Augmentative and Alternate Communication (AAC)

CD 485 Computer Applications in Communication Disorders and Sciences AUGMENTATIVE AND ALTERNATE COMMUNICATION (AAC) DEVICES FOR COMMUNICATIVELY HANDICAPPED INDIVIDUALS. SECTION III: SELECTING AUGMENTATIVE OR ALTERNATIVE COMMUNICATION DEVICES Augmentative devices are those that facilitate the verbal signal. The artificial larynx is one example. Another would be a dedicated computer that corrects a distorted speech signal; and a third, for the visual modality, would be a device that magnifies letters. An alternative device or technique, on the other hand, is one that provides a substitute for oral communication. Bliss symbols, sign language, communications boards and personal computers would be examples of alternate devices. Important also are the services required to help a disabled communicator learn how to obtain, use and maintain these devices. There are many criteria to be considered in assessing the selection and use communication aids. We are indebted to Dr. Bud Risor, the Director of the Center on Disabilities as CSUN for providing us with this clear picture of the assessment process. Of paramount importance here, is the basic philosophy that the selection process should not be randomly based. That is, we should strongly resist the human temptation to recommend a device simply because we have it, or because we like a particular company or representative, or because it is a quick and/or easy solution. These are decision formulas, which often lead to the relegation of a costly device to disuse in the client’s closet. In addition, the most important member of the assessment team, whatever it’s make-up, is the person (client) who is going to use the device. No matter how sound the professional reasons are for assigning a device to the user, if he/she does not like it, it will ultimately end-up on the shelf. Having said this, the following are some of the variables that should be considered in selecting a device or technique. 1. The nature and extent of the disability, e.g.: Flaccid paralysis—causes limitations in strength , movement, control and endurance. Among other things, this relates to the selection of the type and size of keyboard or other input device such as a switch; and in some cases the nature and programming of the software. Palsy and/or tremors—can also cause limitations in strength, movement control and endurance, but in different ways than a flaccid condition. Movements may be erratic, repetitive and hyper. Static pathology—is a condition that persists relatively unchanged over time. This means that the device a person obtains will be useful for a considerable period of time. Progressive degenerative—has a changing level of motor and maybe cognitive ability. In this situation, the prognosis suggests the person will have a device for a short period of time and then will need major and frequent changes to be considered. Degree of Involvement – is variable that can range from an impairment of just the Speech musculature to other or all parts of the body. This will impinge upon the person’s ability to use and care for a device. 2. The characteristics or qualities of the patient, e.g.: Concurrent disabilities—may include things such as other sensory problems in addition to the motor disability. Visual impairment, for example, would be a major factor leading to the selecting a device having special features such as large letters (including certain colors) on the keyboard or visual displays. Other medical disorders may contribute to a lack of energy and motivation, an/or chronic discomfort. Medications—can temporarily affect the cognitive and/or the motor performance of the user. Find out what medications the user may be taking. Motor capabilities--basically involve the parts of the body that the client can and cannot move. The latter determines the nature of the disability, (see the nature and extent of the disability, above); while the former is an important factor in the selection of the communication system. One important feature to be assessed is fine motor control, and range of motion . Keeping in mind that digital control is the most effective way to interface with a communication device, the parts of the body that can be used to interface with a computer directly or through a switch system are: Hands –- most devices are designed to be accessed in this way Arms—or any part of the arms Head—this can include in addition to a head switch (see picture below) a mouth stick, a helmet device, or a wireless mouse emulator etc. …or a head pointer (below) Eyes—can range from eye blinking (e.g., mores code) to directing (reflecting) electro-magnetic beams. Mouth—including a suck and puff switch, the use of tongue movement against a plate in the mouth etc. Leg—this the method used by Steven Hawkings Feet—this is the method most often available to those with cerebral palsey. Multiple—combinations of the above may also be used. Voice—is an option but is not typically beneficial to those with a oral motor disability. Motivation—is a major factor, which relates to the goals of the user and why the he/she wants the device; and equally important, when or where he/she does not want to use it. In certain situations, such as at home, for example, it is more efficient for some individuals to use gestures and other vocalizations to communicate a need, than to struggle with a slowly performing communication device. Family support—is another major factor, but may be difficult to ferret out. Is the family supportive or embarrassed by the disability, and are there any family members (or care takers) who can serve as communication partners? Financial status—may determine the quality of the device available. Will money for the device be coming from agencies, or can it be purchased along with support equipment partially or totally by the user, or in some combination thereof. Environment – may range from home to some kind of a live-in facility. This would determine not only the need for the device but also the support in terms of communication partners that may be available. Age and Age of onset—is, of course, an important factor that impinges upon the level of language development, the knowledge base, the perspective, the motivation and the employment skills that an individual may have. This in turn is going to effect in a major way the type of device, the training, in its use, and the goals that are set for its deployment. Cognitive level—may be affected by the disorder. There is a range of devices and techniques, which require different levels of sophistication. Some individuals, for example can handle a device with many input keys, and complicated techniques, such as semantic compaction (where icons can have more than one meaning depending on their sequence.) Others may be limited to devices with a few keys designated by pictures, or even a one-spaced device (such as BigMac-which looks kind of like a hamburger and produces a recorded message when pressed on top). Language level & Language needs—may be partly a function of age, cognitive level and background. If the client is a young child, language development, in addition to communication, may be a goal if the potential exists. On the other hand, an adult who has language can tap into such devices that are based on oral language such a those that have text to speech capability. The needs of the user—as we mentioned, is a major consideration. These are determined in part by the goals of the user. They correlate, of course, with the roles the user aspires to, and the environment in which the he/she operates. This can range from a home to a nursing facility, a school, a workplace or somewhere out in the community such as stores, restaurants and public transportation etc. The person, moreover, may wish to communicate with family members, adults, children, colleagues, friends, nurses, teachers employers, customers etc.; and to speak to individuals or to groups. 3. The cost of the communication device – is one of the first issues usually to arise. It may range from $1.00 to $50,000+. One of the dangers in assessment is that a device is assumed to be correct if it is expensive and powerful in the options it can provide. Often a non computerized inexpensive device such as a communication board or a system such as PECs (Picture Exchange System) will more effectively meet the needs and capability of the client, at least as a starter. Another pitfall is that once an expensive device is purchased, it often is not possible to change it for a number of years. Hence, if the machine is under-powered (with a relatively low price), it quickly is outmoded; but if it is over-powered (at a high price) much of its capability may go unused, or it may be too complicated and consequently abandoned. Typically, the clients do not have the financial ability to purchase the proper machine. There are, however, public and private agencies, which can provide financial assistance. There is a science, however, to making the request to these sources. Many companies selling Assistive Devices have departments, which will aid families through this process. 4. The sources of available funding -- are varied and include private versus government and/or third party payers. In particular these may be an early intervention service provider, Head Start, Public or Private Schools, a Resource Center, Title 5 Programs, Medical/Medicare/Medicaid, Private Insurance Companies, Vocational Rehabilitation, Disability Organizations (e.g., Easter Seal ), Service Organizations (e.g., Lions, Mason and Elks), Private Organizations and in some rare instances self-pay. In terms of many of these sources, the rule of thumb when you apply is that you will be turned down and must persist in your appeals! 5. The availability and costs of training patients (and/or their communication partner) to use AAC devices or techniques—is a sleeper that can kill an ACC program. Many of the funding sources provide no provisions for training the user or the communication partner. This results in the inefficient use and probable abandonment of the device. Some of the product providers (Private Companies selling AAC devices) do provide initial and sometime on-going training as part of the price of the device. This is a valuable feature to be noted when considering a device. 6. The availability of maintenance—is often a matter of city versus rural dwellers. Users in the country are often far away from the companies from which they purchased the device. Companies that sell devices often have repair warranties that are part of the sale package or that can be purchased. Of interest is the turn-around factor in terms of the time it takes to retrieve a device when it is sent to the factory for repair; and whether or not a loaner device is made available to the user. Some companies have representatives in the area that will come quickly when called to trouble shoot a device that is giving the user problems regardless of where they live. 7. The Particular Features of the Augmentative/Alternative Device itself must match the needs and capabilities of the user—features to be noted include: The Interface method—includes three different categories Direct Selection—where you go directly to the key you want, typically by using a finger, but sometimes with other parts of the body (viz. the tongue) or an extension such as a stick held in the mouth. Of importance here also to consider are the various modifications that are available. Different keyboards, for example provide special advantages. These may include: Large keyboards—good for users with poor fine motor control or visual acuity problems Small keyboards—good for users with restricted movement or restricted visual fields Membrane sensitive keyboards— good for students who may drool on them or spill food etc. Keyboards with sculpted keys or keys that are depressed—for users with poor fine motor control. Virtual Keyboard—is a keyboard, which is pictured on the monitor of the device. The keys can be directly accessed if the monitor screen is touchsensitive. It is also frequently used in conjunction with Proportional Pointing, and/or switches involving a scanning mode. The Operating System--of the device is an integral part of the keyboard operation. Certain features can be activated to facilitate keyboard access. These may include Sticky Keys which, when turned on, allows a function key and an alphanumeric key (viz. Shift & A) to be both activated with one finger consecutively; repeatturnoff, which when employed keeps a letter from repeating if it is held down (viz. ffffffffff); Acceptanc e Rate, which determines how long a key must be held down before it registers. This adjustment in the software would help users with poor motor control who sweep their hands across the keyboard activating in error many keys. Additional Software—programs are available to facilitate input for all three methods of input. One important issue, for example is rate enhancement. This involves software program that run concurrently with others (word processors) and provide the feature of word prediction. Ironically, res earch suggest that word prediction may not improved speed but it provides the same output with less expenditure effort, which is important for individuals with problems. Proportional Pointing—the use of a mouse to activate a key (on a virtual keyboard, for example) is a proportional device. It can be adjusted to move faster or slower, It can also be controlled by head or eye movements or a joystick. Switches—have various functions. One is an encoding device, such as a Sip and Puff switch, that can be used to communicate simple two-way commands, or complex communications like Morse Code. The other is a scanning system, which progressively activates individual (or entire rows, columns or blocks) input keys on a device. This latter method is available to almost anyone but has the disadvantage of being painfully slow. Other Considerations—in selecting the input device are issues of weight, shape, and ethnic representation (of the icons used). The first two relate to the working environment of the user. It should be arranged so that it is comfortable and convenient. The last relates to the social environment. If I am non-Caucasian, it is more appropriate if the icons reflect, at least in part, my cultural heritage. The type of processing including vocabulary storage (letters, sounds, words, phrases, sentences and/or speeches; static versus dynamic display; single versus multiple key activation; symbol systems used (including real objects or miniatures, photographs and pictures, line drawings, bliss symbols, numbers, letters, words etc.). One important consideration is whether or not the symbols used should facilitate the development of language or simply be an abbreviated system of communicating. This relates, of course, to the cognitive ability of the user. The type of output (encoding) including letter coding (abbreviation/expansion, eg. “WL” means “What’s for lunch?”), number coding (eg., “53” means “I want to eat.”), semantic compaction (eg., striking a key with an apple picture twice means “apple” but hitting the apple key and a car-picture key means red car.”), key linking (eg., hitting an apple key takes you to a page of fruit selection options), Morse code, icon or word prediction Output alternatives also include visual printouts or displays, (synthesized or digitized) speech, amplification, ethnicity and gender etc.) and tactile modes such as raised Braille or artificial hands; and interface capabilities with other devices (like a computer or a device for environmental control, for turning on and off the lights or the TV etc.)