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June 16, 2021

The Ultimate AAC Guide

Table of Contents

What is assistive technology?

Assistive technology (AT) refers to any piece of equipment, system, device or object that help people with disabilities engage in day-to-day activities. The two major aims of AT are to help enhance the existing strengths of individuals and to present alternative means to accomplish tasks or to build skills. For instance, a person may not speak in a traditional sense but can communicate through AT devices.

Some other skills that can be improved, maintained or enhanced by using AT are socialization, organizing, academic competency, self-sufficiency, everyday functioning, attention, vocational guidance, expressive and comprehensive communication, movement and many more to count. As it can be seen, healthier development of children can be supported with assistive technology. Consequently, children may establish a sense of individuality and independence as people, while also developing competency to deal with daily problems that might require assistance.

Types of assistive technology

Although the term assistive technology seems to have a high-tech connotation, it actually is not just about smart hand-held devices.

Dry erase boards, photo albums, tapes, clipboards, binders, calendars, checklists, pictures, symbols, sensory balls and many more can be used as AT. These do not rely on electricity to function or require any training before using. For instance, it is a great idea to write daily schedules on boards or to mark important dates on calendars and let the children track their routines or upcoming events.

There are also different devices that are operated electronically and also require a small amount of training to use properly. Tape recorders, projectors, timers, calculators, audiobooks, screen magnifiers, video cameras, computers, voice output devices, apps, mobile devices, tablets, recorders, motorized wheelchairs, robots and many more are some of the examples of AT tools. Many different skills can be targeted using these devices because they enable customizability. For example, apps are very accessible and dependable means that can assist individuals in communication, attention, daily functioning and self-maintenance all at once.

Assistive technology and ASD

Autism spectrum disorder (ASD) is a developmental disorder that can be conceptualized as persistent impairment in social interactions, deficits in verbal and nonverbal communication and restrictive or repetitive patterns of behavior (APA, 2013). In addition, individuals with ASD usually develop language differently or unevenly. For instance, it’s possible to learn to read earlier but without actually understanding the meaning of the material. Also, they may not reciprocate while speaking or may not respond when called by their name.

Moreover, very limited vocabulary use, inability to make requests, lack of eye contact and gestures are also some of the impairments that can be added. People on the spectrum may struggle more when learning about self-care activities and have to rely on others about those. Caregivers usually invest time and effort to always monitor and give the required help, but this can be too much to handle at times.

Various methods of assistive technology were shown to be successful in aiding individuals with ASD develop essential skills such as communication or socialization. Here are some benefits of AT on people with ASD.

Assistive technology and ASD

Benefits of assistive technology on ASD

  • Communication

There is a subfield of AT called AAC (Augmentative and Alternative Communication), in which the main focus is to enhance communication. AT strengthens existing communication skills while adding new means to the mix both verbally and nonverbally. For instance, most individuals with ASD are visual learners. There are many tools that have pictures, videos or other visuals which represent words or phrases. Children can learn these symbols and communicate their messages through them.

Specifically, in speech generating devices (SGDs), images and symbols represent words and actions. SGDs translate individual’s chosen images or symbols into electronically generated speech that others can understand. This way, by using a strength such as visual learning, this device enables even nonverbal people with ASD to communicate. More detailed information about SGDs and AAC will be given in the upcoming section.

  • Sensory issues

Certain individuals with ASD also experience sensory challenges stemming from bright lights, bells, buzzers and similar ordinary sources of sound. They may feel overwhelmed by the sensory information in their environment on a level that is highly disturbing for them. There are different AT strategies that help individuals calm themselves down in those situations.

Weighted vests, soft stress balls, visual timers, sound-cancelling headphones are some of the beneficial tools for sensory issues. These assist in reducing the sensory overload and alleviating anxiety. There are also devices (i.e., apps) that detect the decibel level of sounds and warn when the threshold has been passed to prevent any distress. Another commonly used strategy for sensory regulation is using apps in which people can calm themselves by watching changing images or popping bubbles.

  • Self-regulation

Numerous people with ASD struggle with self-regulatory skills. These include organization, planning, self-monitoring, completing tasks and time management. Previous research concluded that AT supports self-regulation and promotes in-task behaviors (Desideri et al., 2020). There are different devices that assist in these areas. For instance, visual boards indicate daily activities such as getting dressed or brushing teeth and individuals can look at the board and see what needs to be completed next. Apps can also show daily schedules and how much time is allocated to each activity. This way, individuals can be more organized and practice self-maintenance.

Making lists of targeted behaviors (i.e., hand washing) or items (i.e., grocery list) is also another great strategy that can be used. Being able to see what needs to be done increases the likelihood of such tasks being completed. Feeling capable enough to overcome these activities personally improves the sense of self, individuality and self-esteem while developing self-regulation strategies such as goal setting, self-evaluation and insight. It is important to remember that continuing to do the task also decreases the stereotypic behaviors because of the reduced frustration and the added self-confidence (Stasolla et al., 2016).

  • Social skills

Another critical benefit of AT for people with ASD is related to social skills. It’s been shown that these devices act as a mediator between individuals with ASD and others. In doing so, they can get out of their comfort zone slowly, which in turn ensures an increased feeling of relaxation in social settings.

Also, there are devices that present certain social situations and teach how to behave or what to think while experiencing these. People with ASD may not just learn but also get a chance to rehearse appropriate behaviors. Through these rehearsals, individuals can get familiar with empathy, reciprocity, feelings and other important components in social interaction. Promoting better social skills additionally create more opportunities for inclusion with other people.

Children socializing

  • Academic skills

Academic integration to school, developing and improving literacy skills (reading, writing), working on school subjects, projects and tasks can pose significant challenges for people on the spectrum. Traditional teaching methods may not work as effectively. Generally, adding more visual elements to learning materials help children retain information better. For instance, using audio or video recordings can ease this process. Individuals get a chance to revisit instructions of tasks or lectures when they need.

Before moving on, it’s important to point out that there are apps that also specifically aim to eliminate learning challenges such as writing, reading and comprehension, math and so on by transcribing speech to text or vice versa. With these, adjustment to the school system and getting used to subjects, homework, grading and other elements of academic life can be made a lot easier.

  • Motor development

Delays or irregularities in motor development are also pretty common among children with ASD. These may also prevent other activities that are vital for children. For instance, they may not be able to hold some toys so they cannot play with them with friends or family. Manipulating or readjusting toys or objects using AT can benefit the child tremendously. Simply adding more accessible grips or knobs onto toys or objects reduces struggles about holding or grasping.

Issues regarding motor development may also naturally cause great frustration and aggression in individuals when they cannot hold an object or press a button. Using strategies that make these objects more accessible reduces negative feelings or behaviors. When this obstacle is lifted, children feel more capable. In turn, they can be more engaged in the activity or interaction.

  • Emotion recognition

Understanding different emotions from faces or voices of different people is a crucial element of nonverbal communication. Individuals with ASD may have impairments in this area, which is closely linked with socialization. Because they cannot understand what the facial representation of a certain emotion is, they may not be able to infer how the other person is feeling and communication may suffer.

Luckily, skills related with emotion recognition and regulation can also be targeted by the use of AT devices. In a study, a specific software was created in order to teach children how to identify, properly express, understand and rate emotions. Results showed an improvement in all these (Lacava et al., 2007). Likewise, it is also possible to use lower-tech strategies in teaching emotion recognition. Charts can be prepared with pictures of faces expressing different emotions. With repetition, children can learn to recognize different emotions and body expressions of others.

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What is AAC?

Augmentative and alternative communication (AAC) is a collection of techniques, devices, tools and strategies aimed at resolving any communicative struggles. Mainly, problems in production of speech, language development and comprehension regardless of the different communication modes (written or oral) are tried to be managed. Particularly, AAC helps people express their thoughts, desires, wishes, requests and opinions.

Just as it is in assistive technology (AT), the two primary goals of AAC are to support or “augment” existing communication modalities and to demonstrate “alternative” means to communicate more functionally. The difference between the two constructs is that AT can be used to improve many different skills, while AAC focuses mainly on communication. Thus, it is appropriate to say that AT is more like an umbrella term that also includes AAC.

Types of AAC

Any means of communication except for speech that help individuals to interact with others can be considered as AAC and there are several different categories. Primarily these systems are put into two categories: aided and unaided.

Unaided AAC Systems

In these systems, individuals do not use any equipment to assist them in communicating other than their own bodies. Elements of nonverbal communication such as gestures, body language, facial expressions and even sign language are considered within these systems.

Aided AAC Systems

In contrast to the unaided AAC systems, the characteristic of aided AAC systems is the use of supplementary equipment that can either be operated electronically or not. Just like in AT classification, aided AAC systems are also categorized as low-tech and high-tech.

a. Low-Tech AAC

Low-tech aided AAC systems are mostly non-electronic and involve visual boards, cards, pictures of objects or actions, notepads and Picture Exchange Communication System (PECS). These systems are also cheaper to use than high-tech ones.

Also, they can be created easily by printing pictures and sticking them on a board. Individuals just point or touch to the picture and state what they need or want in a simple way. PECS is also developed with the same rationale but includes its own materials and requires training to use. More detailed explanation of PECS can be found in the later sections.

Another form of low-tech AAC systems is facilitated communication, which basically means having a person physically help nonverbal people communicate by supporting their hands or arms while typing or writing. This method is repeatedly discredited by scientific research and no longer supported due to findings that indicate ineffectiveness and also harmful effects on individual communicative competence (ASHA, 2018).

b. High-Tech AAC

High-tech aided AAC systems are electronic and include systems such as speech generating devices (SGDs), tablets, apps, smart phones and voice recorders. The most advantageous side of these systems is customizability. It is very possible to add more words or pictures related with personal interest and experience. Also, because most devices are hand-held, they can be used anywhere with anyone. Being able to do so increases opportunities for interaction and building communication skills.

The main operating logic of high-tech systems is the same with low-tech ones. Individuals use visuals that represent words, phrases or sentences to communicate. Depending on the device (i.e., SGDs), chosen words or actions can also be vocalized, which in turn enables people to “speak”.

High-Tech AAC

AAC and ASD

Many individuals with communicative impairments or developmental delays may benefit from AAC. According to recent estimates, 25% to 40% of people with ASD are nonverbal (as cited in Rose et al., 2016). Although there isn’t an agreement regarding the percentage, it is safe to say that a large group of people on the spectrum experience difficulty with verbal communication.

As explained above, AAC uses visuals as means of communication for the ones who cannot speak in a traditional way. This makes AAC an apparent and popular method for individuals on the spectrum. Previously, it was not a preferred treatment modality and used only as a last resort. Nowadays, with growing scientific support, it is seen as an intervention method with beneficial results in many areas. Improvement in speech development, social communication, language acquisition and decline in problematic behaviors and many more are within the scope of the benefits AAC systems provide for individuals. How and in which areas AAC helps people with ASD will be discussed in the upcoming chapter.

Benefits of AAC on ASD

Usually, development of communication skills begins with listening and observing facial expressions, gestures and body language. Following that, people start mimicking these behaviors and sounds that are then developed into speaking. Later, reading and writing develop in a similar way.

For people with ASD, these developments may occur in a different order. That’s not to say that the development is abnormal, but it means different strategies are needed to be followed to enhance current abilities while assisting the ones that fell behind.

This is the part where AAC comes in the picture. As stated before, people on the spectrum learn and process better if the material is visual. Using this strength, it is possible to elevate areas related to communication in a comprehensive manner.

To understand the benefits of AAC on ASD, we sent a small set of questions to our users to evaluate how their child uses Otsimo apps and their experiences with them. Most children reported to have problems in speech development. We asked parents to indicate in which ways Otsimo was utilized by their child. The most frequent purpose of use was to request something, followed by sharing experiences, asking something, commenting, doing schoolwork, casual talking and learning new things.

Parents were also asked about the areas in which they think Otsimo was especially beneficial. Results show that for overall attention, vocabulary, interest in activities and social engagement, Otsimo was positively influential. There are also some small but meaningful positive effects and improvements regarding negative feelings and behavioral issues.

Here we offer some scientific evidence about the benefits of AAC.

Benefits of AAC on Development of Speech

AAC paves the way for interacting in a nonverbal way. For many years, the use of these devices were believed to hinder development of speech. However, research findings repeatedly refuted this claim and further supported the opposite view.

To be more specific, one review article suggested that introduction of AAC actually improved speech production across 25 studies that were conducted from 1975 to 2020. Other review articles also concluded that there was no negative effect of AAC on speech. Besides the lack of negative effect, recent findings show that in fact, AAC plays a significant role in the development of speech (Millar, Light & Schlosser, 2006; Schlosser & Wendt, 2008; White et al., 2021).

One important thing while interpreting these results is that research on ASD typically consists of single-case design studies as the general population that includes people with ASD is pretty heterogeneous. This is the reason why there is a limited number of participants in the studies. This circumstance did not depreciate the meaning of the results, especially when analyzed together like in the review articles. In reverse, this may mean that it’s worth giving AAC a shot.

Keeping this fact in mind, it’s safe to say that the use of AAC does not affect speech development in a negative way. On the contrary, continuous use increases the number of expressed words, mean length of utterances and requesting behavior. This means AAC actually improves the development of speech.

Benefits of AAC on Comprehension

Previously, improving expressive communication was the main reason to use AAC. However, AAC seems to benefit comprehension in many ways, just as expression. In other words, AAC works not just to convey messages but it’s also useful in understanding what other people mean.

Most conventional speech can be very fast and overwhelming for people with ASD. Matching objects or actions with their definitions and pointing at objects when requested can be considerably hard for them. Using AAC really slows down and eases up this process.

You might ask “How does AAC help in comprehension?”, and the answer can be found in previous research. In one study (Drager et al., 2006), participants, who were children with ASD, were presented with objects such as cars, dolls or tables and asked to show one of the objects. The same question was repeated for picture versions of the objects. After children successfully completed both tasks, they were asked to name objects in the pictures. To be able to do this, children must understand that the visuals and words represent the objects. For instance, they should comprehend that a picture of a car, as well as the word “car” stand for the car as an object. This sequence of events occurred through repeated sessions and eventually, all participants were able to comprehend that the visuals and words represent the objects.

In similarly designed studies, again, AACs were found to be effective in comprehension of speech (Sevcik, 2006; Drager, 2009). Considered together, these results indicate that AAC enhances the ability to understand and identify words by using symbols (i.e., pictures).

Benefits of AAC on Comprehension

Benefits of AAC on Social Communication

Individuals with ASD also have impairments in the area of social communication. For instance, they may not use gestures or body language and may not make eye contact. Also, most of them don’t communicate through speech. With these combined, individuals with autism have few opportunities for social interaction.

Components of social communication are:

  • initiating (starting the interaction)
  • requesting (objects, actions, information etc.)
  • commenting
  • joint attention (sharing focus on the same object)
  • acknowledgements (answering “what, which, where, who” questions)
  • reciprocity (the back-and-forth nature of communication)
  • eye contact

According to an article reviewing 30 studies (Logan, Iacono & Trembath, 2017), AAC proved beneficial for all these mentioned components.

Requesting objects is one of the main uses of AAC systems. However, in time, it was shown that AAC can be utilized to serve several different social functions. For instance, making comments, answering simple questions, actively engaging in activities with others, starting conversations and more socially driven activities can be improved with continuous practice.

Benefits of AAC on Language Development

Language is used for understanding others, expressing self and doing both of these in appropriate social settings. Children begin developing language right after they are born. Relevant skills are improved by observing people around them, trying to communicate their needs through and mirroring their movements or gestures. However, this process does not happen this way in children with ASD.

For instance, they are less interested in people and more interested in other objects or things around them and they may not make eye contact. So, the natural rehearsal process of language with parents or caregivers can be missed. Ultimately the language development may be impaired or delayed.

Luckily, just as speech development, language development can also benefit from the use of AAC. Especially if the intervention started at an early age (birth to age 3), which is the recommended way; language acquisition can be made with the help of visuals on the devices.

Specifically, in AAC systems,visual materials symbolize words or actions. This is similar in other ways to learn language. For example, in sign language, hand movements symbolize the letters or words. Or in conventional speech, lip movements and speech sounds serve the same function. Symbolization is a key element in language development and is also what AAC operates based on.

Vocabulary can be extended with the use of AAC with visual aids. Grammar, on the other hand, is a harder issue to tackle because representing symbols can be harder to find. However, there is evidence that both areas can benefit from use of AAC to the point that the children can understand, express and socially use language in many different settings (Romski et al., 2015).

Benefits of AAC on Academic Skills

The major benefit of AAC is about communication, which is the cornerstone of academic skills in general. These skills are spelling, reading, maintaining attention and so on. Also, thanks to communicative gains from the devices, children on the spectrum can participate in the classroom more and socialize a lot easier.

Research shows that literacy development is one of the areas that draw advantage from implementing AAC (Light & McNaughton, 2012; Ganz et al., 2012). This allows individuals to communicate more independently, engage more in education and enhances learning processes. Before being able to read or write, pictures were used as symbols that aid communication. Written language enables children to visualize patterns of words, phrases and sentences. This new representation opens up new doors into higher education as they are not only relying on pictures anymore. So, being able to read and write further expands development of language.

Other benefits mentioned above also contribute to the classroom setting. Being able to communicate reduces behavioral issues and helps children blend in. Different problem areas or goals can be targeted by adapting the use of AAC. Teachers and parents are advised to work collaboratively to help individuals tackle issues both in school and at home to generalize the gains even more. Tips for parents and teachers can be found in the following sections.

Benefits of AAC on Academic Skills

Benefits of AAC on Challenging Behaviors

Examples of challenging behaviors in ASD are aggression, self-injury, repetitive actions, stereotypes, frustration, shouting, meltdowns, tantrums and many more. The reasons for these can differ, but it would not be wrong to assume that a large part of the reason is inability to communicate. Deficits in expressing self and also understanding others can lead to frustration, disappointment and even aggression.

AAC opens up a new door into effective communication that naturally leads to feeling well understood, fulfilled, pleased and even empowered. Therefore, challenging behaviors decrease with consistent use of AAC, according to two different review articles (Ganz et al., 2012; Walker & Snell, 2013). The results are more effective and continuous especially if AAC is implemented in various settings starting at a younger age.

ASD and SGDs

A large percentage of people with ASD are nonverbal or experience difficulties with speech. As anticipated, these problems affect language development unfavorably. These adversities can be reduced by using speech generating devices (SGDs).

As it was mentioned above, SGDs were developed to enable individuals who cannot use spoken language to “speak” electronically. The way SGDs manage to achieve this is by using pictures or symbols located on the screen. When a person touches those visuals on display (or presses buttons), corresponding phrases or words (speech output) are played. In some devices, besides images and symbols, it’s possible to write words or sentences to be vocalized as well. Generally, SGDs have more than 4,000 words, symbols and images.

The speech output can either be synthesized or digitized. Digitized speech is basically a natural human voice that was previously recorded so it highly resembles natural speaking. Also,igitized speech output allows users to record their own messages, words or phrases. But the recording quality is sensitive to any noise and the output is restricted to the number of recordings.

On the other hand, synthesized speech is generated by the device, so it is produced electronically. Because it does not require recording of a real person’s voice, production of new messages is easier, and the sound is clearer. However, individuals still may not prefer artificial voices. It is important to note that synthesized speech is resembling natural speech more and more as technology advances.

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Benefits of SGDs on ASD

As it was mentioned earlier, SGDs enhance the communication skills and language development of people with ASD. Struggling to communicate can be accompanied by feelings of disappointment, confusion, disturbance or detachment. These feelings may also cause behavioral issues such as tantrums. When SGDs let individuals get in touch with others, these negative feelings fade away and so do the problematic behaviors. Being less agitated and engaging in less disruptive behaviors promote development of verbal abilities. Actually, across different systems of AAC, SGDs were found to be the most effective in resolving behavioral issues (Ganz et al., 2014).

One of the most apparent benefits of SGDs is that they teach people on the spectrum how to request, which is key in initiating an interaction. In nearly all research conducted to assess the effectiveness of SGDs, increase in requesting behavior is the only robust finding (van der Meer & Rispoli, 2010; Schlosser & Koul, 2015).

Besides requesting, research shows that (Thunberg, Sandberg & Ahlsén, 2007; Thunberg et al., 2009), when an SGD was introduced, children’s interest and attention to the activity increased, they started reciprocating and waiting for their turn to answer while interacting. Specifically, if the objective of the activity can be fulfilled by using SGDs, the effectiveness increased. For instance, when a question was asked, individuals used the device more to answer the question and communicate their thoughts. Whereas during mealtime, naturally, the usage dropped because the goal in mealtime is to eat, not to speak. Lastly, it was noted that the examples of interaction really matched those of verbal communication. Once the children become accustomed to the device, their interaction with others becomes more natural.

PECS

Picture Exchange Communication System (PECS) is a one of the most used method of augmentative and alternative communication. The aim is the same; to enable functional communication.

PECS have cards with objects, actions, symbols, words or pictures printed on them and individuals give, show or exchange these cards when they want something. It’s also possible to use the cards to make comments, choices, requests and to ask or answer questions. Basically, these cards mediate the communication between individuals who use them and the world.

Who is a candidate for PECS?

People who cannot communicate traditionally, with no age restriction, can use PECS. Non-verbal individuals, people who cannot initiate conversations or who can benefit from increasing vocabulary or communicating more efficiently create the target group for the system. In other words, people with no verbal communication can utilize the system to interact, while people who can talk may use the system to improve interaction skills. To be more specific, individuals that struggle with verbal communication due to having ASD or other developmental disorders can benefit from the system.

How does PECS work?

There is a specific training program that requires participation of parents, teachers, other specialists and of course the children. It’s advised that all steps are implemented in correct order in a similar manner across people and situations. The duration of this training process differs for each individual.

  • Phase 1: How to communicate

The goal of the first phase is to learn to give the visual of the desired object or activity to the other person. For instance, the child wants a toy car. There is a picture of a toy car in front of them. One person guides the child to pick the picture and give it to another person. In this phase, there are two people other than the child. When the guided exchange is completed, the communicative partner immediately reinforces the behavior by praising. Reinforcement is key in the learning process. It gives the message that the activity was welcomed, approved and should be repeated in the future.

  • Phase 2: Distance and persistence

In this phase, children learn to use this new way of communication in several settings (i.e., home, school etc.) with different people. Reinforcement should continue but any prompts should be eliminated gradually. This enables using the system independently to communicate.

  • Phase 3: Picture discrimination

This time, two pictures are presented and the child must select the desired one and give to the other person. Initially the second picture is something the child does not prefer. For instance, if the child wants a toy car, the second picture can be a food item which is from an unrelated category. One by one, the child understands to distinguish pictures.

  • Phase 4: Sentence structure

Learning to form simple sentences is the aim of this phase. There is a picture that represents the phrase “I want”. The child is expected to combine “I want” picture with another one to state what they desire. Also, pictures of adjectives (i.e., red, big), prepositions (i.e., on, in) and other words are added to further expand vocabulary and enrich sentences.

  • Phase 5: Responsive requesting

The goal is to answer questions such as “What do you want?”. The child opens the book with pictures and gives the answer using them.

  • Phase 6: Commenting

Other questions are asked in this phase such as “what do you see, what do you hear, what is it?”. Children then learn to answer those in correct forms like “I see or hear this” or “it is a…”.

Benefits of PECS on ASD

PECS is a well-studied method. Many scientific studies were conducted to understand and support the effectiveness of the system. The results indicate substantial benefits in several different areas. It is important to say that benefits of AAC are parallel to those of PECS. Specific findings are discussed in this section.

It is important to mention that at first, PECS was developed for ASD exclusively and later expanded to different populations. So, there are many studies conducted to demonstrate the effects of the system for people on the spectrum.

Communication benefits of PECS

Individuals with ASD may possess communicative impairments. They may be non-verbal or may have developed speech but struggle with social components of communication. PECS teaches people an effective but relatively easier means for communication. Actually, the system helps the child to interact but also assists parents, caregivers, teachers and peers to communicate with the child in a simpler and more understandable level.

Initiating interactions is a great benefit that the system provides, regardless of the age (Ganz et al., 2012). Even children who seem indifferent to their surroundings learn to start a conversation spontaneously. Requesting something is the primary objective of PECS. Children are taught to request for their needs or wants which also requires them to initiate communication.

Overall, from two different meta-analysis articles (a method of statistical analysis that combines findings from different studies to understand any general effect) with more than 24 studies incorporated, it can be said that PECS is an effective modality for improving communication skills (Flippin et al., 2010; Ganz et al., 2012).

Social Communication benefits of PECS

The nature of PECS is physically exchanging a visual aid with another person. So, the context is always reciprocal. Initiating, requesting and joint attention are all interactive and reciprocal elements of social communication that are also embedded in PECS training objectives. In short, PECS benefits social side of communication as well (Lerna et al., 2012).

One study investigated communication with peers using the system and found out that when the peers understood how PECS work, their interactions improved (Thiemann-Bourque et al., 2016). This enabled people on the spectrum to play and socialize more with individuals their age. In most of the interactions, children with ASD requested and peers responded but some of the children shared their toys or made small comments as well, even though commenting is not yet a skill they acquired during PECS training. This shows the room for improvement when the system is used in various setting with different people.

Benefits of PECS on Speech

Teaching speech was never an actual objective of PECS however, some children using the system developed skills to use speech in an instinctive manner. In other words, PECS is a method of communication and learning it may make it convenient for individuals to learn another way to communicate such as speaking. Still, this is not a main goal of the system but an added gain. It is important to say that individuals may not develop speech and use speech generating devices (SGDs) instead.

Different articles reported that vocabulary and length of utterances increased after learning to use PECS. In other words, some children started forming longer phrases, clauses or sentences than before. Also, vocalizations that are not recognized as words decreased in the process. However, it is important to emphasize that the findings related with speech outcomes are mixed and not equally effective across participants of studies (Ganz & Simpson, 2004; Jurgens et al., 2009; Flippin et al., 2010).

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Benefits of PECS on Behavioral Issues

Disruptive behaviors such as throwing, destroying or hitting and tantrums including behaviors like yelling, crying are not targeted outcome variables for PECS. This means, the use of PECS was not hypothesized to decrease these problematic behaviors. However, there are both anecdotal and research-based evidence that shows effects as such. In short, there is a supplementary gain of declined behavioral issues in children using the system (Charlop‐Christy et al., 2002; Ganz et al., 2012).

The reason this consequence can be explained with a simple logic. Behavioral issues mostly stem from the frustration of inability to communicate. So, when children began communicating functionally, problematic behaviors could be reduced. Especially when children are adjusted to the system and use it most of the time, the results can be maintained. In this way, children can feel understood and related. Being less frustrated brings emotional stability that is the gateway for less behavioral issues.

How to choose suitable device, system etc.

Prerequisite skills

Before explaining the factors in the process of choosing, it is crucial to understand that there are no skills an individual must have prior to using an AAC system. Previously it was believed that there are some prerequisites to begin with, however, this was proven to be wrong. Here are the so-called prerequisite skills explained one by one.

Understanding cause and effect

First of all, understanding the cause and effect was thought to be necessary in order to use the systems. The main principle of communication relies on cause and effect, which fundamentally means one action causing another. To be more specific, individuals might not know that when they want an apple, they can just ask for it. And because they ask, they will be given one. So, to receive an apple (effect), one must ask for it (cause). However, some individuals may not ask because they may not know that them asking will be linked to receiving what they want. That is, the concept of cause and effect may be missing for some people.

Priorly people believed that the inability of putting these pieces together means a child will not be able to use AAC. However, a body of research stated otherwise. To begin with, many children with cognitive deficits use these systems as aid in developing lacking skills (Drager et al., 2010). This is the main principle of AAC; to augment the skills in hand and to give alternatives for the ones that are absent.

Even if a child cannot understand cause and effect, it can be taught by using AAC. For instance, you can choose a picture of an apple and help the child give it to you or press the picture on the smart device. Then you give the child an apple. Doing this sequence of events repeatedly makes the child understand that an apple was given after giving or pressing the picture. This simple learning process not only teaches the child cause and effect but also lets them start to communicate.

Asking for Apple: Cause and Effect

Understanding that the picture of an apple represents an actual apple can be hard for some children. Being able to associate the visuals with the objects may not be available and this is not a drawback to start using AAC. On the contrary, the systems themselves can be used to teach this association.

Just help the children give (or press) pictures of objects that they desire and then provide the objects to them. This is basically the way AAC works as it was mentioned above, frequently. By doing so, children will start making the connection that pictures symbolize the real objects. Later, the same can be rehearsed with objects they do not like and with pictures of multiple objects to further strengthen the learning.

Having enough language skills

Waiting for children to develop some language before using a communication device seems counterintuitive. Because it is actually expecting them to develop the same skills that they have difficulty with. And also anticipating this development to occur on its own is not realistic. Because there are no tools the children can use to express themselves, let alone improve their language.

Presuming competence in individuals and presenting means to express themselves to see how it affects them is a better approach to begin with. Individuals can literally be assisted to develop language using AAC. First, they learn to communicate then the language skills start to develop more. Giving this opportunity to children and then seeing how they improve is much more constructive then just waiting for some development to happen on its own.

Not having motor developmental issues

This refuted claim is about children not having any significant motor skill deficiency in order to use AAC. In reality, there are many different ways to customize AAC devices. For instance, the size of the buttons or different types of switches can be used. Switches that can be pressed with head, elbow or other more functional body parts exist. Also, if the impairment is severe and children cannot move; there are systems that operate with tracing eye gazes.

It is of high importance to say that many children with sensory-motor impairments are not given any means to communicate and were thought to lack cognitive abilities as well. However, when given means, reality can be demonstrated, and the level of cognitive skills can be assessed to be improved (Romski & Sevcik, 2005). This is crucial because when parents or professionals dismiss using AAC because they think it cannot be adjusted to the child’s needs, they also prevent any further development from happening as well.

Showing interest in communication

Children with ASD may seem indifferent to communicate or to use any device to help in communication. Parents may choose to wait any sign that shows their child is interested before starting to use AAC. Keep in mind that if you never try, you will never know. Individuals might not know the value of communication yet. And they surely deserve to try options that help them convey their messages.

Revealing other methods for communication may change their interest level. Maybe speaking in a traditional sense is very hard for children but using visual aids comes much easier. Previously they might have tried verbal communication and failed so they quitted trying. In this case, it is pretty normal to feel not interested. However, children cannot know there are other ways that go the same direction but maybe willing to try if someone shows them. With the help of AAC, they may understand that they actually can express themselves, feel understood and even enjoy this interaction.

Waiting until school age

This is a repeatedly disproven statement. Priorly, it was believed that children are not ready and do not need AAC before they start school. The reason is the notion that early implementation will hinder speech development. Time after time, evidence showed the opposite to be the truth. That is, starting early increases the level of improvement in communication and other related skills (Romski & Sevcik, 2005; Millar, Light & Schlosser, 2006; Schlosser & Wendt, 2008).

Communication begins right after birth so the reason behind waiting is hard to grasp. Because while waiting, children may miss more milestones, become more frustrated and have more additional problems in related areas such as language or socialization. Even though an individual is non-verbal, they can still learn words, understand others, socialize in their own way and most important of all, they can communicate. So, there is clearly no point in waiting to introduce AAC.

In short: There are no prerequisite skills to AAC. In fact, every individual deserves to communicate using different means. It is a basic human right to speak up in any method that works for them. However, there can be some important considerations in choosing which AAC system, device to choose. In the next section, these factors will be touched upon.

Children Using AAC

Important steps and considerations in choosing the right AAC system

###Assessment Process

The assessment process is key in finding the suitable AAC system for an individual. This procedure is ideally carried out by a multidisciplinary team of professional including speech-language pathologists, physicians, teachers, occupational therapists, behavioral therapists and psychologists. Families or caregivers play an important role in the process as well. Approaching the assessment using different specialists is important because it enables a comprehensive result in determining social, physical, psychological and educational capabilities of the individual.

Of course, not every individual with ASD can get help from this wide range of professionals. It can be very expensive or not available in their area of residence. At the very last, a speech-language pathologist can conduct the assessment with an active help from parents and teachers. Although it may not be as comprehensive, certainly it will be helpful in decision making.

The main goals of the assessment are identifying present and future needs in communication, revealing currently used communication methods, trying out systems with different features and finally, presenting alternative means of communication that can be implemented.

1. Identifying communication needs

Recognizing and labeling communication needs consists of understanding the circumstances where and how communication can take place, and where it cannot or, according to what factors this outcome is affected. For instance, a child can easily interact in certain situations or places with particular people. To be more precise, a child can communicate functionally with a parent at home but there can be problems at school with the teacher.

The aim at this step of assessment is to look over all these situations, places and people to map out the changes in the way the child acts. Then, trying to figure out the reasons for these changes in behavior. “Is there a shift in motivation?”, “is it about certain characteristics of the location?”, “what makes it more comfortable in one situation and not in another?” and many more questions like those are tried to be answered at this stage.

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2. Gathering information about the child

In the second step, general aim is to display currently used ways of communications and to assess the skills that are used. This assessment of skills should be widespread. Besides evaluation of skills, important information about the child should be collected in this stage. Observation, objective psychological tests, interviews with parents or teachers are the common ways to obtain such information. At the end of this step, the specialist should have a great deal of knowledge about the following areas:

  • Sensory development: Assessment about vision and hearing capabilities
  • Motor development: Observing the nature of movement including gross motor skills (broad muscle movements) and fine motor skills (small muscle movements).
  • Written and oral language development: Related areas are intention, comprehension, expression, vocabulary size, literacy and many more
  • Cognitive development: Memory, decision making, problem-solving abilities
  • Communication skills: Understanding the style of interaction, intentionality, requesting, commenting, initiating and terminating capabilities
  • Behavioral issues: Frustration, temper tantrums, yelling and other problematic behaviors
  • Medical, psychological and educational history: Previous treatments, other medical or psychological problems, special training experiences and associated topics
  • Social and daily life: Information about how social interactions take place and with whom. Also learning about daily routines.
  • Likes and dislikes of the child specifically explained: Activities, locations, actions etc.
  • General concerns of parents: What are the main issues they struggle with, in what areas they need help.
  • Behavior in different settings (home, school, other locations): Differences and preferences can be learned. What aspects of the setting affect behavior?
  • Play behaviors: Does the child engage in joint attention, what is different when playing alone vs playing with others?

3. Experimenting with different systems

In the third stage, depending on the results from the skills assessment, specialists can let the child try different systems with varying characteristics. For example, one of the first topics for discussion is deciding on low-tech or high-tech AAC. Examining both options in a detailed manner is very important in this part of the assessment. Financial status is important to consider in this step as some parents may not afford high-tech systems. Also, high-tech systems can be seen as distracting or overwhelming cognitively for some children so low-tech options can be chosen.

Also, the portability of the system can be important for an individual to use the device everywhere to generalize communication gains. The more the device is carried to various locations the more communication is be enabled. One other factor is whether the system requires training before using, like PECS, or it can be implemented right away, like an AAC app such as Otsimo. Another important issue is the maintenance of the system. Is it durable or need constant care? Not to forget, previous experience with other systems should be noted as well. In what ways the system was effective and was insufficient.

Customizability of the system should also be examined. Can you add visuals, words, symbols easily or do you have to settle with what’s available? If possible, features of the device may be altered for trial in line with needs of the child. For instance, types or sizes of symbols or buttons; display screens (color or motion settings, layout organizations) and input (pressing, selecting) or output (voice or not) settings can be customized in some systems. How does the level of comfort changes with alterations of the features?

For each difference, the child’s reaction or the ability to adapt should be noted. For example, a child with restricted motor abilities may be more comfortable using devices with bigger switches whereas a child who has sensitivity for motion may not feel pleasant using a dynamic display. These conclusions are essential in the decision-making process.

It is crucial to also incorporate communication partners in the process of experimentation with different systems. Parents, teachers or other people should also try to use different systems both to give opinions about how the child can adapt to the system and also to indicate how convenient it is in using or reciprocating. The communication partners should feel comfortable enough to use the device while interacting with the individual.

4. Suggesting a suitable AAC system

With all the data gathered through the steps of assessment, the professional is expected to suggest an AAC system that is suitable for the child. The aim in this last stage is to make sure the features of the system match with the needs of the individual. After that, the adaptation process and the benefits or obstacles should be observed and tracked by the family and the same specialist. That way, any readjustments or changes can be made at the right time.

Assessment procedure is key in finding the right AAC solution for a person with ASD. This process can be overlooked with the increase in accessibility of technology. We strongly recommend consulting a specialist before starting to use an AAC system. Even though it may not be convenient to work with a professional for many reasons, conducting research on the internet using credible sources (like this guide you are reading) to try to find options and experimenting with your child is possible. Remember, you won’t know unless you try.

Likewise, in the following sections, we present tips for parents and teachers about introducing the systems, training the child, using the devices and solving problems about AAC.

Parent teaching child how to use AAC

Tips for parents & caregivers

Before discussing tips and considerations for parents or caregivers, it is important to note that parent training is vital in the process of adjusting and using new communicative modalities. After the assessment procedure, it is basically up to the parents to introduce the system properly and create opportunities to incorporate AAC into everyday activities. In other words, parents play a crucial role in improving their child’s communication capabilities.

How to introduce the AAC system?

After a comprehensive assessment process and finding the suitable device, the first question every parent or caregiver has in their mind is “How do I introduce this system to my child?”. Here we summarize the steps and considerations in doing so.

Understanding how the AAC system works

Before showing the system to the child, it is important for parents to get a grasp of the device. Simply by pushing buttons, using switches and trying to communicate using the device can be helpful. For instance, if it is a speech generating device, how can it vocalize your intended message? Can other people understand and give their response in return? Questions similar to these should be answered.

The main purpose is learning about this new means of communication that your child will be using. Ultimately the parents will be on the receiving end of this interaction. This is just like learning another language, if you cannot understand it, you cannot respond to it and the communication suffers. Also, having familiarity helps in solving any future problems related with the device or the communication itself.

Last but not least, it can encourage parents to empathize with the individual who will be using the system. As it is known, a little empathy goes a long way. Trying to interact with another person using the AAC system can enable appreciating the frustration, anger and other emotions your child might be feeling. This experience itself is valuable for the relationship between the child and the parents. So, as it can be seen, it is crucial to comprehend the use of the system before introducing it to your child.

Demonstrating how to use the system to the child

After completely understanding the general way of functioning of the system, parents can introduce the child with this new method of communication. Starting slow is a good strategy. Maybe at this level, just handing the individual the device and allowing some exploration is more than enough.

Then, using it to communicate is the next step. For example, the chosen AAC system uses visuals that represent words, and the child is asking the parent to give the toy car. You can find the picture of the object and show it to the child while saying its name (“A toy car”) and then you can give the object to the child. Another example can be an SGD vocalizing the name of the object after the parent pushes its buttons, followed by receiving the object.

This is called “modeling” and it is an important method of learning for all children. With repetition, children connect an action (showing picture or pushing button) to its consequence (receiving the object). And in the future when they need something, they just mimic the action.

Using the AAC device everywhere and with everyone

Modeling the use of the system is essential in teaching the child how to operate the system to communicate. The key in this is to do this repeatedly in every occurrence of interaction. In order to do so, the child must always have the system nearby so that it is ready to use. Also, parents should use the AAC while talking to the child or around the child. This way, the system becomes a very familiar and common method of communication for everyone and most importantly, for the child.

Another way to have consistency is generalizing the use of the system to different locations, settings or environments. Communication should not be limited only to the home or to parents. People can interact in various places with numerous others using their voices so why individuals who are non-verbal be any different? The AAC can be carried anywhere the child goes. Having the system nearby creates different communication opportunities. And this contributes to consistency and generalizability. In time, individuals can automatically reach to the device when they want to communicate something through just like opening the mouth to speak.

To make sure the child uses the system continuously, reinforcements can be utilized. A basic definition of reinforcement is anything that increases the possibility of an outcome to happen. Tangible rewards (i.e., toys, food), praises, activities (i.e., extra tv time) and many more can act as reinforcers.

When parents try to increase the child’s use of the system, they can use certain rewards. For instance, parents can give rewards immediately anytime the child reaches out to the AAC to interact. In the beginning, children may not look for the device when they want something. Remember it takes time to get familiar. However, parents can physically help their children by moving their hands to push buttons or looking for and selecting pictures together. Immediately after doing so, rewards must be provided so that the behavior of using the AAC strengthens over time.

Remember that if children are confused, frustrated or behave as if they are uncomfortable about the current situation, do not continue. In the end, parents should remind themselves that this system supposed to aid their child, not cause a disturbance. If children are clearly unhappy, being slow and advancing at their pace is more appropriate.

Enabling unaided use of AAC

Strategies mentioned above like modeling and reinforcing are great in teaching and increasing the use of these new communication systems. However, children should not be always relied upon other people to use this new communication modality. Once children learn how to operate the device and get what they desire, parents can start cutting down on the rewards, cues and other helping behaviors.

Of course, observing how the child adjusts to being more independent is key. If more frustrated, parents can proceed to help but do it in moderation. Slowly the child will be more independent and feel more competent in using the AAC to communicate. Don’t worry, requesting something and receiving it using the system is still a constantly rewarding process. Your child will keep on relying on the device because of the responses. For instance, interacting with another person, getting what they want and generally the socializing aspect of communication are naturally reinforcing the use of the device.

How to maintain the use of AAC?

Now that the child understands how AAC works and starts using it independently, what can be done to be sure that this new means of communication is here to stay? Here we offer some tips:

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Teaching new symbols or words

Of course, this is important because it expands vocabulary and improves communication. Learning new things motivates the use of the system on its own. Modeling and reinforcing are methods that can be used while introducing new words, symbols or visuals. When it’s certain that the child understands, parents can gradually withdraw from using helping strategies.

Having the AAC at hand during the day is crucial. As it was mentioned above, this enables the child to be familiar with the device and also generalize it as the main modality of communication. Also, when the system is always nearby, there are more circumstances to add to current symbol vocabulary.

Eating, playing, getting dressed, walking and many more daily activities carry many opportunities. For example, food items can be presented according to what’s for dinner at that very moment. The association will be stronger when introductions are blended into natural settings. It is a good idea to start with naming items that the child is already interested in. Also, making sure the child is in a positive or stable state helps this process a lot.

Setting achievable goals to communicate using AAC

When creating goals, both for the parents and the child, being as concrete as possible is key. For example, the aim should be specifically about the child using the device to request certain items: “the child will give the picture of a cookie to the parent to get a cookie”. This kind of a goal indicates that both the parent and the child know how the system functions. The aim is using the AAC to communicate.

However, goals about just using the system (“the child will give picture to request”) is not aimed at meeting interaction needs because it is not specific enough. Also, this type of goals can be too broad and demanding because one can never be sure if it’s achieved.

In short, clear, specific and short-term goals should be preferred while tracking the progress of the child using the AAC.

There are many different reasons for readjustments. Maybe the system does not have enough words or symbols to enable better communication. Switching to a system with wider vocabulary of words and symbols may be beneficial.

Or, at first it was a good fit for your child but in time it fell behind. Naturally, as the child ages and acquires new skills, different modalities can be tried out. Also, same system can be updated for increased skill levels. For example, PECS have different progressive stages that are passed one-by-one.

On a different note, there can be maintenance issues with the device, meaning that it failed to operate. Children may be more upset, frustrated and had a difficult time adapting to the system. After contacting with the developers and also the specialists, if issues still continue regarding the system or the child, it may be a better idea to try a different system.

Child running freely

Monitoring the child’s activity

Some high-tech AAC systems are not exclusive for communication. Apps, for instance, are downloaded to tablets or smart devices that also include games and access to internet. This is when monitoring the child’s activity, screen time and setting some ground rules regarding these become essential.

In order to protect the child, access to other apps or internet can be restricted. Certain sites or apps that are addictive or inappropriate can be blocked. If your child also uses the device for playing games, scheduling may help in preventing too much screen time.

Children may also use social media on these devices. It can be a less upsetting and less stressful option for them to interact. Parents can lay down rules about the use of this platforms. Just make sure that this way of communicating does not replace their real-life interactions.

With respect to the child’s age, parents can openly discuss why these restrictions or schedules are needed and encourage them to always ask for permission. Last but not least, it should be clear for the child and the parents that this device is initially for communicating using the AAC app. Which means that parents should not use it for their needs as much and have it always available for the child to use.

Tips for better communication

Just like learning to speak, learning to use AAC requires support. Even if it’s not conventional, it still counts as communication that needs to be improved. To support the development of using AAC to interact, here are some tips.

  • Let them guide the interaction. Initiating and leading a conversation is crucial because this is not something they are used to. Previously, the communication was very one-sided; others talked, and they listened (possibly in frustration). Now they can express themselves too, so it is essential to let them lead.

  • Be patient and go slow. Through the interaction, parents should take their time, use few words, repeat them and stop after sentences or words. This facilitates processing what was said and makes responding easier. Questions on the other hand should be short and closed-ended meaning that the child should choose between options. Yes or no questions for instance, are great because they promote interaction.

  • Wait for turn-taking. Do not rush and wait for them to finish their part of the conversation. This may take time, longer than in traditional speech. But waiting for an increased amount of time is important because it shows that you respect their efforts. And also, it teaches the reciprocity aspect of interaction; first they communicate, then it is others’ turn or vice versa.

  • Have face-to-face contact. Facing the child helps in understanding how AAC is used by them. It is like learning how they use this new language for interaction. How does the child look for symbols, press buttons, wait for response or use additional body language? This gives the message that parents are focused on the child and the interaction is important for them. In time, parents can be coded as the “communication partners” that the child seeks to interact with when it’s needed.

  • Use supports for communication. These can be animating actions such as impersonating holding a fork and a knife to symbol “eating”. Also waving hand for “hello” and nodding head for “yes” can be used to teach that communication is more than just sounds, words or visuals. Still, photos of relatives can be used while mentioning them. Also, you can act out interactions and give feedback about behaviors without being too critical.

  • Encourage children to communicate. Creating opportunities for them to interact is crucial. This can be playing a song and then letting them continue. Or, putting a desired item nearby but on an unreachable shelf to let them ask for help. Also, asking them to play a 2-person game and allowing them to understand the rules and then, play along. Not to forget, recognizing that they do not want to continue with the activity and letting them signal that they need to stop is important.

  • Attract and maintain attention. Being face-to-face helps this process although the child may not engage in eye contact. Still, they know about the other person’s presence and attention. Using their names, engaging in activities that they show interest in and eliminating any distractors (i.e., tv) can help.

  • Avoid saying “no” at first. Most AAC systems teach requesting. It may seem unreasonable to always grant every request of the child. Parents may even worry if their children will become needy or spoilt. However, in the process of adjusting to this new means of communication, it is important to respond to every request with providing the desired item. At the first stages, this is necessary to establish trust for the device as a communication method. Otherwise, children may become upset and give up using the system. When it is certain that the child regularly uses the system to communicate, “no” can be introduced as a possible answer.

Tips for teachers

Tips for teachers

Previously we mentioned that the assessment process should be a team effort. Parents, teachers and other specialists should collaborate. Likewise, implementation of the system should be supported by all of the people in the child’s life, including teachers. Only then AAC can support communication successfully. But how can the system be adapted to the school setting? Before answering this, it is important to note that tips that we gave for parents also apply for teachers to benefit from. But there are also additional suggestions that we offer.

  • Know how the system works. Most essentially, teachers should understand how the system operates. Also, they should be aware of the existing vocabulary and symbols, their locations and other aspects of the device.

  • Keep the system always available in the classroom. Because AAC is the way the child communicates, it should always be present and available for use. This holds even for the activities that do not aim for students to express themselves like watching a video. Children without communication issues can talk no matter the activity they are engaging in. The same privilege should also be given to the children that use the systems. Full time access is the key element in this process.

  • Create communication opportunities. Using AAC in the classroom can be a unique experience. Certainly, there are no structured rules that show how to integrate the system into the class, so teachers may have to be creative. Pairing the child with different classmates, modelling words or verbs of activities, using songs and many more can help. Also, the function of communication can differ. Mostly AAC is used for requesting and labeling but there are many more reasons for communicating. Other chances to practice the system are rejecting, commenting, saying hello or goodbye, giving opinions and so on.

  • Acknowledge communication attempts and respond. Being on the alert for every communication attempt made by the child is important. These attempts can be gestures, mimics, facial expressions or the use of AAC. Any effort to communicate should be noticed and answered, especially when using the system. It is like saying “I see and hear you” which further strengthens the use of the device to communicate. When the child uses the system while the teacher is talking or covering a subject, this attempt should still be acknowledged. Teachers can indicate that it is lecture time, and it is their time to talk but always return to the child when they are finished. Even if the attempt is accidental, teachers should give a reaction.

  • Start small and go along with the child’s pace. Teachers should begin by choosing one word to practice and wait until they are sure the child can comprehend and use it properly. That way, they can understand the speed in which the child feels comfortable in and then pass on to teaching another word. Remember, there is no need to rush and it may take longer for children to adjust using the system in class. The aim is to support in this duration and practice at all times.

  • Use supplementary methods and materials. Traditional ways of teaching are not sufficient and different approaches should be taken. Showing pictures, photos, gifs, videos, scripts and so can be used to assist the learning process. Acting out verbs, showing pictures of people, pointing places from the map and performing facial expressions of emotions are some of the examples that can aid in teaching.

  • Have other students and staff learn the system. Because classmates and other staff will be communication partners to the child, they should also be familiar with the AAC. Teachers can allocate some time to explain how the system works and answer any questions. Support, reinforce and encourage communication partners in using the system while interacting with the child. That way, everyone in the child’s life can understand that this is the communication modality for the child and respect it.

References used in this article

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