Interventions for Infants,

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15 Νοε 2013 (πριν από 3 χρόνια και 6 μήνες)

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Evidence
-
based AAC
Interventions for Infants,
Toddlers, and Preschoolers

Janice Light and Kathryn Drager

Penn State University


Seminar presented at ASHA 2007, Boston

The Penn State Team


Emily Angert


Julia Birmingham


Jacky Cammiso


Jen Curran


Elizabeth Hayes


Melissa Ihrig


Lauren Karg


Line Kristiansen


Wendy Lewis


Ashley Marzzacco


Jen May


Holly May


Ashley Maurer


Rebecca Page


Elizabeth Panek


Sarah Pendergast


Kate Shapiro


Nicole Sherman


Kristin Stoltzfus


Melissa Witte

The challenge


How do we provide access to the magic and
the power of language and communication
for young children with complex
communication needs who require AAC?


What did I learn watching my
kids learn language?


Young children


Start learning communication & language at birth


Learn language during daily activities in their
environment, especially play


Learn language in the context of social interactions with
familiar partners


Communicate not just to express needs and wants, but
also to build social closeness and share information


Social interactions are prime times to build language


Depend on context to learn language


“First words” are context
-
bound

What did I learn watching my
kids learn language?


Young children


Receive scaffolding support from their parents to help
them learn language


Parents provide opportunities for communication & language
learning


Parents adjust language input to children’s understanding


Parents respond to children’s communicative attempts


Receive 100,000s of models of language use


Parents say words to children before they “know” the words


Learn language rapidly


Have fun learning language

Principles to guide AAC
intervention with young children


Start as early as possible


Intervene with infants, toddlers, preschoolers who are at
risk


Intervene in natural environment during daily
activities


Maximize functionality, familiarity, meaningfulness


Focus on sustained social interactions with familiar
partners


NOT just expressing needs and wants,


but also building social closeness & sharing information
in sustained social interactions

Principles to guide AAC
intervention with young children


Provide contextual support to help children learn
language


Use context to support comprehension & expression


Infuse familiar experiences /contexts into AAC systems


Show parents how to provide appropriate
scaffolding support


Provide frequent opportunities for communication


Provide appropriate language input


Respond to child’s communicative attempts

Principles to guide AAC
intervention with young children


Provide models of AAC & speech


Use AAC & speech when talking to child


Sign & speech


Aided AAC & speech


Expand on child’s messages using AAC & speech


Ensure that AAC systems are dynamic


Support language learning


Regularly introduce/ add new concepts for child


Model their use

Principles to guide AAC
intervention with young children


Ensure that intervention is FUN!!


Integrate communication & play


Enhance motivation of child and family


Ensure that AAC systems are appealing and
fun!


Ensure that AAC systems are easy to learn and
use!

Goals of the presentation


Share the results of a research study that
developed, implemented, & evaluated the
effects of AAC interventions on the
language and communication skills of
young children with complex
communication needs


Multiple baseline across participants


Share case examples to illustrate AAC
intervention and outcomes

AAC
-
RERC


Project is part of the AAC
-
RERC II


Collaborative virtual research center funded by
the National Institute on Disability and
Rehabilitation Research


Grant #H133E030018 (2003
-
2008)


For more information


http://www.aac
-
rerc.com to access the webcast
or


Janice Light JCL4@psu.edu

Participants


Single subject multiple baseline design


9 participants to date


6
-
40 months old upon referral


Significant communication disabilities


All nonsymbolic or minimally symbolic at baseline


0
-
25 symbols expressively


Evaluated impact of AAC intervention


Collected longitudinal data to track language
development


Pragmatic, semantic, syntactic development

Goals of AAC Interventions


The overall goal is to build social interaction
between young children & familiar partners


Maximize child’s functional communication


Enhance child’s language development


Increase participation /turn taking


Express range of communicative functions


Develop breadth of semantic concepts


Build greater complexity of language structure to
support more complex communication


Build phonological awareness skills /foundations
for literacy development

AAC Interventions


Scheduled for 1 hour per week


In natural environment


Typically at home


Sometimes at preschool


Within play and other activities of daily
living


Involved parents and other primary
facilitators

Departure from typical

AAC intervention


Focus on sustained social interaction


Don’t just focus on needs and wants


Redesign AAC to better meet young child’s
needs and skills


Provide contextual support to support language
learning


Encourage language learning through AAC


Don’t require language learning prior to AAC

Components of effective evidence
-
based AAC intervention

1.
Identify meaningful social contexts for
communication

2.
Develop appropriate AAC systems for the child

3.
Set up the environment to support social
interaction

4.
Use appropriate strategies to support child’s
communication


Meaningful opportunities for communication


Appropriate supports to ensure successful
communication

Case #1 AAC intervention with
infants
-

Initial intervention


Goals


To increase active participation in social
interactions with familiar adults


To increase communicative turns /social bids


To introduce range of communication purposes



Identify meaningful contexts for
social interaction


Meet with parents; observe child


Select contexts that are


Interactive


Rich in opportunities for participation


Reciprocal


Easy to sustain over multiple turns


Motivating to the child


Meaningful / familiar for the parents and child


Frequently occurring


Valued by the family


Fun!!

Identify meaningful contexts for
social interaction


Focus on contexts that provide


Sustained social interaction


Offer multiple opportunities for participation /communication


Not just expression of needs and wants


Single opportunity for communication e.g., snack


Initially choose contexts that


Involve only the infant and the partner (and AAC)


Minimize the joint attention demands


Have predictable structure


Identify meaningful contexts for
social interaction


Social games


E.g., Peek
-
a
-
boo, So Big


Songs (line by line)


E.g., Itsy Bitsy Spider


Musical instruments & toys


E.g., Winnie the Pooh, crib toy / mobile


Books


E.g., Brown Bear, Who’s hiding?, Baby Faces

Develop appropriate AAC systems


Communication is multimodal


Identify modes that are used currently by child


Vocalizations


Facial expressions


Introduce additional modes to augment /enhance
communication


Signs


Light tech symbols


Speech generating device (SGD)

Introducing AAC to parents


AAC intervention results in significant gains in


Functional communication


Language development


Will AAC inhibit speech development?


Meta
-
analysis (Millar, Light & Schlosser, 2006)


0% demonstrated decreases in speech production



11% showed no change



89% demonstrated gains in speech



Gains observed were modest ones

+20 spoken words or less



Ceiling effects in many cases


AAC does NOT inhibit speech development

Develop appropriate

aided AAC systems


AAC systems should


Be fun


Be easy for infants to understand and use


Be dynamic

AAC systems should be fun


(from Light, Drager, & Nemser, 2004; Light, Curran, Page, & Pitkin, in press)


AAC systems should appeal to infant


Multiple bright primary colors


Familiar motivating content


Preferred people and activities


Fun interactive play activities


Engaging characters


Expressive faces


Engaging speech output, songs, musical instruments,
sound effects, laughter


Child’s preferences

AAC systems should be easy to use


AAC systems should be easy for infants to
understand & use


Use touch screen for selection if possible


Immediate cause and effect / direct relationship


Selection upon activation not release


Provide scaffolding support to assist with navigation


Set up menus / arrows for future navigation


Model use, but do not require use


Use visual contextual scene displays to provide
meaningful interactive contexts to promote social
interaction

Traditional grid layout


Vocabulary represented by separate AAC
symbols in “boxes”


Language is taken out of context


“Decontextualized”


Concepts are presented separately


Visual
-
spatial relationships are not preserved


Contextual relationships are not preserved


Imposes greater cognitive /linguistic
demands

Visual scene display layout


“Graphic metaphor”
(Shane, 1998)


Vocabulary embedded under “hot spot” in
visual scene display (VSD)


Digital photo of child’s experiences


Scanned image of familiar book


Vocabulary presented in meaningful context



Concepts related visually and conceptually as in
life

Develop appropriate VSDs


Develop visual contextual scene displays that
represent the selected interactive contexts to
expand the child’s communication


VSDs are designed to provide a high level of contextual support


VSDs provide a context to support the communication of young
children and their partners


VSDs can be implemented


On dynamic display speech generating devices (SGDs)


As low tech systems


Choose appropriate representations for VSDs


E.g., digital photos, scanned images

What makes a “good” VSD?


Visual scene displays for young children should


Be meaningful and relevant


Represent motivating contexts /activities


Portray interactive social experiences


Provide a rich context for communication


Reflect the child’s perspective on the event /experience


Reflect the child’s conceptual development
/understanding


Be appealing

Develop appropriate VSDs


Adapt VSD as required to accommodate


Visual skills


Reduce complexity for very young children,


Remove background to increase contrast for
children with visual impairments


Motor skills


Number of hotspots


Size of hotspots


Cognitive/ Language skills


Amount of vocabulary


Type of vocabulary provided

Select appropriate vocabulary


For each interactive context, select appropriate vocabulary
to expand the child’s communication


Individualized


Motivating / fun


Functional


Developmentally appropriate


Kids should sound like kids!


Culturally appropriate


Supportive of language learning


Include a range of developmentally appropriate &
functional concepts



people, actions, objects, places, social words, relational concepts,
questions, etc
.


Support participation in social interaction not just expressing wants


Young children can only learn language if we provide
access

Select appropriate vocabulary


Identify appropriate “hot spots” in the VSD for
vocabulary related to the context


Be sure hot spots are an appropriate size


accommodate child’s motor & sensory perceptual skills


Consider child’s language and cognitive development
when adding vocabulary


Initially beginning communicators may only have a single
hotspot in a VSD


Gradually add more hotspots / vocabulary concepts


Observe child’s interests in VSD


If child selects same area of the VSD, add vocabulary to this
area of interest to reflect the child’s intent / meaning

Develop appropriate VSDs


VSDs can be very simple or more complex
depending on the needs and skills of the child


Single image with a single hotspot


Single image with a few hotspots


Single or multiple images with multiple hotspots


Hybrid displays including a visual scene as well as
additional vocabulary items organized outside the scene
in a grid


Traditional grid displays with symbols displayed in
rows and columns

Introduce appropriate AAC systems


Light tech symbols


Meaningful & appealing representations of
concepts


Digital photos, scanned images, color line drawings


Covered in contact paper & backed with Velcro


Taught in meaningful contexts; paired with the
referents

AAC systems should be dynamic


AAC systems should be dynamic


Start with systems that provide potential access
to 1,000 of concepts


Do not let AAC systems limit language
development


Gradually build language

AAC systems should be dynamic


Young children experience qualitative &
quantitative changes in development


AAC systems must reflect these changes


Introduce new activities regularly


Respond to child’s preferences


Introduce new concepts regularly


***Provide access to range of language concepts


Model their use in meaningful contexts


Don’t wait for child to “prove” comprehension


Introduce more hotspots as motor skills develop


Embed more language

Set up the environment to
support social interaction


Ensure appropriate positioning to maximize
attention and participation


Accommodate motor skills & cognitive skills


Minimize joint attention demands and maximize
the child’s attention to partner and AAC system


Sit directly in front of the child at eye level


Hold the AAC system directly in front of the child, just
below the partner’s face


Use appropriate strategies to
support child’s communication


Have FUN!!


Engage in social interaction using
appropriate strategies to ensure


Meaningful opportunities for communication


Appropriate supports to ensure successful
communication


Initiate the context / identify
opportunities for communication


Initiate the interactive context / start the activity


Locate the appropriate display for the child


Initially do not expect the child to navigate
independently


As the child develops competence, model navigation to
the appropriate display


Identify numerous opportunities for the child to
participate within the context


Initially context may be repetitive


As child develops competence, build in numerous
varied opportunities for interaction

Mark opportunities for child to
communicate


Clearly mark each opportunity for the
child to communicate


Use expectant delay


Focus attention on child; maintain eye contact


Use expectant body posture


Wait and allow the child time to communicate



Respond to the child


If the child attempts to communicate, respond
immediately


Fulfill the intent


Repeat or expand on the child’s message


Model AAC + speech


Continue the activity


Continue to provide meaningful opportunities for child to
communicate


Repeat over successive turns


Introduce new context as required


Watch for loss of interest


If the child does not attempt to
communicate,


Model an appropriate turn


use AAC + speech


Use a third party model to demonstrate if
available


Parent, sibling, or aide demonstrates for the child
what to do


Present the opportunity again

Model AAC + speech


When talking to child, always model AAC


Speech + sign/ gestures


Speech + aided symbols


Speech + SGD


Model AAC use to


Support child’s comprehension


Show the child how to communicate


Provide opportunities for child to learn new language
concepts & new structures


Make note of gaps in available vocabulary; add
required concepts

Work with parents

to enhance participation


Identify opportunities for communication


Infuse into familiar, meaningful, motivating, social activities


Opportunities to sustain social interaction


Model use of AAC plus speech


Demonstrate how to use AAC to communicate


Provide scaffolding support in AAC use


Locate appropriate light tech symbols to offer choices


Help locate appropriate pages in VOCA


Recognize and respond to child’s communicative attempts


Fulfill communicative intent


Expand and model more complex messages using aided AAC


Have fun!

Intervention Stage 2

Developing semantic concepts


Goals


To continue active involvement in social
interactions with familiar adults


To expand expressive vocabulary to
communicate more diverse meaning


To teach questions gradually to provide control
over vocabulary acquisition /language learning

Work with parents


Continue to


Set up numerous opportunities for communication


Recognize and respond to child’s communicative
attempts


Model use of aided AAC


Model known concepts as well as new ones


Expand on child’s messages


Teach new concepts


Link new symbol to the concept directly


Demonstrate concept


Model use


Provide scaffolding support in AAC use


Help locate appropriate pages in VOCA as
required


Teach organizational system


Organize vocabulary according to meaningful
events


Use appropriate menu symbols


Intervention
-

Stage 3

Learning syntax and morphology


Goals


To continue active involvement in social interactions
with familiar adults


To take turns with peers with adult scaffolding


To continue to expand expressive vocabulary


e.g., question words, etc


Read, read, read


To encourage communication of more complex, novel
meanings by combining symbols


To introduce early morphological structures to specify
meaning

Developing the foundations for
social interactions with peers


Important to develop the foundations for peer
interactions


opportunities to develop friendships


“testing ground” for communication skills


Develop repertoire of activities as contexts for
interactions with peers


books


songs


games


play activities

Learning the form of language


Begin to introduce more complex forms of
language


Model AAC + speech


Build up sentences


Break down sentences


Use message bar with VOCA to provide visual
/auditory feedback


Teach in context; demonstrate appropriate use


Explain rules as appropriate


Expect use only in contexts where obligated


E.g., “writing” activities / publishing books


Gradually introduce expression of
morphology/ syntax


e.g., present progressive, plurals, past tense,
auxiliary


Challenges


How do we represent grammatical parts of
speech?


Intervention Stage 4

Phonological awareness / literacy


Goal


To continue active involvement in social
interactions with familiar adults


To interact socially with peers


To continue to expand expressive vocabulary


To continue to develop syntax and morphology


To teach phonological awareness skills and
literacy skills


AAC systems


Introduction of alphabet board


light tech


Access to alphabet on high tech system


Speech output letter sounds not names


Introduction to literacy curriculum


Letter
-
sound correspondences


Phonological awareness skills


Sound blending


Initial phoneme segmentation


Early decoding & shared reading


Early writing activities

Ongoing literacy instruction


Ongoing reading of books, talking about
stories


Teaching reading skills


Decoding of more complex words


Sight word recognition skills


Reading simple stories


Building comprehension


Teaching writing skills


Writing stories

Summary of results to date


All children have demonstrated significant
increases in their rate of turn taking


All children sustain interactions with others for
significantly longer


All children participate in interactions that involve


Social routines


Play activities


Not just expression of needs and wants


Children use their AAC systems independently for
play & learning as well


Children use their systems as contexts to interact
with peers


Shared books


Shared singing


Play


All children have demonstrated significant
increases in their expressive vocabularies


All children have acquired a range of semantic
concepts


Children are combining concepts to
communicate more complex meanings


All children have been able to use VSDs on
initial introduction once use is modeled


seem to be more interested & motivated when
scene displays are used to integrate AAC &
play, book reading, music


Children have learned to use other displays


Hybrid displays


Grid displays


All children started with adult scaffolding
support to find appropriate pages in aided
systems


Children have learned some navigational tools


Menu


Forward and back arrows to change pages


Some children navigate independently


Some children are developing phonological
awareness and literacy skills


Early AAC intervention supports language
development and communication


Increase participation and build social
interaction


Develop breadth of semantic concepts
/vocabulary to support more diverse
communication & conceptual development


Build greater complexity of language structure
to support more complex communication


Build phonological awareness skills and
foundations for literacy development

The art and science of

AAC intervention



The science of AAC intervention


Implementation of evidence
-
based intervention
procedures


Research is available to guide in planning and
implementing AAC intervention with young
children


Monitoring effectiveness with individual child


Evaluating outcomes

The art of AAC intervention

The belief and the commitment to the right of
all individuals to express themselves fully
and seek their full potential


For further information,

Visit www.aac
-
rerc.com

for the webcast on young
children who require AAC or

E
-
mail JCL4@psu.edu


This research is part of the AAC
-
RERC II and is funded by
the National Institute on Disability and Rehabilitation
Research of the U.S. Department of Education, under grant
# H133E030018 (2003
-
2008). The opinions contained in this
presentation are those of the grantee and do not necessarily
reflect those of the U.S. Department of Education.