BCASLPA 2015 AACASD.pptx

SUPPORTING
MINIMALLY VERBAL
STUDENTS WITH AAC
BCASLPA
Penticton, BC
October 24,
2015
Pat Mirenda,
Ph.D.
University of
British
Columbia
AGENDA
 W ho are we talking about today?
 W hat are some myths and facts about
these individuals?
 H ow can we maximize spontaneous
communication from the outset of
instruction?
 H ow can we support generative
language development using AAC?
 W hat does the research say?
 H ow can this be done system-wide?
WHO ARE “MINIMALLY VERBAL”
STUDENTS?
 Students with developmental disabilities who fail
to acquire spoken language skills beyond a
minimal level, despite access to intervention
from an early age (Kasari et al., 2013)
 May or may not have an intellectual disability
 May or may not have a significant motor impairment
 May or may not have childhood apraxia of speech (CAS)
 Examples:
 Down syndrome
 Other genetic syndromes
 Cerebral palsy
 Autism spectrum disorder
©Pat Mirenda, Ph.D., October 2015 1 WHAT DO WE KNOW?
 Down syndrome: 1/700
(US CDC, 2010)
  ~90% communicate via speech but ~27% of parents report that
their children frequently or always have difficulty being
understood by persons outside of their immediate social circle
(Kumin, 2006)
 Other genetic syndromes that significantly impact
speech/language development: prevalence varies
widely
  In Rett syndrome, Angelman syndrome, trisomy 13/18, and
others, almost 100% are or become MV
 Cerebral palsy: 1/323
( US C DC , 2 014 )
  30% non-ambulatory
  21% speech disorder, 32% MV (Nordberg et al., 2013)
 Autism spectrum disorder (ASD): 1/66
(US CDC, 2014)
  10%-30% are MV; 23.5% may have CAS (Tierney et al., 2015)
ASD AND SPEECH DEVELOPMENT
 W E USED TO THINK: if a child doesn’t
develop spoken language by age 5, it is
unlikely that he or she will ever do so
 B ut: Pickett et al. (2009) surveyed the
literature from 1951–2006 and identified 167
cases of children with ASD who started
speaking after age 5
 The majority began talking between ages of 5-7,
and some developed speech at even older ages, up
to age 13
AND…
 O f 500+ children with ASD who were
unable to speak in 2-word phrases at age
4, 70% reached this milestone by age 8,
and nearly half were able to speak fluently
by that time (Wodka et al., 2013)
 S o…focused work to support MV students
with ASD (at least!) is more likely than not
to be productive vis a vis speech
development!
©Pat Mirenda, Ph.D., October 2015 2 WHAT IS THE ROLE OF AAC?
 A ct as (at least) a temporary mode of
communication; this may be long-term as well
 P erhaps, enhance speech development/
production
 P revent the development of problem
behaviour
 P romote language and literacy development
REQUESTING
 S hould the primary goal of
AAC be to teach MV students
to request preferred items or
activities?
 T hat’s what the research
implies:
 7 0%-90% of studies targeted
requesting alone (Alzrayer et
al., 2012; Ganz et al., 2012;
Stephenson & Limbrick,
2013; van der Meer &
Rispoli, 2010)
REQUEST/CHOICE DISPLAYS
©Pat Mirenda, Ph.D., October 2015 3 WHY START WITH REQUESTING?
 It’s relatively easy to set up motivating situations
where “wanting” is required
 Out of reach item
 Wrong or missing item
 Etc.
 There’s an immediate, naturally-occurring payoff
for the learner, who gets what he/she asked for
 We know how to teach this!
 Informal/incidental teaching
 Picture Exchange Communication System (PECS) – a
manualized, evidence-based instructional package for
that begins with requesting as a target
GANZ ET AL. 2012
 M eta-analysis of aided AAC research for MV
individuals
 24 studies, 57 participants; ages 3-40
 Calculated Improvement Rate Difference (IRD)
scores from study data -- “difference or change in
percent of high scores from baseline to
intervention” (p. 67)
 I RD results:
 A AC without PECS: .61 (moderate effect)
 A AC with PECS: .99 (very large effect, significantly
higher than without)
EVEN IF REQUESTING IS A GOOD PLACE
TO START….
 W hen we teach students to request, how
spontaneous are they?
 Does the student ask for what he/she wants, when
he/she wants it? OR
 Does he/she wait to to be invited to ask?
  “What do you want?”
  “You need to tell me what you want”
  “Use your pictures/iPad to tell me what you want”
  Etc.
 I f spontaneity is limited -- this is a symptom of
an instructional problem, not an “disability
problem”
©Pat Mirenda, Ph.D., October 2015 4 PECS
 If PECS has been
implemented with
fidelity, spontaneity
should not be an issue,
because the whole point
of PECS is to teach
spontaneous
communication from the
outset of instruction
 Hmmmmmm………………..
 What are some common
mistakes that lead to
lack of spontaneity – aka
“prompt dependency”?
PHASE 1, COMMON ERRORS
 N o preference assessment prior to starting
 Failure to use two people for instruction
 Failure to wait until the student reaches for
the offered item
 U se of verbal prompts of any kind
 P resentation of more than one picture/symbol
at a time
 Failure to use a variety of reinforcers
 F ewer than 30-40 trials/day across settings
and people
PHASE 2, COMMON ERRORS
 U se of verbal prompts of any kind
 Failure to use two people for instruction
 Failure to reinforce traveling and persistence
as the key skills being taught
 P resentation of more than one picture/symbol
at a time
 Failure to use a variety of reinforcers
©Pat Mirenda, Ph.D., October 2015 5 PHASE 3, COMMON ERRORS
 Use of verbal prompts of any kind
 Failure to change the position of the preferred
item randomly
 Selecting an ineffective discrimination training
procedure and sticking with it for too long
 Presentation of more than two pictures at a time,
initially
 Failure to use a variety of reinforcers
 Failure to provide a requested item when the
student asks for it spontaneously
 Failure to insure that the PECS book goes
everywhere with the student
PHASE 3 APP (IPAD AND ANDROID)
 $8.99
 https://
itunes.apple.com/ca/
app/pecs-phase-iii/
id551356825?
ls=1&mt=8
 Video demo:
http://
www.pecsusa.com/
phase3videodemo.php
 Designed for
instruction ONLY; not
designed to be a standalone PECS book
PHASE 4, COMMON ERRORS
 Use of verbal prompts of any kind
 Failure to wait until the student initiates the
picture exchange with one symbol before
physically prompting the “I want” symbol
 Failure to fade the “I want” prompt quickly
 Failure to “read” the sentence strip with the
student after the exchange, and inserting a 3-5
sec time delay after “I want”
 Failure to use a variety of reinforcers
 Failure to provide a requested item when the
student asks for it spontaneously
 Failure to insure that the PECS book goes
everywhere with the student
©Pat Mirenda, Ph.D., October 2015 6 PHASE 4
  By the of Phase 3 (or Phase 4
at the LATEST), the PECS book
should be available to the
student all the time,
everywhere
  Not just at school or just at
home
  Not just in structured
“teaching sessions”
  All the time, everywhere!
  And, when the student ask for
what he/she wants, it should
be provided!
  At Phase 4, also begin
teaching attributes
COLOR
SHAPES
circle"
square"
©Pat Mirenda, Ph.D., October 2015 7 BODY PARTS, COLORS
ACTION WORDS, BODY PARTS
Mark!
Julie!
MULTIPLE ATTRIBUTES
©Pat Mirenda, Ph.D., October 2015 8 PECS IV+ APP
 $ 119.99:
https://itunes.apple.com/ca/app/pecs-iv+/
id919593979?ls=1&mt=8
 V ideo demo:
http://www.pecs.com/PECSIV/index.php
 D esigned as a stand-alone communication app
for students who have mastered Phases I-IV+
using traditional PECS materials
PHASE 5: RESPONDING TO “WHAT DO
YOU WANT?”
©Pat Mirenda, Ph.D., October 2015 9 PHASE 5, COMMON ERRORS
 F orgetting that just because the student can
now respond to “What do you want?” –
spontaneity is still the main goal!
 Failure to use a variety of reinforcers
 Failure to provide a requested item when the
student asks for it spontaneously
 Failure to insure that the PECS book goes
everywhere with the student
PHASE 6, COMMON ERRORS
 N ot getting to Phase VI!
 Failure to provide a requested item when the
student asks for it spontaneously
 Failure to insure that the PECS book goes
everywhere with the student
I HEAR PECS ANIMALS APP
 $ 2.29:
https://itunes.apple.com/ca/app/ihear-pecsanimals/id811255558?ls=1&mt=8
 I nfo:
Info: http://www.pecs-canada.com/
ihearpecs.php
 1 2 Pics for PECS™ animal images and two
sounds for each animal
©Pat Mirenda, Ph.D., October 2015 10 I HEAR PECS ANIMALS APP
PECS PUNCHLINE
 I f PECS does not result in AT LEAST
spontaneous requesting within a reasonable
period of time, it is probably not being
implemented with sufficient intensity and with
fidelity
 B UT….
©Pat Mirenda, Ph.D., October 2015 11 MV STUDENTS AND AAC
 C ONVENTIONAL WISDOM: Start with just a few
(4-6) picture symbols and add a few more at a
time, as the student shows that he or she can
communicate appropriately with them, usually
by requesting
 R eally? Where is the research that defends
this practice?
 This is certainly not how other kids learn new words
and acquire language
UNIMODAL OR BIMODAL?
FRINGE VOCABULARY
 S pecific to a topic, situation, or activity
 O ften consists of primarily nouns
 Verbs, adjectives, etc. are directly related
to the topic
 S upports conversation about specific
topics, events
©Pat Mirenda, Ph.D., October 2015 12 FRINGE DISPLAY
CORE VOCABULARY
 7 5%-80% of the words we use daily come from
a set of 350-400 words: these are the CORE
VOCABULARY WORDS
“What are you eating for lunch today?”
top
20
top
75
top
20
top
30
“I want chicken nuggets”
top
20
top
20
top
200+
In most AAC
systems, the only
available words
would be chicken
nuggets!!
CORE DISPLAY
©Pat Mirenda, Ph.D., October 2015 13 CORE VOCABULARY LISTS
 M ANY options available; see
http://praacticalaac.org/praactical/aacvocabulary-lists/
HOW MANY
SENTENCES
CAN YOU
MAKE?
YEAH, BUT…
 “ Beginning communicators need concrete
vocabularies and concrete symbols”
 Over a 2-year period, 12 youth with moderate-severe
ID were provided with 35-44 lexigrams on an SGD,
including 61% fringe and 39% core vocabulary (e.g.,
stop, help, more, good, wait, excuse me, I’m sorry)
 BOTH types of words were learned and used, in equal
proportions ( Ro m s k i & S evc i k , 1 9 9 6 )
©Pat Mirenda, Ph.D., October 2015 14 IN OTHER WORDS…
 I conicity (i.e., the extent to which a symbol
“looks like” its referent) is NOT everything!
 S tephenson (2009): “In the past, it was
believed that iconicity would assist early
symbol learners and that different processes
underlay learning of iconic symbols compared
to arbitrary symbols, but this does not seem to
be the case. Iconicity in communication
symbols does not appear to provide an
advantage for very young children, who map
the meaning of a range of arbitrary and iconic
symbols onto referents” (p. 196).
YEAH, BUT…
 “ For beginning communicators, it’s normal to
communicate with mostly fringe words (i.e.,
nouns)”
 True – the first 20 words typically developing
(TD) children say are mostly nouns, and they
primarily use nouns between 15-18 months of
age
 B ut: by 24 months, TD children have 150-300
words and nouns no longer predominate, and…
 B y 26 months, TD children use 80% core
words, and will continue to do so for the rest
of their lives!
SO…
 I f we want MV students to be
perpetual beginning
communicators – just give them
fringe words!
 O kay to start AAC intervention
with small set of highly
motivating fringe words (nouns),
but not exclusively and not
indefinitely
 L anguage development requires
fringe and core words!
©Pat Mirenda, Ph.D., October 2015 15 YEAH, BUT….
 “ Students need fringe vocabulary to participate
in the general education curriculum”
 A bsolutely! Including core doesn’t mean
excluding fringe!
 B ut -- consider a unit on plants. In his or her
lifetime, how often will a student need to say
 stem, leaf, stamen, pistil, and flower
 c ompared to
 not, grow, tall, pretty, like, green, and healthy?
HOW? STEP 1
 D esign
communication
displays with BOTH
core and fringe
vocabulary
 O rganize the displays
strategically so core
symbols are in the
same place on every
display
CORE ONLY, MASKED
©Pat Mirenda, Ph.D., October 2015 16 CORE + FRINGE: LEFT-RIGHT
LEVELED CORE + FRINGE
LEVELED CORE + FRINGE + QUESTIONS
©Pat Mirenda, Ph.D., October 2015 17 FRINGE ON TOP
FLIP ‘N TALK (MAYER JOHNSON)
SGD CORE WITH FRINGE ON TOP
©Pat Mirenda, Ph.D., October 2015 18 HOW? STEP 2
 “ Speak AAC”: Point to AAC symbols on the
display as you talk, or as someone else talks
 Use your finger
 Use a small flashlight
 Use whatever – just do it!
 D ON’T expect the student to use the symbols
as well, at least initially (remember, you have
to make deposits…) – but provide lots of
opportunities for this to occur!
AIDED LANGUAGE MODELING
 M any names, same idea
 Aided Language Stimulation (Goossens’, Crain, & Elder, 1992)
 Partner-augmented input and Aided Language Input
(Romski & Sevcik, 1996)
 Natural Aided Language (Cafiero, 1998)
 Aided Language Modeling (Drager et al., 2006)
 N OT the same as “using visual supports” –
ALM targets vocabulary and language
development, not choice making or schedule
following
YEAH, BUT….IS IT AN EVIDENCE-BASED
PRACTICE (EBP)?
 YES!!!!! Research in ALM shows that it can be
used to increase:
 Turn-taking
(Beck et al., 2004; Kent-Walsh et al., 2010; Rosa-Lugo & Kent-Walsh,
2008)
 Receptive vocabulary
(Dada & Alant, 2009; Drager et al., 2006; Harris &
Reichle, 2004; Romski & Sevcik, 1996)
 2+ word/morpheme combinations (S-V, S-V-O, S-(is)-V-ingO (Binger & Light, 2007; Binger et al., 2008, 2010; Bruno & Trembath, 2006; Romski &
Sevcik, 1996; Romski et al., 2010)
 Grammatical morphemes (-ing, -’s, -ed, -s) (Binger et al., 2011)
 Responses to yes/no questions (Kent-Walsh et al., 2015)
 ALM has been taught to and used successfully by:
 Parents
(Binger et al., 2008; Jonsson et al., 2010; Kent-Walsh et al., 2010; Rosa-Lugo &
Kent-Walsh, 2008)
 Educational assistants
(Binger et al., 2010)
©Pat Mirenda, Ph.D., October 2015 19 STAY TUNED…
 F or an upcoming
systematic review on ALM
in Research and Practice
for Persons with Severe
Disabilities
 https://us.sagepub.com/enus/nam/research-andpractice-for-persons-withsevere-disabilities/
journal202263
KASARI ET AL., 2014
 61 MV children with ASD
 Mean age = 6 years (school-aged)
 Mean of 17 different words in a 20 min natural language
sample (range 0-51; but only five spoke >20 words)
 Mean receptive language age = 2 years
 Mean NVIQ = 4 years (SS 68 on the Brief-IQ)
 All had at least 2 years of previous treatment
 Two basic treatment conditions
 JASP+EMT
 JASP+EMT+SGD (iPad, Dynavox with both core and fringe
vocabulary related to the play context)
  Clinician modeled at least 50% of spoken utterances on the SGD
  Clinician expanded at least 80% of child’s communication bids
on the SGD
KASARI ET AL. 2014
 C hildren were randomized to JASP+EMT or
JASP+EMT+SGG
 Two 1-hr sessions in clinic for 12 weeks; parents
watched via one-way mirrors
 A fter 12 weeks:
 Responders received another 12 weeks of their
assigned treatment
 JASP+EMT “slow responders” were randomized for 12
more weeks to intensified JASP+EMT (3 hrs/wk) or
JASP+EMT+SGD; parents were also trained
 JASP+EMT+SGD slow responders were randomized
for 12 more weeks to intensified JASP+EMT+SGD (3
hrs/wk); parents were also trained
©Pat Mirenda, Ph.D., October 2015 20 WHAT HAPPENED????
 MV school-aged children made significant and
rapid gains in spoken spontaneous language with
the JASP+EMT+SGD intervention
 Adding the SGD later on for slow responders to JASP+EMT
alone did not provide the same benefit as adding in the
SGD from the beginning of treatment
 On average, 92.1% of the children’s total
spontaneous communicative utterances (across
all time points) in the JASP+EMT+SGD group were
spoken
 MV children’ s spontaneous communication
included different types of words and functions
beyond requesting
WHERE TO START? ASK:
 D oes this student have way to communicate
basic wants and needs and does he/she do so
spontaneously?
 “Want” (food, drink, activities, social interaction) AND
“Don’t Want” (break, leave me alone, stop/finished,
etc.)
 I f NO: consider starting with PECS, to AT
LEAST Phase IV
 This is the phase where research suggests that
speech production will be enhanced as a side effect,
at least sometimes
©Pat Mirenda, Ph.D., October 2015 21 WHERE TO START? ASK:
 D oes this student have
multiple opportunities every
day (at least 20 times per
hour???) during which
someone is “speaking AAC”
to him/her?
 I f not, teach SEAs, BIs,
parents, and others to
provide aided language
modeling, with emphasis on
core vocabulary
SYSTEMS APPROACH
 D ON’T re-invent the wheel for every student!
 Decide on a core vocabulary list that everyone will
use
 Decide on ONE low tech and ONE SGD display layout
format that everyone will use
 Create at least beginning core displays for everyone
 As fringe displays are created for specific routines,
activities, and curriculum areas, figure out a way to
share them so everyone can access them
 Provide inservices and coaching so everyone knows
why and how to provide ALM
AND REMEMBER…
Whether you think
they can, or
whether you think
they can’t –
you’re right!
-- Henry Ford
©Pat Mirenda, Ph.D., October 2015 22