AAC and Telepractice

An important component of communication is the efficiency of the methods we use to deliver messages.  Regardless of the type of communicator, human beings are really good at finding and utilizing the fastest and most effective way to interact with others.  For most hearing individuals, that is speech.  For many deaf and hard of hearing individuals, sign language is highly-productive.

When our typical mode of communication doesn’t do the job, we are also pretty good at finding alternatives.  Most of us who have been to a foreign country have done our fair share of pointing and gesturing.  Written language is frequently a helpful bridge when users of spoken and signed languages interact.  We also do more to augment communication in those situations.  We pay extra attention to the body language and non-verbal cues of the people we are interacting with.  We may heighten our own use of facial expressions and tone of voice to help make our intent clear.

Augmentative and Alternative Communication (AAC) is an important tool and area of study in the field of communication sciences and disorders.  A way that I like to think about AAC is that we draw on a variety of systems, many of which people naturally use, to systematically enhance communication for individuals with communication impairments.  The American Speech-Language-Hearing Association (ASHA) has an appropriately more technical definition:

“AAC is, foremost, a set of procedures and processes by which an individual’s communication skills (i.e., production as well as comprehension) can be maximized for functional and effective communication. It involves supplementing or replacing natural speech and/or writing with aided (e.g., picture communication symbols, line drawings, Blissymbols, and tangible objects) and/or unaided symbols (e.g., manual signs, gestures, and finger spelling).”  (ASHA, 2002)

One of the most accessible images of what AAC “looks like,” is Stephen Hawking – a brilliant physicist and cosmologist at Cambridge whose diagnosis of progressive amyotrophic lateral sclerosis (ALS) prevents him from using speech to communicate.  Instead, Dr. Hawking makes use of a speech-generating device (SGD) from which he has given the world a wealth of knowledge about the universe we live in.  It’s definitely a powerful example of the usefulness of AAC; however, it’s only one example of the wide variety of processes that can make up AAC.  In other words, AAC is much more than an expensive, electronic device.  I have seen eye-tracking technology, computer software, laminated pieces of paper, three-ring binders, American Sign-Language and stuffed animals all used effectively to increase individuals’ communication.  AAC is also not a matter of finding which one system will work well for an individual.  An AAC user can employ a variety of strategies at the same time.

Some of the major keys for successful AAC use are the knowledge of the practitioner and her observation, coordination and adaptation skills.  An SLP needs to understand clients’ motor and sensory skills to determine the type of tools they can access and consistently use.  For example, Dr. Hawking uses an infrared sensor and his cheek muscle to operate software that scans through and composes text on his computer.  Other individuals may select buttons on a screen, flip through a communication book, or use complex signed language like ASL.

Professionals also need to assess cognition and communication skill then be systematic in planning to use AAC to compensate for deficits, and/or develop new skills.  An example of this would be an SLP shaping a child’s involuntary physical reactions or grabbing behaviors into more complex behaviors like awareness of cause/effect, (“When I reach for it, I get the toy”), intentional communication, (“Reaching for the toy tells that woman I want it”), and eventually symbolic communication, (“This picture represents the toy, and when I point to it, she will get it for me”).  SLPs also need to understand the different communication environments the individual needs to navigate, how different forms of AAC may be perceived in those environments and the type of communication they will need for each.

Suffice it to say, AAC can be pretty “hands-on” from both the client and clinician’s standpoint.  In my personal experience, AAC services seem to be one of the areas that clinicians have more reservations about addressing through telepractice.  However, there is emerging literature that documents some circumstances where AAC-users were effectively helped through telepractice, and provides some thoughts on how to approach assessment and intervention through this method of service delivery.

Allen and Shane, (2014), recently published an article discussing assessment of individuals with Autism Spectrum Disorders (ASD) through telepractice.  The authors looked at individuals who were minimally verbal candidates for AAC.  They found preliminary evidence that the skills and needs of these clients could effectively be assessed through telepractice.

Hall et al. (2014) performed a case study in which they provided a seven-year-old AAC-user with four weeks of face-to-face services followed by four weeks of telepractice services.  Intervention focused on increasing the child’s performance on certain grammatical structures.  The authors found that gains made in both the onsite and telepractice conditions were comparable.

Curtis (2014) reviewed several case studies in Tele-AAC.  Three of these participants were previously-independent communicators with cerebral palsy (CP) or ALS.  Each made improvements in their use of eye tracking technology and other AAC-related systems through telepractice support.  A fourth participant – also with CP and who did not previously have a formal communication system – presented with greater challenges during intervention.  However, she too made improvements through telepractice services.

Looking at speech-generating devices (SGD) Hall and Boisvert, (2014), described several formats in which telepractitioners could support AAC-users.  A few of these include:

• Direct text based Tele-AAC: In which the client has a SGD that can interface directly with a computer. The telepractioner and client input text in their own device, which is transmitted to the other person’s.  This system requires that the client have a certain degree of literacy, language skills and access to technology.
• Direct tele-AAC with two SGDs: In this system, the client’s SGD is displayed on the teletherapist’s screen using a webcam.  The clinician also has an SGD and webcam, which is used to model and modify use.  This system requires that the client and clinician have a comparable SGD.
• Direct tele-AAC with one SGD: Here, the clinician uses simulation software provided by the SGD producer to model use of the SGD through screen sharing. Typically, a webcam is used to help the teletherapist observe the client’s SGD.
• Active consultation for tele-AAC: This is considered an “indirect” form of service provision in which the teletherapist monitors and guides a facilitator, (preprofessional, parent, or other adult) who is on site with the client.  Arrangements should be made to provide training to the facilitator and to permit the clinician to observe the SGD.
• E-Supervision, E-Mentoring, E-Training for AAC: In which a telepractioner with experience in AAC provides various levels of mentoring or support to other professionals who provide direct services to the individual.

Much of the literature on tele-AAC focuses on users of SGDs.  We need to know more about overall best practices in tele-AAC, including how a telepractitioner can support individuals who use simpler forms of communication.  As with all clients, clinicians and caretakers need to assess the potential advantages and disadvantages of using telepractice to serve individual AAC-users.  However, the initial evidence follows the trend that we see in other areas of telepractice, namely:  Skilled and creative clinicians, paired with dedicated caretakers, can be effective in providing services to certain AAC-users through teletherapy.

Disclosure: Mr. Cornish is the current CE Content Manager for SIG 18: Perspectives on Telepractice.  He does not receive financial compensation for his role with the journal.

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Works Cited

Allen, A.; Shane, H. (2014).  The evaluation of children with an Autism Spectrum Disorder: Adaptations to accommodate a telepractice model of clinical care. Perspectives on Telepractice 4(2):42-51.

American Speech-Language-Hearing Association. (2002). Augmentative and alternative communication: knowledge and skills for service delivery [Knowledge and Skills]. Available from www.asha.org/policy.

Curtis, T. R. (2014). Case studies for telepractice in AAC. Perspectives on Augmentative and Alternative Communication, 23(1), 42–54.

Hall, N. ; Boisvert, M. (2014). Clinical aspects related to tele-AAC: A technical report. Perspectives on Augmentative and Alternative Communication, 23, 18–33.

Hall, N.; Boisvert, M.; Jellison, H.; Andrianopoulos, M. (2014). Language Intervention via Text-Based Tele-AAC: A Case Study Comparing On-site and Telepractice Services.  Perspectives on Telepractice, Vol. 4, 61-70.