Augmentative and alternative communication (AAC) is a clinical practice area within speech-language pathology that makes use of a number of different kinds of non-verbal communication systems – everything from software and devices to good old fashioned sign language – as a way to assist individuals with particularly severe speech/language production or comprehension impairments.
People that commonly require AAC include those dealing with:
- Autism Spectrum Disorder (ASD)
- Intellectual or developmental disabilities
- Developmental apraxia of speech
- Cerebrovascular injury caused by stroke
- Traumatic brain injury
- Neurodegenerative diseases
When these conditions affect speech so dramatically that traditional SLP therapies are unable to quickly restore a person’s ability to speak, AAC is the answer that SLPs reach for.
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When Speaking Skills Aren’t Immediately Trainable
AAC tools and techniques come into play for SLPs when conventional therapies are incapable of restoring speech to levels where normal communication is possible, or in situations where the road to recovery is likely to be a long one.
A well-designed AAC program can allow patients to communicate over either the short-term or the long-term, alleviating anxiety and increasing their comfort and independence. Few things are so frustrating as knowing what you want to say but being unable to express it, or having simple questions but being unable to get them answered. AAC is an outlet for patients who are otherwise trapped in their own heads.
Using or recommending AAC does not mean throwing in the towel on speech and language, however. SLPs most commonly use AAC tools and techniques as an aid or a bridge to better spoken communication. In some cases, AAC, may be viewed as a long-term supplement to assist in communication. In others, it may be a temporary technique on the road to more complete spoken language skills.
From High Tech to Low Tech, AAC Finds a Way
AAC isn’t a new field. Anne Sullivan’s work with Helen Keller is only one of many ad hoc approaches to improvising alternative communication channels throughout human history, but it’s one of the most familiar to modern audiences and has a direct lineage to modern American SLP practices.
Sullivan drew from her experience as a visually impaired student herself for instructing Keller. The basic method of tracing letters of the alphabet into the palm of the hand seems primitive to modern SLPs, but it’s not too distant from some techniques still used today. It’s a method that today would be called unaided AAC.
AAC systems fall into two groups:
- Aided – Technology or props are used to assist communication
- Unaided – Vocalizations, hand-gestures, or facial expressions are used to convey meaning
Unaided AAC Is Portable And Flexible: Conventional Sign Language and Other More Simple Solutions
Unaided AAC is used, to some extent, by almost everyone, even people with full functional command of speech and language. It’s often easier and more natural than aided AAC and because it does not require external tools, it’s also often faster and less expensive. Unaided AAC may be preferred when the speech-language issue is thought to be temporary, or requires only light augmentation for the person to be able to communicate effectively.
Sign languages may be the most complete form of unaided AAC, but they can also be the most difficult to teach. For patients with long-term or permanent speech disabilities, however, sign is usually the preferred technique. The language is rich and can express even complex concepts fluently and fluidly.
Less formal unaided AAC is common in cases where speech can be recovered in full or in part. These can include basic gestures or informal vocalizations if the patient is capable of them. Making recognizable facial expressions and gestures often occurs naturally to people who can’t express themselves through speech.
Where SLPs have their work cut out for them is with patients who also have mental deficits, or were born with congenital problems that leave them without the ability to make gestures and expressions most of us are capable of and familiar with. In those cases, an SLP might have to channel outbursts or other self-evolved attempts at communication into more commonly recognizable gestures or vocalizations.
Aided AAC Fills in Where Nature Cannot: Speech Generating Devices and Smartphone Apps
In some cases, unaided AAC becomes either too difficult or impossible. For instance, when speech is affected by whole-body neurodegenerative issues that lead to loss of motor functions, it’s likely that manual dexterity will also be affected, preventing the use of sign language. In other cases, assistive technologies might allow more global communication skills. For example, through a text-to-speech device would still present challenges for someone with dexterity issues, it can be used to communicate directly to more people.
Aided AAC can be as low-tech as pointing at pictures or objects, or using drawing or writing. These methods are as old as speech therapy but they can be very effective and inexpensive. But in cases where sight or motor function is also impaired, these systems may be too simple to work.
Modern technology offers a large slate of solutions that overcome the limitations on low-tech AAC systems, though.
Speech-generating devices are perhaps the best known of these solutions and some of the most amazing. Thanks to the famous example of Steven Hawking, a genius English theoretical physicist who was struck early in life with amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease) and whose speech deteriorated by the late 1970s to the point of being unintelligible. In 1986, he was given one of the earliest text-to-speech computer programs, and his synthesized voice is now recognized around the world.
SLPs working in AAC quickly learn the capabilities of such systems and the differences between digitized and synthesized speech. They know when to use a voice amplifier, when a patient can vocalize properly but not loudly enough, and when instead to reach for an electrolarynx device, for patients who have lost their voice box.
As tablets and smartphones are now as common as the air we breathe, the number of tools has expanded and have become more accessible and easier to use for the people who need them. Today, tablet-based assistive tools are increasingly looked to as a first solution when high-tech AAC is needed.
Resources for SLPs Working With AAC
With the explosion of technology to support AAC, it has become a complex and rapidly evolving specialty area for SLPs. In addition to the solid bedrock that comes with a master’s degree in SLP itself, it can be useful to pursue a specialty certificate in AAC.
These courses are usually offered by colleges and universities that provide SLP education. They can run from anywhere between 15 hours to 15 weeks of instruction. The longer and more in-depth certificate courses are usually aimed at post-degree practitioners, while the shorter courses also cater to groups such as teachers or parents.
There are a number of organizations that provide AAC information and resources for practitioners. These include:
- The AAC Institute
- The International Society for Augmentative and Alternative Communication
- Rehabilitation Engineering and Assistive Technology Society of North America (RESNA)
AAC specific continuing education can also be applied to other SLP certifications. In particular, ASHA accepts continuing education units (CEUs) offered by the AAC Institute that can go toward maintaining your CCC-SLP.
As technology continues to evolve, AAC options are likely to become more common and more easily incorporated into almost all facets of SLP practice.