is beneficial to the user . So presume competence and add more vocabulary to your child’s life in naturalistic settings. It is also important to have a dedicated device for communication. For entertainment, you tube and cartoons a different device should be used .

THE GOLDEN RULE : MODEL MODEL MODEL– There is no other way in which language can be developed. Essentially this is the way natural language is acquired by all children. Parents of typically developing children model vocabulary multiple times throughout the day unknowingly and children pick up those words. AAC is a new language- So we have to model its use so that children develop rich language. Aided Language stimulation/ Input is the more technical term used for MODELLING WITHOUT EXPECTATION.So essentially what we do is we speak to the child using the device and our voice. For example : When I say to my child “ Amma feels thirsty “ , I simultaneously model the key words like feel and thirsty on the device. I do not expect the child to repeat after me or respond using the device. Attention towards the AAC system is a pre requisite for this step and you can build on it. It might sound very impossible or undoable when we start . But with practice we become more proficient in it and believe me it works.It is the process by which we are consistently showing the child where a particular symbol is there on the AAC system ,repeatedly ,so that slowly he will learn to navigate and find the word. In this regard it is very important not to keep on shifting symbols every now and then because it hinders the development of a consistent motor plan. Also do not use very long sentences and do not model every word that you say. Model the key words, model just one word above the child’s present level. If the child can say ‘water’ , we will model ‘want water’. Here is a useful article on aided language stimulation:

MODEL MORE, PROMPT LESS- The process of prompting should only begin after a word has been modelled a significant number of times. The more a child sees a word being modelled, the more the chances that the child might use that word on his own. Be aware of the PROMPT HIERARCHY– start from the least intrusive prompt and move up to more intrusive ones. Physical prompts must be used only as the last option since they are very difficult to fade off. Refer to this article to learn more about prompting and the prompt hierarchy.

MODEL ACROSS SITUATIONS , USE WITH MULTIPLE COMMUNICATION PARTNERS– Success and communication autonomy happens when the AAC is used in multiple situations and by every one around the child. This builds confidence in the child regarding this new mode of communication. This means that the family has a large role to play. A therapist spends very little time with the child whereas family members get multiple communication opportunities which should be utilised in modelling language. To take all the family members into confidence regarding AAC use is not an easy task ! It will always be a work in progress. But start the process and it will slowly evolve.

• Be aware of the POWER OF THE PAUSE- An expectant pause gives opportunity and time for the individual to process the information and come up with a response. The minimum we can give is 10 seconds upto about 45 seconds (RDI recommended wait time) before you repeat the question or prompt. Literally count in your head. Slowly you will understand how much time your child is taking to process and will be surprised too when you realise that you are the one who was impatient. I have suffered this guilt!

BE AWARE OF THE COMMUNICATIVE FUNCTIONS: This is essential ,so that we can model each of these functions during our every day interactions. Looking at the image below (Ref theaac, one will realise that communication is not just need based, there are myriad other functions of human communication! These communicative functions can be effectively modelled during routines and daily life interactions, if we are mindful. Again, will be difficult in the beginning but gets better with practice.

• Use COMMUNICATION TEMPTATIONS: Use everyday opportunities to engineer situations where the child will have to communicate. Sabotage certain situations so as to bring in initiation . For eg: If colouring is your child’s favourite activity, you can give your child paper. Wait for the child to look for crayons and use this opportunity to model ‘WANT CRAYONS’. This helps to build requesting. This resource helps with communication temptation:

TEST VERY LESS -Reduce the number of Questions that you ask. Continuous testing results in lot of performance demands and adds on to anxiety and stress. This might lead to
communication breakdowns and device abandonment. So avoid phrases like “show me, tell me, what is” etc which may become communication stoppers. Remember an AAC is a communication device, not a testing or academic work device.

• Always REINFORCE– Any attempt at communication , be it verbal, non verbal or using an AAC must be reinforced which will motivate the child to communicate more.

• Understand the difference between CORE AND FRINGE VOCABULARY – Although we always start teaching apple, ball and cat, these words may not be very functional for the child except in certain specific scenarios. On the other hand core vocabulary is used in a majority of our daily life situations in a variety of situations. Eg: Consider the word ‘go’. We can use it in a number of situations like ‘ go to park, go in auto, lets go, go to toilet, go with daddy, ready set go, bubbles go up’ etc. Similarly consider the words ‘help’ , ‘like’, ‘don’t’ etc which can be used in a variety of situations. These are core words.Teaching these core words will help in language generalisation.

TARGETED PRACTICE AND SHARED READING– It is a good idea to select one or two core words for a specific period like a week or 10 days to model during shared reading. Here is a great resource providing simple stories which targets specific core words which keep repeating in the story.

In the beginning if interest in stories is less, we can make social stories with the child as the person of interest. This can be facilitated by taking photographs and putting into a power point and highlighting the core words. Use simple sentences and highlight the key words. For example we can write a story about our visit to the park. We can highlight words like go, play, fun, climb, jump etc. We model the highlighted words on the AAC when we read the story. This kind of story telling will also aid in recall of events and in creating memories. It will feel cumbersome in the beginning ,to read and model at the same time, but with practice we get better at it. This kind of targeted practice is also a great way to introduce and teach certain useful words that may not come into everyday language on a regular basis. For eg : lets consider the word ‘pain’. There will be limited opportunities to model. So if we have a story around it, we can model the word ‘pain’ , teach to localise the pain, ask for help when in pain etc. One can use CREATIVE WAYS to make the story very interesting by adding not just pictures , but GIFs as well. This is especially true for action words and emotions were a static picture may not be able to convey the true essence of the word. Consider the two pictures below . The dynamicity of GIFs will help the user relate to the word more.


• Last but very important point: Know your child’s way of language processing- Analytical Language Processing (ALP) versus Gestalt Language Processing (GLP). I would urge the readers to refer to Ms Triveni’s blog on Gestalt Language Processing

This is essential because the way you are going to model language is going to be different. ALPs will start with single words, then two words phrases and gradually increase their language complexity. So modelling will also follow the same path. GLPs on the other hand will require pre stored phrases and sentences to begin with. Professional help will be useful to decide on this. This resource helps in understanding Gestalt language processing

Other useful resources:

AAC is a whole new language. So as caregivers we need to learn and use it in the right way so that communication becomes a success.
Disclaimer: I am not an AAC expert. These are the strategies I have learnt through personal experience and through reading. I actively pursue these strategies and find them very helpful. My sincere thanks to team Avaz for guiding me in my AAC journey.

Author Dr. Indu Manicketh

Dr Indu Manicketh did her MBBS from Madurai Medical College and MD in Pathology from St John’s Medical college Bangalore. She runs a histopathology laboratory at Jeeva Janaki hospital Madurai and she is associated with Apollo Hospital Madurai as a consultant . Her areas of interest in medicine include transfusion medicine, lymphoproliferative disorders and Quality management systems. The cause of autism and neurodiversity is very close to her heart and she actively pursues these interests. She is trained in Oral Placement Therapy, Level 1 , Introduction to PROMPT by the PROPMT Institute, Sensory motor approach to Apraxia by Renee Roy Hill, Solving the puzzle of autism by Robyn Merkel- Walsh. She believes in continuous learning and improvement. She has a seven year old son. A trained carnatic vocalist, she loves to sing, read and research during her free time.

Creative representation for this blog is done by our extremely talented CreativeSaathi associate Vinayak Raj

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