Designing No Tech Augmentative Alternative Communication (AAC) Devices

My new job involves working with kids ages 2-5 who have been diagnosed with autism or other neurological disorders. The range of abilities I have worked with in the last 6 months has been challenging but exciting. One of the biggest challenges for me is trying to develop no-tech AAC options for my non-verbal clients. The clinic I work at is unique because it is considered a "kick-start" into therapy. Most of our clients are recently diagnosed. Our program offers them and their parents an intensive 3 month introduction to treatment. Having only 3 months with each client is the greatest challenge to this new position. It's hard to so frequently start over. And it really requires me to think through the most essential ways I can help them in the short time before we transition them to their more permanent therapy approaches.

Right now I don't have access to any high tech augmentative alternative communication (AAC) devices. I am hoping to find a dedicated AAC team here in the state of Washington that might be able to come in and consult with us, but I have yet to find one. In the mean time, I'm trying to design simple, functional communication boards or binders for those clients who need them.

Here are a few of the issues I have to deal with in designing these simple communication devices. I am going to put a big disclaimer out there that I am definitely not an expert in AAC. These are just the lesson's I've had to learn during the process.

• SIZE: In order for the communication book or board to be truly functional it needs to go with the client everywhere. That means they need to be able to carry it. I have experimented with a lot of options and a lot of times it just depends on the individual kid which thing will work best. Here are a few ideas I considered. 
• mini 3 ring binders
• business card holders
• laminated file folders or mini file folders (if you have a small laminator like me)
• 3 x 5 index card binders
• simple durably laminated pages or half pages hooked together with book rings
• small wristband communication board (velcro wristband with small laminated sheets, or a hand sewn insertable option)
• spiral bound flip books
• in all honesty after all the experimenting and trial and error I have settled mostly on making small laminated file folders for ease and cost effectiveness purposes. At the clinic the file folder follows the kid wherever they are going so they always have access to it. Once the kid has mastered it at the clinic we make a copy for them to use at home with their family. The child needs access to their communication folder at all times in order for it to be effective. 

• CORE VOCABULARY: Holy smokes this is a daunting task for me. Deciding which words will be the most functional for each child is really overwhelming. I have read so many websites and books and still haven't found that dream one-size-fits all core vocabulary. But there's gotta be a good solid core to the initial steps of English. I'm still teasing that out while swimming through all the info out there and trying to maintain balance in my life. I'm still so new to this process and I'm learning a lot. But each time I design a new system, I have to to remind myself to START SIMPLE. You are likely going to spend a lot of time teaching each word and concept. So start small and basic. Here are some things that are really important to keep in mind.
• DO NOT use only nouns for things the kid likes. The purpose of communication isn't just to ask for something we want. Communication has many purposes (Light 1998): 
• to communicate wants/needs
• transfer information
• establish social closeness
• fulfill social etiquette
• develop internal dialogue (Beukleman & Miranda)
• Make it individual. It's a lot of work to make a new communication board for each kid, but I'm getting faster at it each time. And honestly in the past when I've tried to use another kids communication board, it is usually awkward and I have to make changes immediately.  
• Basic core vocab suggestions: these are the core words I've used most often
• greetings: hello, goodbye 
• pronouns: I, You
• verbs: want, see, feel, hear, smell
• adjectives: like, don't like, fun,
• commands: yes, no, go, stop, again, wait, my turn, your turn, more, done
• familiar/favored nouns/verbs core board: activities, games, objects, people that the child frequently wants (e.g. coloring, blocks, balls, cars, book, singing, swing, jump)
• feelings core board: happy, sad, mad, tired, silly
• Make core phrases: for many of my kiddos they are just learning the function of communication. We try to keep things very simple for them. With one kiddo I'm currently working on core phrases of:
• I want...  I hear...  I see... I feel...  I like.... I don't like...
• Make an easy to access place for the most important core phrases. Here are some things I've used in the past for this section.
• I need a break (this is only used if the kid needs a break from a learning task, it doesn't mean they get to go play. If they ask for a break from a task, the task is removed for a short period of time.)
• I need to go Potty
• I need to Eat
• I need a Drink
• I need Help
• I want a New Toy

• FRINGE VOCABULARY: The fringe vocabulary is additional vocabulary that is more specific to certain activities or situations. For example if you are playing with a toy house you might pull out a fringe board that has different toys that go with the toy house (e.g. boy, girl, bed, table, chairs, pot, plate etc). For my kids who have mastered the use of the basic core board, I try to introduce a new fringe board every week, or every day, depending on the child's skill level. Keep in mind that you might want to start simple with only 3 or 4 fringe vocab words for each activity. If your client does well with the fringe boards and learns quickly you can do more. 
• fringe board examples I've used in the past, I put the different activities I've used with the fringe boards in parentheses:
• Descriptors: colors (with coloring, play doh, etc), 
• numbers (with number puzzles, or counting activities), 
• shapes (with shape sorter, matching games, art projects from cut out shapes)
• sizes (with mommy and baby animals, objects of various sizes, etc)
• Farm Animals (with I went walking book, farm animals game, barn toys, Old Macdonald song, little blue truck book)
• Toy House Accessories (with naturalistic functional play)
• Mr Potato head parts
• Body Parts (with head shoulders knees and toes, simon says games, do as I'm doing song)
• Textures with sensory play toys
• Art Supplies
• Cookie decorating supplies
• Play doh accessories
• the options are limitless!!!

• Organization:
• It needs to be chunked into groups that make sense. It needs to be easy for the child to navigate, otherwise they will not use it. And if they don't use it, well, it's useless. It might be the most beautifully thought out communication board, but if it isn't easy to quickly pick out necessary vocab, it will not work for them. I'll put a few suggestions I've found useful in the past 9 months of experimenting.
• Have a visual schedule on the front or back. Somewhere that is easily accesible.
• Have quick social greetings on the front or back. For those times when they are quickly passing by.
• For our little autism kiddos having a removable first, then board velcroed to the back has been very helpful. If their system has removable pictures it's easy to place those pictures on the first, then board.
• Put Basic Core Vocab at the top or on one side, chunked in specific groups like: 
• greetings (hello, goodbye), 
• commands (go, stop, again, wait, my turn, your turn, more, done), 
• yes and no in a well defined separate space that is easy for the child to find.
• carrier phrases (I want, I see, I hear, I feel)
• essential needs phrases: (help, break, potty, eat, drink)
• Put Core Vocab Boards in a specific space: I usually place mine directly below the basic core vocab listed just above.
• feelings core board
• preferred toys/activities core board
• familiar people core board
• Put Fringe boards on the other side in an insertable, flipable or easily removable way. Here's some idea on how to make it easily changeable
• cheap photo albums 
• baseball card pages
• Velcro 
• business card holders
• those photo insert things they put in wallets (anyone know what that's called)

• Speech Generation: Ideally this no-tech AAC system is a step toward more functional communication, like speech itself, or a high tech communication system. Consistent modeling of the spoken words for each selected vocabulary item is really important so the client can pair the spoken word with the visual symbol and what it represents. Here are some important things to keep in mind.
• Write out the exact words you'd like all communication partners to say when the client selects that symbol. The words need to be on the picture symbol. 
• don't say good job right after they select a symbol. I know it's so hard to resist! But believe me this is important. You want to pair the picture symbol with a consistent spoken word for each picture. When they select a symbol, say the word that is written on the symbol, fulfill the communication request, and then you are welcome to praise the heck out of that awesome communication.
• Adjust the number of words to the child's level. Modeling one word for each picture is usually appropriate but for some of my higher functioning kiddos two or more words can be appropriate. You will have to gage this individually. For example one kid's break symbol will just say "break" another kid's might say "Need break" and another kid's might say "I need a break".
• Train communication partners to say the words that are written on the picture symbol whenever the child selects that symbol.
• Immediately refer to the actual object, activity or task that the symbol represents. This will help the child learn the spoken words and picture symbols represent specific things in the world around them. This immediate reference is really important when the child is first learning the new picture symbols. Note: Once they solidly know what the picture symbol represents there is a little more wiggle room in response time. 

• Physical considerations: You need to consider what the child will be able to handle phsycially.
• movable picture symbols usually secured  to a base with velcro. This is particularly important if you are going to teach symbols in a picture exchange protocol like PECS. Or build individual picture sentences. So far, in my limited experience, my autism kids LOVE ripping the moveable pictures off and dropping them on the ground. so if you have a kid like that there are other options. If you do moveable symbols it's important to consider the child's motor skills. Are they going to be able to pull off the symbol effectively and place it in the right spot for communication? Do you need to make the symbol bigger or smaller based on their visual needs, etc.
• pointing! teaching a distal point is such a great skill to start off with. Let's be honest. Printing, laminating, and cutting out pictures is time consuming! but then you add cutting and attaching the dang velcro? Goodness, that is a lot of work! It is so much easier to prepare a communication system for a child who can point at individual symbols instead of having to physically pull them off and move them. The only issue with that is that the communication partner has to be watching and the phrase that the child built is not visible later. And the child needs to be able to navigate multiple symbols on a page.
• view finder system. So far this is my favorite system. It was one of those ideas that came, mid session, while I was trying to problem solve with a kid who couldn't quite grasp the distal point. It is a movable window that helps the child highlight the picture symbol they are selecting from a board of printed pictures. My view finders are usually a bright yellow rectangle or square frame that the child can place over the selected picture symbol. This way there is still a lasting sentence structure, but there is a lot less prep time involved. I place reusable stick dots on the view finder. That way the viewfinder stays in place. Reusable stick dots are great cause you can just wash them once they get dirty and then they are magically stick again! 

• USE in all contexts: I can't stress enough the importance of using the communication system in all contexts of the child's life. They need it at home, school, at the store, at the park.... WHEREVER they go! 

One last note, for the picture symbols themselves, I often use LessonPix which is a web-based picture library. It's an online picture symbol library. It is a really great resource that I would highly recommend. I might have to write an article about how much I love Lesson Pix someday. You can also use board maker, or a simple google image search.

Phew....That was a long winded post. Believe me it has been a learning curve with this new job. But I am loving this new insight into the world of augmentative alternative communication. What lessons have you learned about low-tech, or no tech AAC? What has worked for you? What hasn't? Please share!

Here are some pictures of a communication board for a higher functioning kiddo.