Assistive Technology, AAC, and ASD

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1 Evidence-Based Practice: part of the decision making process of selecting assessment and interventions approach in which current, high-quality research evidence is integrated with professional knowledge and expertise and preferences and values of the family and individual Research Professional Knowledge/Practice Preferences of Families/Individuals Kretlow, A. & Blatz, S. (2011). The ABCs of evidence-based practice for teachers. Teaching Exceptional Children, 43, pp Publication by Council for Exceptional Children Federal Policy: scientifically based research methods must be used in answering question What is most likely to work? 1

2 EBP: key concepts Type of research: systematic way researchers apply an intervention and measure its effectiveness Intervention must be measurable Intervention must show a clear cause-andeffect relationships with improved outcomes Magnitude: refers to the amount of a strong, positive cause-and-effect relationship Demonstrated in research synthesis (i.e., systematic reviews, meta-analysis, narrative reviews, professional guidelines) Intervention fidelity: accuracy, exactness, or a strick adherence to details; adhering to the details of the practice or program that makes it effective Ongoing progress monitoring or curriculumbased measures Define the component skills of the goal or curriculum Find or create measures of these components Establish the student s baseline level Introduce the intervention, paying attention to fidelity 2

3 Introduce the intervention, paying attention to fidelity Periodically measure progress Graph baseline and progress measures Use data to determine whether or not to adjust your instruction Number of Correct Responses Single-symbol-S Single-symbol-P National Research Council (2001): Educating Children with Autism. Washington, DC: National Academy Press. For children with autism who do not acquire functional speech or have difficulty processing and comprehending spoken language, AAC and assistive technology (AT) can be useful components of an education program 3

4 AAC includes use of visual language systems, such as visual symbols or words, representing specific communicative units which capitalize on strong visual processing of many children with autism (National Research Council, 2001) Visual information is static and predictable Enables child with autism to rely on recognition rather than recall memory to receive language input or generate language output AAC provides a motorically simple way to communicate needs and may preempt the development of challenging coping behaviors Low-technology AAC tools, such as picture systems, PECS, Pragmatic Organization Dynamic Display (PODD) communication books, are relatively simple and inexpensive to implement 4

5 National Standards Project classified AAC under the category of emerging treatment and Simpson and colleagues (2005) rated it as a promising treatment strategy National Autism Center (2009). National Standards Project: Addressing the need for evidence-based practice guidelines for autism spectrum disorders. Randolph, MA: Author Unaided systems: Teaching natural gestures for children in the early developmental levels (e.g., pointing, showing, waving, and nodding) is critical to development of joint attention and forms the basis of language development and social interaction Kasari, C., Freeman, S., & Paparella, T. (2006). Joint attention and symbolic play in young children with autism: A randomized controlled intervention study. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 47,

6 Unaided Strategies: Pointing, Joint Attention, Naming Joint Attention Use of computer with touch window and power point adapted book used to teach Pointing response Beginning of joint attention Initial literacy skills Child learned to: Listen to a page prior to turning page Modeled Point to an object on page and name it and look at child Child eventually pointed to an object, named it and looked at adult 6

7 Teaching Manual signs: children with fine motor difficulties are less likely to benefit from this form of AAC Goldstein (2002) reviewed the literature on sign language and ASD and concluded that total communication (sign + verbal) can be effective for early vocabulary development both receptively and expressively Goldstein, H. (2002). Communication intervention for children with autism: A review of treatment efficacy. Journal of Autism and Developmental Disorders, 32, Advantages of graphic symbols over manual signs or abstract symbols Demands on memory and cognitive skills may be lower for graphic symbols Little demand regarding motor ability Graphic symbols are more easily understood by unfamiliar communication partners Graphic symbols are easier to prompt Wendt, O. (2009). Research on the use of manual signs and graphic symbols in autism spectrum disorders: A systematic review. In P. Mirenda & T. Iacono (Eds.). Autism Spectrum Disorders and AAC. Baltimore: Paul H Brookes Publishing Co. 7

8 Lord and McGee (2001) argued that, while manual signs may support children in making a transition into first words, they are not generally an entry into fully functional language One major drawbacks of communicating through manual signs and gestures for children with ASD demands placed on communication partners increased fine motor skills for most signs and finger spelling dynamic rather than static symbols most manual signs are abstract rather than transparent & translucent (hierarchy) Aided systems: Study designed to investigate use of PECS and its effects on language development; results indicated that all children met learning criteria for PECS and showed increases in use of speech Charlop-Christy, M., Carpenter, M., LeBlanc, L., & Kellet, K. (2002) Using the picture exchange communication system (PECS) with children with autism: Assessment of PECS acquisition, speech, social-communicative behavior, and problem behavior. Journal of Applied Behavior Analysis, 35,

9 Another study found increased spontaneous expressive communication using a variety of modalities across all environments in which PECS was trained Kravits, T., Kamps, D., & Kemmmerer, K., (2002). Brief report: Increasing communication skills for an elementary-aged student with autism using the picture exchange communication system. Journal of Autism and Developmental Disorders, 32, Bondy and Frost (1998) reported that for 66 children who used PECS 59% (n = 39) developed functional speech and 30% (n = 20) combined some functional speech with PECS Body, A., & Frost, L. (1996). The Picture Exchange Communication System. Topics in Language Disorders, 19,

10 One drawback to PECS: teaches limited number of functions of language Requests Commenting Does not teach questioning, providing information (e.g., answering questions, describing, explaining, etc.), imaginative use of language, initiating and maintaining conversations, etc. Grace: itunes: Goal of Grace App is to encourage independent social interaction with user taking control of what they want to say. AAC TechConnect: AAC App Assistant: provides a description of Apps and allows you to compare across apps 10

11 Simple picture exchange system No digitized or synthetic speech Users select pictures to form sentences which they share by tilting iphone, ipod Touch, or ipad to create a full screen view Child points to each symbol to hear listener speak sentence No research to compare use of app with traditional PECS No research indicating that individual s increase use of speech using app (although this has been found with PECS) Evidence-based question: PICO Person-Intervention-Comparison Intervention-Outcome questions may be used (PICO) For children with autism disorder (P) does PECS (I) lead to significantly more spontaneous speech (O) than using Grace app on an ipad (C)? 11

12 Schlosser and Wendt (2008) and Schlosser, Sigafoos, & Koul (2009): systematic review related to the effects of AAC on speech production for children diagnosed with autism or pervasive developmental disordernot otherwise specified (PDD-NOS) Interventions did not impede speech production Interventions may result in increased natural speech production Modest gains made for most participants Speech Generating Devices (SGDs) should be considered as a viable AAC option Use of a systematic instructional package can promote rapid acquisition of SGD use Creating opportunities for communication, beginning with requesting but gradually increasing the functions of language (i.e., describing, providing preferences, asking questions, providing information, etc.) Wait for individuals to demonstrate a behavioral indication (i.e., reaching for an item) 12

13 Prompt individual to touch the corresponding button on SGD using least amount of guidance necessary (i.e., visual, gestural, partial physical prompt, physical prompt) Fade prompt Provide requested item or respond to communicative function immediately Schlosser, R., & Wendt, O. (2008) Effects of augmentative and alternative communication intervention on speech production in children with autism: A systematic review. American Journal of Speech-Language Pathology, 17, Schlosser, R., Sigafoos, J., & Koul, R. (2009). Speech output and speech-generating devices in autism spectrum disorders.. In P. Mirenda & T. Iacono (Eds.). Autism Spectrum Disorders and AAC. Baltimore: Paul H Brookes Publishing Co. 13

14 RAA and RAAP Strategies: strategies that are systematic and teach communication partners to model the use of AAC systems during book reading activities Strategies have been found to be efficient in teaching parents, teachers, peers, and para-educators to model AAC systems for a variety of children with disabilities Uses a systematic procedure for teaching communication partners the strategies Read-Answer-Ask (single symbol use) Read-Model-Wait/Pause If child points to symbol/pushes button on SGD, turn the page and begin strategy on that page If no response: Ask-Model-Wait/Pause If child points to symbol/pushes button on SGD, turn the page and begin strategy on that page If no response: Answer-Model- Wait/Pause If child points to symbol/pushes button on SGD, turn the page and begin strategy on that page 14

15 Read-Answer-Ask-Prompt (primarily for teaching multi-symbol responses but could be modified for single symbol responses) Read-Model multi-symbol combination- Wait/Pause If child points to multi-symbol/pushes button on SGD, turn the page and begin strategy on that page If no response: Ask-Model multi-symbol combination-wait/pause If child points to multi-symbol/pushes button on SGD, turn the page and begin strategy on that page If no response: Answer-Model multisymbol combinations Wait/Pause If child points to multi-symbol/pushes button on SGD, turn the page and begin strategy on that page If no response: Prompt child to use the device for multi-symbol combinations (verbal or physical prompt) If child points to multi-symbol/pushes button on SGD, turn the page and begin strategy on that page 15

16 Use of preferences for low technology system versus high technology system, such as an ipad, may be an individual preference thus assessment using both types of systems should occur Sigafoos, O Reilly, Ganz, Lancioni, & Schlosser (2005) used a teach and choose procedure in which they taught individuals with ASD to use both PECS and an SGD for requesting; once systems were taught the individual had to choose which system to use for requesting Flores, Musgrove, Renner, Hinton, Strozier, Franklin, & Hil (2012) compared the use of an ipad with a simple static requesting page with the use of picture communication system with 5 children (ASD = 3, Intellectual Disability = 1, Multiple Disabilities = 1). All participants had been using the picture communication system and were taught how to use the ipad system prior to beginning the study No clear pattern across all participants 16

17 Two participants clearly showed increase when using ipad one participant refused to request using the picture system after using the ipad and looked around for the ipad second participant picked up the pictures and threw them in the trashcan No participant showed a decrease in requesting when using the ipad Teachers preferred the ipad due to: ease of use less time in preparation Note: teacher s were not having to program ipad for specific individual needs Programing AAC apps to meet needs of specific individuals is critical fewer materials required participant s increased speed in communication 17

18 Flores, M., Musgrove, K., Renner, S., Hinton, V., Strozier, S., Franklin, S., & Hil, D. (2012). A comparison of communication using the apple ipad and a picture-based system. Augmentative and Alternative Communication Early online publication. Sigafoos, J., O'Reilly, M., Ganz, J., Lancioni, G. & Schlosser, R. (2005). Supporting selfdetermination in AAC interventions by assessing preference for communication devices. Technology and Disability, 17, Schlosser, R., Sigafoos, J., & Koul, R. (2009). Speech output and speech-generating devices in autism spectrum disorders. In P. Mirenda & T. Iacono (Eds.). Autism Spectrum Disorders and AAC. Baltimore: Paul H Brookes Publishing Co. 18

19 ipad: Turn Taking, Watching New Activity ipad: Turn Taking, Watching New Activity 19

20 ipad: Motivation, Reinforcement ipad ipad for first child was being used to teach taking turns and using verbal request (e.g., my turn) when provided visual supports ipad for second child was used as reinforcer for completing all work on schedule As you could see, the number system was being used to help the child understand the number of activities he could complete with the ipad 20

21 Aided Modeling Interventions AKA: Aided Language Stimulation (ALgS), System for Augmenting Language (SAL), Natural Aided Language Stimulation, Aided Language Modeling Strategies that require that the speaking partner use AAC as well as speech during interactions Provides a model of both input and output for the child using AAC and similar to models that typical children receive in the natural environment during the language-learning years Aided modeling interventions are implemented during opportunities that arise out of natural contexts, they augment the input child receives and they employ modeling to expand vocabulary as well as syntactic structures These strategies have been found to be effective for individuals with autism as well as intellectual disabilities Most aided modeling interventions may be used with either nonelectronic, low technology systems or electronic high technology systems 21

22 Aided Language Stimulation & Partner Assisted Scanning: PODD Emma's PODD with Linda Emma diagnosed as presenting Rett Syndrome Linda begins by providing partner assisted scanning for Emma since she cannot access page through direct selection After Emma s response, Linda uses aided language stimulation to provide a response to Emma s message System for Augmenting Language (SAL) components include (Romski, Sevcik, Smith, Barker, Folan, & Barton-Hulsey, 2009): Speech-generating device: serves as a medium for language experiences; provides use of a visual communication system + vocal output; particularly important when children integrated in general community settings 22

23 Individually chosen vocabulary words and the visual-graphic symbols to represent them based on child characteristics Type of symbols Number of representations presented simultaneously Arrangement of symbols on page Natural everyday environments that encourage child to produce symbols; use communication embedded in natural routines (e.g., meals, bed time, play, etc.) Communicative partners model use of symbol in these natural contexts Role of speakers who provide communicative input by speaking and by using Augmented input by selecting AAC symbols (visual) Augmented input by activating speech output on the SGD Augmented input by the environmental context; that is, using system in natural contexts 23

24 Role of listeners who respond to communicative attempts by children and may use device to expand child s communicative attempts Monitoring ongoing use: regular meetings with parents and other communicative partners to determine how things are going. Romski, Sevcik, Adamson, Cheslock, Smith, Barker, & Bakeman (2010): study with 60 toddlers Random assignments for all children to three groups; ASD children 6 randomly assigned to the augmented group 3 randomly assigned to augmented communicative input 3 randomly assigned to augmented communicative output 24

25 5 children diagnosed as presenting ASD assigned to the speech communication condition After 18 sessions 6 participants in augmented language interventions were using 71% of symbols on SGD Children in augmented language interventions showed a larger type-token ratio and produced significantly more intelligible communicative utterances than the children in the speech communication intervention Reasons why these aided modeling interventions work with children who present ASD Aided language modeling makes use of relatively strong visual-spatial skills Modeling of aided AAC while speaking makes communicative interactions naturally slower, which allows children with ASD more time to process information When adult is using the system, language input (auditory + visual) will naturally be relevant to the context 25

26 Aided language modeling focused on teaching family and other caregivers on how to use the AAC system for augmented input and output Recent research (Romski et al., 2010) found that both input only and using model with a prompt (verbal/physical) increased both spoken and symbol vocabulary more than speech alone Modeling was found to be an established intervention by the National Standards Project Drager, K., Postal, V., Carrolus, L, Castellano, M., Gagliano, C., & Glynn, J. (2006). The effect of aided language modeling on symbol comprehension and production in two preschoolers with autism. American Journal of Speech-Language Pathology, 15, Drager, K. (2009). Aided modeling interventions for children with autism spectrum disorders who require AAC. Perspectives on Augmentative and Alternative Communication, 18, Goossens, C., & Crain, S. (1986). Augmentative communication: Intervention resource, Wauconda, IL: Don Johnston Incorporated. 26

27 National Autism Center (2009) National Standards Project: Findings and Conclusions. Retrieved from C%20Findings%20&%20Conclusions.pdf Romski, M., Sevcik, R., Adamson, L., Cheslock, M., Smith, A., Barker, R., & Bakeman, R. (2010). Randomized comparison of augmented and nonaugmented language interventions for toddlers with developmental delays and their parents. Journal of Speech-Language-Hearing Research, 53, Romski, M., Sevcik, R., Smith, A., Barker, M., Folan, S., & Barton-Hulsey, A. (2009). The system for augmenting language. In P. Mirenda & T. Iacono (Eds.). Autism Spectrum Disorders and AAC. Baltimore: Paul H Brookes Publishing Co. 27

28 Visual schedules display whole, partial, or miniature objects or graphic symbols to represent daily activities and used to help individuals understand structure or sequence of events (what will I do), helping them to anticipate what will happen next thereby reducing anxiety between transitions (where do I go) Between-task schedules to retrieve information about what will happen next Visual schedules found to be an established intervention by the National Standards Project 28

29 Within-task pictorial schedules to help with completion of specific activities Mirenda, P. (2001). Autism, augmentative communication, and assistive technology: What do we really know? Focus on Autism and Other Developmental Disabilities, 16, Mesibov, G., Shea, V., & Schopler, E. (2004). The TEACCH approach to autism spectrum disorders. New York: Springer. National Autism Center (2009) National Standards Project: Findings and Conclusions. Retrieved from 20Findings%20&%20Conclusions.pdf 29

30 Quill, K. (1997). Instructional considerations for young children with autism: A rationale for visually cue instruction. Journal of Autism and Developmental Disorders, 27, Sainsbury, C. (2003). Martian in the playground: Understanding the schoolchild with Asperger syndrome. (8 th reprint). Bristol: Luck Duck Publishing. 30