Autism and Augmentative and

Alternative Communication:
Research-based Best Practices

Autism NOW Webinar

May 19, 2011

Joanne M Cafiero, Ph.D.

www.cafierocommunications.com
drcafiero@joannecafiero.com
 This presentation will:
• Detail the features & types of AAC
• Correlate AAC with processing styles in
ASD
• List evidence-based & promising practices
in AAC & ASD
• Discuss latest low and high tech AAC tools
 What is “Evidence-Based
Practice”?
• Integration of:
– Best and current research evidence
– Clinical and educational expertise
– Relevant stakeholder preferences and
perspectives
• (Mirenda, 2009)
 Autism and Mental Retardation
(Edelson, 2006)

• Autism and Intelligence Timeline

• Reviewed 215 articles (1937-2003)
• 74% of claims non-empirical sources
• 53% of 74% not traced to any data
• Empirical data was from developmental or adaptive scores
rather than cognitive scores
– Language based
– Unanswered questions considered wrong

Joanne M. Cafiero PhD, 2010

 Autism and Motor Planning
• Motor Delays, difficulty in executing movements, exacerbated by
stress
– Bauman, (1992)
• Persistence of newborn reflexes, stereotypies
– (Mari et.al, 2003)
• Parkinsonian movements
– (Vilensky, 1981)
• Failure to use gestures in communication
– (Mari et. Al., 2003)
• Atypical & Impaired Movement Preparation & Initiation
– (Rhinehart et.al. 2005; Rhinehart, Bellgrove, et.al., 2006,
Vernazza-Martin, 2006)

Joanne M. Cafiero PhD, 2010

 Conclusions of Researchers in
ASD and Motor Skills
• Motor disturbances are intrinsic to autism.
• Early motor “soft signs” may indicate
autism.
• Shift in focus to movement perspective may
inform practice and intervention.
• Individuals with ASD may not be able to
show what they know.
Joanne M. Cafiero PhD, 2010
 Autism and Co morbidity with
Affective Disorders
• Oppositional-Defiant Disorder
• Obsessive-Compulsive Disorder
• Anxiety Disorder
• Psychosis
• Selective Mutism

Joanne M. Cafiero PhD, 2010

 Progress?
• Deinstitutionalization
• Outcomes better for individuals 70 & above
• Outcomes for 50-70: dependent on others
• Outcomes dismal for individuals 50 and
below most of whom are non-verbal

Joanne M. Cafiero PhD, 2010

 What is Augmentative and
Alternative Communication?
(AAC)

– NO pre-requisites required
– Compensates for or replaces speech
– Multi-modal
– Provides supports for development of language
– Includes no-tech, low-tech, high tech
– Icons, tangible symbols, text
– Unaided and Aided AAC
 What IS AAC?
• Schedules
• Visual cues
• Communication boards
• Communication books
• Keyboards, letter boards
• Speech-Generating Devices
• Portable Electronic Devices (iTouch™)
• Visual Scene Displays
 Types of AAC by Vocabulary
Format
• Activity-based Communication Displays
• Core Vocabulary Displays
• Dynamic Communication Displays
– Electronic
• Linked vocabulary
• Semantic compaction
– Low-tech PODD (pragmatically organized
dynamic displays
 Myths about AAC and Autism:
• Inhibits speech development
• Not needed if an individual has some speech
• Providing AAC insures student will use it
• Success or failure depends on trial period
• No & low-tech or mid/high tech are better options

Joanne M. Cafiero PhD, 2010

 ASHA Position on AAC
• There is NO evidence-based practice for
determining if an individual could benefit
from AAC, therefore, no one should be
denied based on some arbitrary criteria.
• Eligibility should be based on NEEDS
ALONE.
 Aided & Unaided AAC
(Millar, Light & Schlosser, 2006, Mirenda, 2003)
• Unaided - Manual Signs
– Requires good fine motor abilities
– Unlimited vocabulary
– Portable
– Not readily comprehensible
– Daily access to signing communicators necessary
• Aided - SGDs, communication boards, keyboards, email,
paper and pencil
– requires lower fine motor skills
– more readily comprehensible
– not portable
– Limited vocabulary, syntax & semantics (device
specific)
Effects of AAC on Speech Production
in Children with ASD
Schlosser & Wendt, 2008

• Systematic review 1975-2007

• Stringent criteria for inclusion
– Calculation of % non-overlapping data (SSD)
– Calculation of effect size (group studies)
• Peer-reviewed journal or approved dissertation
• Included SSD studies and Group
– 5 PECS, 1 Manual Sign, 3 SGDs
AAC (aided & unaided) does
not inhibit
speech production; most
studies showed modest
increases in speech
(Schlosser & Wendt, 2008)
 Current Evidence:
• Vocal imitation is correlated with speech
• Motor imitation is correlated with
successful signing
• Object exploration skills correlated with
more speech using AAC (PECS)
• Time delay facilitates greater speech
production
 What is the ultimate goal of AAC?
SNUG
• Spontaneous
• Novel
• Utterance
• Generation
– The ability to access individual words,
expressions, and commonly used phrases.
– The ability to say anything about anything at
anytime.

Joanne M. Cafiero PhD, 2010

 Interface of AAC (aided) and
ASD
ASD AAC
Visual processing Uses visual medium
Motor planning Requires less motor skill
Multiple Cue Responding Scaffolding for
complexity
Social difficulties Buffer and bridge
Interest in inanimate Uses tools & technology
objects
 Principles of AAC Assessment
• Profile of learning characteristics
• Communication environments
• Preferences & perspectives
• Communication partners
• Ownership of device/language
• Continuous cycle of assessment and
intervention
• Never a gatekeeper
 Assessment Tools for AAC
• Participation Plans (Beukelman & Mirenda)
– What does the student need to participate? What are the barriers?
What AAC tools facilitate participation and eliminate barriers

• SETT (Zabala)
– Student, Environment, Task, Tools (available online)

• Social Networks (Blackstone & Berg)

– Circles of Communication Partners
Autism and Aided AAC: What
are evidence-based practices?
• Picture Exchange Communication System

• Functional Communication Training

• Augmented Input Strategies

• Speech Generating Devices

 Evidence-based Practice:
PECS
• Systematic sequential protocols
• Exchange a symbol for a desired item
• Expressive communication only
• Acknowledges communication partner
• Approximately 1/2 children developed speech
 AAC: Course 101
Visual Supports: Receptive Input
• Schedules
• Picture prompts
• Written directions
• Visual behavior cues
• Token boards
• Contingency maps
• Power cards
• Cognitive picture rehearsal
Joanne M. Cafiero PhD, 2010
 Preponderant Evidence for
Visual Supports:
• Improve receptive language
• Improve expressive language
• Improve independence
• Decrease aberrant behavior
• Decrease prompt dependence
Joanne M. Cafiero PhD, 2010
Joanne M. Cafiero PhD, 2010
Zach’s Contingency Map

Joanne M. Cafiero PhD, 2010

Joanne M. Cafiero PhD, 2010
• There is a strong inverse relationship
between problem behavior and
communication skills.
– Sigafoos (2000)
 Evidence-based Practice: FCT
with Aided AAC
• Functional Communication Training
– PCS, objects, SGDs, Ideographs
– Views all behavior as communicative
– Replaces aberrant behavior with communication
– Must be efficient, acceptable and recognizable
– FCT produced “immediate, substantial and
sustained” decreases in aberrant behavior (Mirenda,
1998)
 AAC and Choice Making
• Visual supports facilitate choice making
• Require less cognitive effort
• Reinforcement is more immediate
• Increases in positive behaviors
• Increases in initiations
 No Tech vs. High Tech/SGD
• No Tech • High Tech/SGD
– Less costly – More costly
– Single stimulus – Multiple stimuli
– Ease of use for – Language within a
communication partner language
– Limited vocabulary – Repair issues
– Fewer “repair” issues – Model for speech
– Auditory feedback
– May be “prestigious”
– Summon
communication partner
 Evidence-based practice:
SGDs
• Low-tech (1 - 32 cells, single & multi-level)
• High-tech
• Summons attention of communication partners
• Model for speech
• Used alone or with other aided AAC
• Augmented input model (SAL, Romski & Sevcik,
1996, 2009)
 Case Study: Josh
• 6 years old
• 3 years of no-tech communication boards,
books, wallets
• “barking” as primary requesting behavior
• emergence of SIB
• introduction of High-Tech AAC
– Springboard
– Training of communication partners
 Jacob’s Springboard™
Intervention
• Introduced Springboard during structured
academic settings
• Communication partner viewed Springboard as
Jacob’s voice and ears & provided augmented
input
• Navigation strategies were modeled naturally
• Jacob’s requests were immediately acknowledged
• Incidences of SIB charted
 Josh’s Journey
• From engineered environment, picture
exchange and augmented input to…
• High tech device provided with training for
staff
• Communication partners provided input &
created communication opportunities
• Device used for academics (math, reading)

Joanne M. Cafiero PhD, 2010

 Josh’s Journey
• Adopted device as his voice
• Maintained some intermittent vocalizations
for requests
• Uses multi-modal communication; sign,
paper communication boards, writing on
white boards and high-tech device

Joanne M. Cafiero PhD, 2010

 Functional Vocabulary on High Tech
AAC and Incidence of SIB

45

40

35

30

25 SIB
20 Funct.Vocab.

15

10

0
8

08

08

08

08
8

08
/0

0
/0

5/

2/

6/
8/

9/

/
25

13
1

/
9/
9/

10
8/

9/

9/

9/

/
10
 Observational Results: Josh
• Used device during academics, meals, and
preferred activities
• Navigated and found new vocabulary not
previously modeled by communication partners
• Vocalized while activating SGD
• Continued to use and accept low tech for some
receptive and expressive language
• Vocalized to make requests and engaged in SIB
when SGD was not available
 Eye-Gaze Communication
MyTobii
• Designed for physically disabled individuals
• Now piloted with girls with Rett Syndrome
• Eye tracking technology
• 15,000 symbols or text
Tobii Communicator
 Evidence-based practice:
Augmented Input Strategies
• Communication partner essential
• Receptive language training (INPUT)
• AAC viewed as legitimate language
• Mother-tongue method
• Natural Aided Language, System for Augmenting
Language, Visual Routines, Aided Language Modeling
• Effective in increasing spontaneous speech and
augmented communication & decreasing aberrant
behaviors (Cafiero, 1995, 2001, 2005; Dexter, 1998,
Acheson, 2006)
 Toddler Study: SAL
Romski, Sevcik, Smith, Barker, Folan & Barton-Hulsey, 2009)

• 60 randomly placed toddler/parent dyads

• ACI (input); ACO (output) & SCI (speech)
• Parent Training (8 weeks); parent practice
w. feedback (7 weeks); parent solos (9
weeks)
• 30 minutes: 10 minutes of play; 10 minutes,
literacy; 10 minutes snack
Joanne M. Cafiero PhD, 2011
Toddler Study: Results for ASD
Participants
• Retrospective Analysis of 11 of 60 dyads
• ACI & ACO were able to communicate
after 18 sessions & maintained skills.
• Only some in SCI acquired speech.
• ACI/ACO: 5% SCI: 1.13%
• Are gains maturational?

Joanne M. Cafiero PhD, 2011

 Natural Aided Language: An AAC Based
Methodology
(Acheson, 2006, Cafiero,1995, 2001)

• Incorporates Developmental, Incidental and Pivotal Response

Methodologies
– Engineered environments
– Child preference
– Shared control
– Practitioner extends engagement
– Systematic input & prompts
– Mixture of novelty & familiarity
– All communicative attempts reinforced
– Communication outcomes are observable and measurable
 Zak
• 3 years old; middle child of 3
• Involved parents
• Communicates by taking hand of adult
(non-symbolic)
• Tantrums
• Aggressive
• Seems to “read” video material
 Objective: will increase
communicative interactions

• Intervention
– Identify reinforcers
– Identify vocabulary
– Create Natural Aided Language
comboard
– Train communication partners
Number of Communicative Initiations and
Responses: Parent and Child with and
without NALS

12
10
8
parent
6
child
4
2
0
1 2 3 4 5 6 7 8
Weekly Probes
Parent Perception of Autistic Symptoms on CARS (mean)

4
3.5
3
2.5 Pre-NAL
2
1.5 Post NAL
1
0.5
0
NV Body Verbal
Comm Use Comm
 Parent Stress (Mean) on Parent
Stress Index Pre & Post NALS
90%
80%
70%
60%
50% Pre-NALS
40% Post NALS
30%
20%
10%
0%
 Case Study: Timothy
• 13 years old, non-verbal
• Learned 5 signs in 5 years
• Diagnosis of Autism (severe range)
• Aggressive, bolts from classroom
• Self-stimulatory behaviors
• Screaming
 Timothy- Natural Aided
Language Intervention
• Increased augmented communicative input
(visual symbols) from 9 to over 60

• Engineered all environments and activities for

communication

• All staff trained in Natural Aided Language

Number of PCS Initiations with Natural
Aided Language Intervention
30

25

20
15

10
5

0
Baseline INV After Resume
ESY NAL
Charting “Bolting” (standing up, leaving instructional group
without directions to do so)

Mean Weekly Incidence of Bolting

18

16
Number of Bolts per Week

14

12

10

0
3 3 3 3 3 03 03 3 03
4/0 1/0 8/0 5/0 1/
0
8 / / /0 /
3/ 1 1 2 / 4/ 15 22 29
3/ 3/ 3/ 4 4/ 4/ 4/
 Results of Natural Aided Language
Intervention for Timothy
1. Increased compliance
2. Decreased bolting
3. Increase in number of symbols used
4. More complex & academic IEP
5. Greater staff satisfaction
 Looking at typical babies &
toddlers
• How long do we talk to babies and toddlers
giving them receptive input before we
expect them to start talking?

– One month?
– 3 months?
– 1 year?

Joanne M. Cafiero PhD, 2010

 Aided Language is NOT
• Quizzing with an AAC tool or device
• Saying “Touch this one.” or “Do this.”
• Using hand over hand
• Communication boards only
• Restricted to 100% non-verbal individuals

Joanne M. Cafiero PhD, 2010

 What are you modeling?

• Verbs, nouns, descriptors

• Syntax and pragmatics
• Operational use of vocabulary
• Mistakes and repair strategies

Joanne M. Cafiero PhD, 2010

 Aided Language: Backing it up!
• Cafiero, 1995, 2001
• Dexter, (1998)
• Drager, Postal et.al., (2006)
• Acheson, (2008)
• Romski, Sevcik et.al., (2009)

Joanne M. Cafiero PhD, 2010

 PRT and NAL: How do they
compare?
Pivotal Response Treatments
• Shared control
• Natural reinforcers
• Mix new with mastered
vocabularies
• Partner extends engagement
• All attempts are reinforced
Joanne M. Cafiero PhD, 2010
Natural Aided Language
• Shared control
• Natural reinforcers
• Mixes new with mastered
vocabularies
• Communication partner
extends engagement
• All communicative attempts
reinforced
 Communication opportunities
don’t just happen!
• They are overtly or covertly embedded in
everyday routines
• Practitioner needs to recognize them or…
• Practitioner needs to create them
• Engineering the environment
• Creative sabotage
• Interrupted behavior chain
• Time delay
 Transitions, PECS and Aided
Language Strategies
• Make least harmful assumption
• Remember communication must be efficient to be
reinforcing
• Include receptive language input always!
• Communication is multi-modal, and inclusive.
• Students may transition in and out of needing
Picture Exchange
 Visual Scene Displays
Drager, Light & Finke, 2009

• Targeted conceptual framework of CCN

• People, places, objects in backgrounds
within which they exist
• “hot spots” were communication targets
• Increases in social language, turn taking and
combining concepts for novel utterances
• Increases in navigation of SGD
 Pragmatically Organized
Dynamic Displays (PODD)
(Porter & Burkhart, 2008)
• Low-tech. augmented input
• Speaking partner intrinsically involved
• Complex architecture
• Symbol or word based displays
• Pragmatic branch starters
• Developed for physically disabled children
• Promising practice for ASD
Michelle: A Promising Practice
with PODDS Intervention

• 6 years old Dx ASD; limited speaker;

meltdowns with aggression.
• Literacy/Math above grade level
• PODDS used during high stress situations
• Conversation occurred between Michelle
and her communication partner.
Pragmatic Organisation Dynamic
Display
PODDS & Partner Assisted Scanning
(Burkhart & Porter)

Joanne M. Cafiero PhD, 2010

Michelle’s PODDs Intervention
• Increased receptive language
• Increased expressive language
• Increased choice making
• Decreased aggression
 Core & Fringe Vocabulary:
both are required for
communication
• Core
– More open ended
– Applicable to many situations

• Fringe
– Specific to a particular activity
– Vocabulary size across activities can be enormous
8 Location Phrase-based Core
Vocabulary
Picture Word Power
Proloquo2Go Communication
Software (iPod & iPad)
 Literacy and AAC
• Robust literacy (reading & writing) is
essential.
• Impossible to separate AAC from literacy
• Emergent literacy behaviors should be
encouraged.
• Opportunity to engage in literacy learning
supports functional spontaneous
communication.
 Why kids with ASD do not
have literacy experiences:
• Low expectations
• Behavioral difficulties
• Delayed developmental milestones
• Motor planning challenges
• Medication issues
• Other

Joanne M. Cafiero PhD, 2010

Why individuals with ASD should
have writing experiences:
• Print is visual medium
• Communication is core challenge
• Reports from adult autism advocacy
movement
– Real time speech, keyboard communication,
later adopters of AAC
• Basic human right
• May become primary means of FSC & SNUG
Joanne M. Cafiero PhD, 2010
 Writing as Input; Writing as
Communication
• Keyboards
• White boards
• Post-its™
• Alphabet boards
• Keyboard VOCAs

Joanne M. Cafiero PhD, 2010

Writing is an essential part of the
communication continuum:
all components are mutually reinforcing

• Receptive Language
– Listening, processing graphics or print
(reading)
• Expressive Language
– Speaking, using AAC, adapted and
conventional pencils (writing)

Joanne M. Cafiero PhD, 2010

 Emergent Writing:
• “Children begin reading by writing. People
are natural message makers; we want to
leave our mark.” (Erikson, 2008)
• Writing challenges children to think about
print.
• Provides scaffolding for cognitive
development

Joanne M. Cafiero PhD, 2010

 The Home-School Journal -
Tools-No/Low Tech
• Boardmaker Symbols for home and school
• Visible storage bank for symbols at both home and school
• Custom made journal sheets
• Laminated bifold or file folder
• Velcro and laminate

Joanne M. Cafiero PhD, 2010

Joanne M. Cafiero PhD, 2010
 Keyboard Communication
• Adult Autism Advocacy Movement
• Keyboard Communication vs. “real time”
communication
– Wait time, coordinating listening & communicating
– Mechanics of the device, positioning
• Note qualitative difference between our own
spoken vs. written language
• Former speaking communicators as adults
transitioned to AAC
 About Communication
Partnerships:
• Speaking communication partner must view
AAC as the voice and ears of the student
• Speaking communication partner must use the
AAC device, pairing speech with AAC to
acknowledge, repair, expand and model the
language
• Speaking communication partner’s investment is
essential for a successful AAC intervention.
 Principles of AAC Interventions
• NEVER use a “wait & see” approach.
• AAC should be ubiquitous; across all
environments.
• Augmented input must continue or language
will regress
• Communication partners must create repeated
planned opportunities.
• Ask: “How can AAC be applied? not ‘If’”.
 More Principles of AAC
• Give augmented communicative input.
• Assume that every individual, especially those with
the most difficult behaviors has something to say.
• Remember AAC helps develop language.
• Do not place arbitrary timelines AAC intervention -
learning a language takes time.
• Functional spontaneous communication is the
most important, life-enhancing skill an individual
can learn!