Most children with autism have some difficulty understanding and talking with people. Communication skills are fundamental for participation in family activities, to do well at school and for long-term social development. It is hardly surprising that it is top of the list of concerns from every family who visit me for advice on supporting their autistic child.
Many of the children I meet find spoken words to be very abstract and can communicate more easily when using pictures or objects. The use of these tools when communicating is known as Alternative & Augmentative Communication (AAC) and the most famous examples are now found on the iPad.
We know that AAC can be very effective in helping autistic children develop communication skills to lead more fulfilling lives with their families and at school. But we also know that there are plenty of wrong-turns that can be made by caregivers and professionals that can lead to ineffective treatment and AAC abandonment.
1. Finding the right solution
Every child is different and the effects of autism differ greatly. No two families are the same and the way in which they communicate with each other, and the environment and culture in which this takes place, is different for every family I meet.
It can be tempting to download a popular iPad app because it is marketed at people with autism, or because a friend’s child is successful in using the app. This approach misses the richness of communication and the diversity of people’s strengths, needs and preferences. Making the wrong choice isn’t just ineffective but can be harmful as a failed attempt can jeopardise further attempts.
Fortunately there is a wide range of AAC tools available for consideration, and most of these tools can be customised to meet the needs of the person and their family.
2. Low Tech vs High Tech
Low-tech AAC tools usually consist of laminated pictures which are used in visual timetables and communication systems such as the Picture Exchange Communication System (PECS). High-tech AAC tools include the iPad apps, dedicated Speech Generating Devices (SGDs) and simpler tools such as the BIGmack.
Evidence from a number of research studies show that both low-tech and high-tech tools are effective in improving communication skills but there is evidence that PECS is more effective for young children who have both autism and learning disabilities.
PECS is probably more effective because it is a system of communication exchange and language development, not just a tool placed into the hands of the user.
3. When to introduce AAC
Reviews of case studies tell us that while AAC is beneficial for all age ranges, preschoolers benefit the most as improvements at this age lead to greater lifelong benefits. In these case studies the preschoolers were supported by professionals in the use of the AAC device
4. How to improve behaviour
Challenging behaviours often result from a difficulty in communication and improvements in these skills often result in better behaviour and social function. The evidence seems to show that high-tech SGDs result in better improvements compared to low-tech approaches. In order to achieve success the AAC device should be accompanied by some form of functional communication training, usually provided by a speech and language therapist.
5. AAC doesn’t limit speech development
Many parents are concerned that an AAC device may affect the possibility of children’s developing natural speech. In reality AAC can actually help many children develop their speech, more so if they have some speech when the AAC is introduced. AAC does not have a negative effect on speech!
6. Where to use AAC
Children often learn to use AAC in small rooms with a speech and language therapist. In these cases children should be given the opportunity to quickly practice these skills in a range of other ‘real-world’ environments and with different communication partners. Children with autism are known to have difficulties generalising skills from one situation to another and so providing support in accomplishing this is critical if the AAC is to provide meaningful benefit.
7. Allow the freedom to communicate
A common observation is that children are ‘forced’ to communicate using their AAC device, to the extent that attempts at speech or gesture are ignored by the caregiver.
Although evidence of use of multiple methods of communication is very limited, the professionals studying these issues do agree that children should be permitted to express themselves in multiple ways depending on their preference at the time. This makes sense as using an EyeGaze system to navigate to an item on a page to express the need to go to the bathroom is far more time-consuming than using a simple hand gesture or laminated symbol.
8. Don’t use Facilitated Communication
Facilitated Communication (FC) involves a caregiver or facilitator who provides physical support to the AAC user’s arm in helping them select symbols or letters from an AAC device. This approach has been found to be harmful and should not be used.
This is one of many unsubstantiated treatments for Autism that are promoted by some parties on the internet an elsewhere. Caregivers and professionals who would like more information about what works and what doesn’t for autism could visit the National Standards Project hosted by the US National Autism Center.
9. Use AAC for more than requesting
We all use our communication skills for more than asking for food or protesting when we want something to stop, yet most AAC solutions focus on these two areas. Ensure that the support is put in place to allow the autistic child to greet other people, to tell jokes, to show off and to share social routines. The AAC device should also enable the child to be involved in joint attention activities whereby two people attend to the same thing at the same time (such as playing the Switch Skills for Two games).
10. It’s not what you have, it’s how you use it…
The introduction of the iPad and other mobile devices has had a huge impact on the use and development of AAC tools for children with autism. For many children, however, the iPad is not the best tool and low-tech tools such as PECS or simpler SGDs should be considered.
But more importantly, the evidence indicates that success is less determined by the AAC tool itself and more by the way the person learns to use it, who they choose as communications partners and the environment in which it is used.
Much of the above information is discussed further in an excellent article by Jennifer Ganz, Associate Professor of Special Education at Texas A&M, which reviews all the science we know so far about using AAC with children on the autistic spectrum.
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