Core vocabulary are those words used with high frequency and make up about 75-80% of the words we use everyday. Core vocabulary should be a main part of all AAC systems because it allows for most flexibility across most situations.

With an emphasis on core words, we also use Fringe Vocabulary 20-25% of the time.  Fringe vocabulary are used in a continuum of low-frequency to lower frequency situations (e.g., ‘mountain’:  ‘glacier’, ‘crevasse’). Personal vocabulary can also be included under fringe vocabulary and would relate to personal words someone might need for their individual needs, interests, work, school, or even community.

So, in the best communication world, AAC users would have access to core and fringe vocabulary so that they have maximum communication power no matter where they are,  who they are with, or what they are doing.

Now the more complicated part, how do we get all of that ‘power’ onto a communication board. As with anything complicated, there are a variety of philosophy considerations, teaching strategies, questions to ask, and ways to do it. Here we go:

Some Philosophical Considerations

Communication boards should:

• Have emphasis on core vocabulary- Core vocabulary needs to be emphasized in individual communication systems. Core words are the most flexible and can meet someone’s communication needs most of the time.

• Have inclusion of fringe vocabulary- Fringe vocabulary is also important and should join core vocabulary for a more total or comprehensive communication system.

• Keep core vocabulary in static positions- A principle of core vocabulary learning is that the words stay in a consistent position across communication tools and even when new words are added (long-term planning is important here know where the first 100 words will go, even if you are starting with 12).

• Add fringe vocabulary in a static organizational/placement system- Create a core to fringe word systematic layout, so AAC users (and facilitators) know where to locate the consistent core words and know where the framework for the fringe vocabulary will be located.

Remember:

• Core vocabulary needs to be taught- Use core vocabulary teaching strategies. These words are often abstract and might be harder to learn than more concrete ones and therefore need many, many communication opportunities for the learner to prAACtice using them in authentic situations.

•  With core word vocabulary communication boards, ‘Ease of Use’ at first is not predictor of success- Teaching, prAACtice, teaching, more prAACtice (maybe even more teaching and prAACtice) is necessary when learning a new communication system.  Make sure true teaching and prAACtice happens before testing and making a decision as to whether or not an AAC learner can be successful. Think of it like learning a new language, most anyone would need more than a 6 week trial period before losing the opportunity to be allowed to speak that new language. Keep in perspective, in the teaching/learning process is the AAC user truly immersed in AAC language. Do people speak AAC to the AAC learner all the time?, are there opportunities for them to prAACtice speaking back (even if their response is not perfect?), and do they have access to a full range of that language at all times?  The answers to all of these questions do not have to be ‘yes’, but i if not yes then the ‘no’s’ need to considered when deciding the level of learning and communication success.

• Create many communication opportunities- Make sure there are many opportunities to USE the communication system for a variety of communication functions/reasons: requesting, commenting, protesting, chatting, conversation, and more.

• Use Aided Language Input (ALI) and other specific teaching strategies- Can not be said enough, Use AAC to model AAC language.

• Provide specific feedback to AAC communication and respect good.

Ways To Do It: 5 Ideas

1. Single page communication board with core vocabulary on one side and fringe vocabulary on the other.- With this framework for your communication board, a consistent set of core vocabulary would always be on the left side and a set of fringe vocabulary would be on the right side. The core vocabulary would stay constant, but the fringe vocabulary would change based on the context.  This would mean that the AAC user would have a predictable way of knowing where vocabulary was located. Check out the impact of a system like this at:  A Few Good Words by Barbara Cannon & Grace Edmond.

2. Single page communication board with core words with attached flip page set of fringe vocabulary  - Within this framework, core words are static on a communication board but there are a variety of tabbed pages that flip based on the fringe vocabulary needed. The core words are always available (able to be seen and accessed).  The Pixon™ Project Kit is an example of this type of communication board arrangement (and much more).

3. Single page communication board with core words with attached side velcro or magnetic fringe vocabulary- Within this framework, the core vocabulary is in the center of a communication board and the fringe vocabulary attaches around the sides, bottom, and/or top, but the core center remains constant. The fringe vocabulary can be changed easily depending upon the context of communication.

4. Tri-fold communication books- A tri-fold communication book can have the core vocabulary in the center available at all times and fringe vocabulary ‘flips out’ or opens from the sides and bottom to reveal fringe vocabulary. In this example, the specific fringe vocabulary stays fairly constant but covers a range of needs.  A sample of a tri-fold communication board was developed from the AT Team at Orange County Public Schools (Florida)

5. Individual communication boards with core words and group or activity area boards with fringe vocabulary- In this framework, each AAC user would have their own core word communication board that goes with them where ever they go. The environment or area would have a group communication board that has the fringe vocabulary relating to the environment or context. An example of this could be, science lab. The learner has a core communication board but once in the science lab, the fringe vocabulary to talk and learn specific ‘science’ is at the lab station on chemical reactions.

We would love to see any pictures of core and fringe communication boards that you have used.

1. “Show me [on your device].”  (Instead, build the language of communication, with directives such as “Tell me” or “Say it.”)

2. “Press the switch.” (Instead, refer to the function that the switch is being used for. E.g., “Make it go”) See Ian Bean’s great post on this subject.

3. “Tell me on your talker.” (If they tell you one way, and you understood the message…celebrate, reward, and encourage! If you make them repeat themselves using a different strategy, they may come to view communication using AAC as a chore. And that’s not so good for motivation…)

4. “I know you can do it. You did it yesterday. You’re just being stubborn.” (There are lots of good reasons for inconsistency but even if that wasn’t so, there is no room for calling someone stubborn in a professional context.)

5. “Hurry up.” (Just. Wait.)

I am thrilled to have this opportunity to post about Rett syndrome, and share some strategies on successful use of AAC with individuals with Rett on this blog!!  Thanks to Carole Zangari for this gracious invitation.

Background

I began working with individuals with Rett syndrome (RTT) about 15 years ago, and at that time, there was very little information available for clinicians, teachers and families regarding best practices in working with this population. Rett Syndrome was initially described in the 1960’s in Europe, and the first individual with RTT was diagnosed in the U.S. in the 1980’s. A fairly rare disease, it occurs in approximately 1:10,000 live female births, but is the second-most common cause of severe intellectual disability in females. RTT does occur in males, though less frequently than females, and most times the males are very severely affected.

So – why is there so much interest in RTT and why are more and more clinicians seeing cases of RTT?

Genetic Cause

The genetic mutation that causes RTT was identified in 1999 and as a result, a great deal of interest in the disorder has been generated since that time.  RTT most commonly occurs as a spontaneous mutation on the X chromosome in the MECP2 gene. This gene plays a major role in the development of the brain and in healthy brain function throughout the lifespan.  At present there are countless studies underway to learn more about this very complex gene, and more importantly, to identify clinical treatments, and eventually, a cure.   The diagnosis of RTT is made clinically, typically by a developmental pediatrician or neurologist, and then confirmed through a blood test. Many early cases of RTT are initially misdiagnosed as autism, especially when the signs of the disorder first become apparent.  Until recently RTT was considered to be part of the autism spectrum, but with the release of the new DSM 5 this year, it is no longer listed as an autism spectrum disorder.

The finding of the gene has resulted in more accurate diagnosis of RTT and better understanding of the challenges faced by individuals and their families. As recently as 10 years ago, individuals with RTT were believed to be incapable of intentional communication and likely faced the loss of all motor skills at an early age, and an early death. We now know this is not the case. It is not a degenerative disorder. Many individuals with RTT live well into middle age, retain walking skills and some hand function and participate in their community.  We are beginning to learn about the variations in cognitive and communication ability as well. Though most individuals are severely cognitively challenged, nonverbal, and dependent for self-care, they tend to be very social and interested in people and various activities. The key challenge is how to identify the best way for the individual to communicate and to maximize their potential.

Characteristics of RTT

Individuals with RTT have severe challenges in cognition, communication and motor function.  Here are some key facts:

• Symptoms usually appear between six-18 months of age
• Most infants with RTT appear to function normally until experiencing a regression in motor skills, language and cognition sometime before the second birthday
• The period of regression can last for several years
• Most individuals can then regain skills, or learn some new skills, in later childhood through adulthood
• Seizures, respiratory, and feeding problems are often present
• Hand function is usually very limited
• Apraxia is commonly observed and affects most body movements
• The overwhelming majority will be nonverbal and not develop functional spoken language skills
• Many individuals with RTT have excellent eye gaze – this modality has strong potential for communication
• Early intervention with AAC can assist in development of communication and cognitive skills and improve quality of life for those with Rett syndrome

Assessment of Communication

Because of the complexity of the disorder, standardized tests usually do not provide the most functional, clinically applicable or relevant information for clinicians to identify the best approach to designing communication intervention. Two tools which I recommend are The Inventory of Potential Communicative Acts (IPCA) (Sigafoos et al.,2006)  and The Communication Matrix (see references at the end).  Each of these tools use a series of questions to gather information from a communication partner of the individual you are assessing.  These are highly functional ways to gather useful information about communication and social behaviors of individuals who are at a prelinguistic or early linguistic level of communication development.

Communication Intervention

Most individuals with RTT will not develop functional verbal skills. So, for this population, implementation of AAC strategies EARLY will help provide the best outcomes.  Volitional hand control is usually limited because of severe difficulties with apraxia. They often need additional time to generate a response, so keep that in mind when asking questions or giving a command.

Many individuals with RTT use nonstandard behaviors for communication. For example, to make a request, a person with RTT may walk towards or lean towards an object. Some of the behaviors to be on the lookout for are: vocalizations, laughing, crying, eye gaze, head or body movements.  These nonstandard behaviors are often described as prelinguistic, in that they don’t fit the criteria for symbolic communication, but if acknowledged as communicative or potentially communicative, a meaningful, symbolic act can be shaped. The communication partner, someone who is familiar with the individual with RTT, can provide an abundance of information about interests and help you interpret the meaning of these behaviors.

Consideration of alternative access for AAC using body parts other than the hands, including head, arm, or eyes should be a primary goal.  Persons with RTT are often described as making consistent eye contact with others, so this is a good modality to begin to explore. There’s lots of interest at present in using electronic eye gaze systems, and there’s some excellent research that demonstrates individuals with RTT have gaze patterns similar to typically developing children (Djukic & McDermott, 2012; Djukic et al, 2012).  However, before making significant investments of time, money and other resources in electronic systems, you may want to consider trying to utilize low-tech or no-tech eye gaze options, using partner-assisted scanning.

Here are some ideas for Best Practices in AAC Intervention for RTT:

• Begin by teaching a simple requesting response
• Ensure the targeted response is within the individual’s physical abilities – consider nonstandard behaviors
• Consider a simple motor act rather than speech or gestures
  • Touch a switch
  • Hand movement
  • Natural gesture
  • Assess use of eye gaze
    • Offer choices
    • Develop consistency across two favored objects
    • Explore expanding set to three or more choices
    • Begin with no-tech; establish a consistent, valid level of response
    • However, allow for inconsistency (remember – apraxia can affect consistent motor responses)
    • Allow time to respond – many individuals with RTT have delayed responses – asses an individual and adjust your expectations
    • Move to low-tech or high-tech, depending upon:
      • Interest level
      • Skill
      • Resources
      • Contexts

Specific Interventions

The evidence for successful use of AAC with RTT is limited, but here are some techniques that are discussed widely in the RTT community:

• Communication Coaching –See Bartolotta & Remshifski (2013) for more information.
  • The communication partner is the best resource to interpret what behaviors mean
  • Coaching is highly effective in terms of SLP time and resources
  • You can implement any type of AAC strategy into a coaching model
  • How to do it:
    • Observe an interaction between an individual with RTT and a familiar person
    • Provide targeted strategies to implement during familiar settings, such as:
      • Offer choices
      • Increase wait time to allow for responses
      • Acknowledge behaviors that can be potentially communicative
        • Eye gaze, open mouth, vocalization, hand and body movements
        • Ask questions or make comments that require responses

• PODD
  • Pragmatic Organization Dynamic Display Communication Books – developed by Gayle Porter
  • Provides guidelines and templates for communication books

• Contains tips for teaching strategies and how to choose relevant, motivating vocabulary

• Books can be accessed using direct selection, scanning, partner-assested scanning

• Available from Mayer-Johnson (www.mayer-johnson.com)

• See Linda Burkhart’s website for information on training opportunities for PODD
  

• Electronic eyegaze systems
  • Infrared cameras provide access to a range of devices using eyegaze
  • Very population devices: Dynavox Eyemax, TobiiC12 or C15 Communicators
  • Emerging  interest in using this type of AAC strategy given the strong eye gaze modality we observe in those with RTT
  • Suggestions for implementation
    • First establish consistent eye gaze using high-interest objects, photos or symbols
    • It can be very challenging to achieve calibration for individuals with RTT – go slow, and don’t be discouraged. It takes time to learn how to activate buttons using eyegaze
    • Begin slowly using high-interest activities
    • Trial a device before recommending a purchase (as you would with other clients)
    • Remember that one system won’t work in all contexts, so explore multiple communication options

Working with individuals with RTT and their families can be challenging yet highly rewarding! We can learn so much about alternative ways to meaningful communication with this population. As one family said, “these girls have so much to say if we only listen”.

Any questions – please contact me at: theresa.bartolotta@shu.edu

References/Resources

Bartolotta, T.E. & Remshifski, P.A. (2013). Coaching communication partners: A preliminary investigation of communication intervention during mealtime in Rett syndrome. Communication Disorders Quarterly, 34(3), 162 – 171.

Communication Matrix – http://www.communicationmatrix.org

Djukic, A. & McDermott, M.V. (2012). Social preferences in Rett syndrome. Pediatric Neurology, 46, 240-242.

Djukic, A., McDermott, M.V., Mavrommatis, K., & Martins, C.L. (2012). Rett syndrome: Basic features of visual processing – a pilot study. Pediatric Neurology, 47, 25-29.

International Rett Syndrome Foundation – http://www.rettsyndrome.org

Sigafoos, J., Arthur-Kelly, M. & Butterfield, N. (2006).Enhancing everyday communication for children with disabilities. Baltimore, MD:Brookes.

Pogo Boards

Pogo Boards is a communication board creator for both the computer and the iOS platform. You can make traditional grid-based communication boards and a variety of other visual supports.  Pogo Boards also has a variety of pre-made boards that users share.  Price: - Free trial period with premium account, then Free basic account, Subscription price for ongoing premium account

 Symbly Go & Symbly

Symbly is a computer based communication board creator. Communication boards are super easy to create, share, and print out.  Symbly Go is an iOS platform app that allows you to view your communication boards (and other visual supports) on your iPad.  Your communication boards will automatically be downloaded to your iPad (even when there’s no Internet connection available).  There is text to speech capability if needed.  Price: free 30 day trial then monthly subscription

 Custom Boards 

Custom Boards Premium is a communication board and activity creator for iOS platforms.  Custom Boards allows for a variety of grid based communication boards with an option to use a symbol library (smarty symbols) or your own images. The Custom Board app also lets you create individual games and activities.  Price- $29.99

Picture Card Maker 

Picture Card Maker allows you to create communication choice boards in a grid style. You can print the communication boards or access them on your iOS device. There is capability to record speech into each communication picture. Price: Free

PhotoVoca Android &  PhotoVoca iOS

PhotoVoca is a is switch accessible communication board creator for iOS AND Android platform tablets and phones. It supports both text-to-speech and digital voice recording. There are grid templates that can be used. Price: Free

 Not an App but… Free and Easy (computer based, need internet connection to create but can save as PDF)

   ConnectABILITY is a virtual community and website focused on lifelong learning and support for people who have an intellectual disability, their families and their support networks. It is based in Canada and funded by a grant from Ronald McDonald House Charities.  ConnectAbility has many great resources, but today we are talking about supports for creating communication boards. The  Visual Engine allows you to easily create grid based communication boards with their pre-set symbol or image library or  you can add your own images.

Fun and communication go together. Meaningful (and fun) communication and language activities can often make the difference between a disengaged passive learner and a participatory, engaged, and excited learner.  We have talked about many picture symbol communication boards, but there are also tangible and tactile communication boards that have been essential for learners that have vision impairments as well as those who have difficulty discriminating between picture symbols. While exploring a variety of communication boards, we came across Adaptive Design Association Inc. Adaptive Design Association Inc. reminds and teaches us about the role of appropriate customized  adaptions to allow for authentic communication, developmental, social, and academic learning (who knew what you could do with cardboard?).  Within our search through adaptive design, there was a link or connection to the fun theory.  Fun can change behavior for EVERYONE and the fun theory demonstrated this.  After exploring the fun theory website, we will be thinking a lot more about adding more fun to classrooms, schools, and even our clinic with the fun theory principles applied to communication opportunities. Got fun ideas? Please share.

Click on Picture to Play

We’re so excited to continue our PrAACtical Look series with a guest post from Vicki Clarke, who is the CEO of Dynamic Therapy Associates, a speech language therapy clinic in Kennesaw, Georgia.  Vicki specializes in AAC, conducting local and national device evaluations, consultations, treatments and trainings for individuals, clinics, school systems and professional organizations and manufacturers. Vicki has a wealth of knowledge in the prAACtical aspect of AAC service provision and shares a tiny bit of that with us in this post about preparing clients who use AAC for medical encounters.

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I was asked to contribute a “favorite therapy activity” kind of post to this blog a few months ago.  Decisions, decisions, decisions….I love Arts & Crafts Therapy, Cooking Therapy, iPad Therapy, Shopping Therapy, and Hang-Around-And-Chat Therapy but what to share?  I mulled it over and I decided on “Serious Medical Procedure Preparation Therapy.”  Fun stuff, right?!!?

We do a lot of good work in therapy sessions with our patients but what I hope to highlight today is the significance of the work we all do in modifying devices to meet our patients’ complex, and changing needs.  I believe firmly that our support for families and well thought out modifications are as important as the actual face-to-face work we do with our young friends.  Speech generating devices can be “translators” for some of our friends.  These talking boxes translate what patients see into words they hear.  Speaking boxes allow our friends to use their pictures to talk and translate this visual language into something their family and friends can understand.  Today we are talking about helping our patients understand language and then discuss the really BIG stuff in their lives.

I have the fortune of working with my patients for a very long time.  I’m serious, as in 15 or more years for some of them.  I’ve wiped their snotty noses and hugged them through minor illness and distresses since they were 3 and 4 years old.  Lately several of these friends of mine have had significant medical situations arise, a need for a CT Scan, VNS battery replacement surgery, onset of diabetes, reconstructive inner ear surgery, to name a few.  These friends of mine have a variety of diagnoses such as autism, chromosome deletion syndrome, cerebral palsy, developmental delays, and mitochondrial disease. They are all functionally nonverbal, communicating with speech generating devices.  Most of my friends have  small comfort zones: places, activities and people with whom they are comfortable.  As you can imagine this rarely includes hospitals, CT’s and doctors.

For me the answer is often TECHNOLOGY, so why not for this problem as well?  The route we took was using our communication devices to introduce these new places, procedures and people in a safe, familiar manner before the big events.  The devices were loaded with pictures, videos and slideshows our young people could explore at their leisure, when they were calm and in familiar environments.  On the big day, the devices moved with their owners from their homes, into their cars and vans and helped them transition to their medical appointments.  Maestros and NovaChats joined their owners in waiting rooms, on wheelchairs and in hospital beds.  Step by step our young people touched pictures of procedures, watched snippets of videos and allowed their blood pressure to be taken, blood to be drawn, IVs set in place and a lengthy CT Scan to be completed:  nothing short of a miracle for all of these teenagers.  Ears were repaired, VNS batteries replaced and cancer ruled out! These young people left a sea of nurses, doctors and their parents with dropping jaws as they calmly navigated waters where they previously struggled.  Instead of nervously handling our children, doctors and nurses went out of their way to come into their rooms to see what they had to say.

“How are you supposed to put into words the significance of this?  It’s ‘ginormous!’ For the first decade or so we didn’t go to the doctor unless it was something significant.  You only went to the doctor as a last resort, if we couldn’t fix it ourselves. Now (Zachary) goes and has physicals and regular checkups with the ENT to make sure everything is okay. I don’t have to wait until he has the 105 degree fevers, seizures and raging infections before we have it checked out.  Preventative medicine is now an option.” Shari Willingham, Zach’s Mom

So here’s how you do it!

Add photos of medical procedures, generic doctors/nurses, facility building & rooms

1. All of our devices allow you to put a photo on a button.  The easy answer to this dilemma is to simply take pictures of each medical procedure, the facility and generic doctors/nurses all dressed in their uniforms.  Since it’s not always practical to actually take these pictures yourself,   we supplemented personal pictures with images we saved from Google searches.
2. Organize the photos on the devices.  We organize based on what we know makes sense to the individual client.  Zachary actually helped label, arrange and color code his pictures on his NovaChat.  He chose to put each doctor’s pictures on one row, labeled the doctor “Dr. Ear,” (ENT) “Dr. Lisa,” and “Dr. Head” (Psychiatrist) and gave each their own color row.  For Zachary, it made sense that this page was placed under the category of “People” on his “Doctor” page.  Dr. Ear got his own special page since the event was a major surgery.

Some of our friends understand visual scenes (context based communication) so these pictures live in their scene pages. Their parents and I created their pages for them.

Use the advanced features of the devices to give even more information to our friends.

Our friend Chad required a CT Scan, 15 minutes of lying completely still, in a tube with clanking and buzzing sounds all around him.  To help him understand this concept, we introduced a video we downloaded off the internet which gave a thorough visual walk through of the event.

Katie’s Maestro has slide shows which she uses for “Learn About It.”  Her doctor pages were incorporated into her device in this familiar format.  She can select to watch the slide show of pictures or simple page through her images.  Each image has a verbal explanation and personally relevant image.

So what does this have to do with expressive communication?  Each of our patients used their devices to understand what was happening to their bodies.  The response in the hospital and doctor’s offices was overwhelmingly positive.  Chad’s mother, Kellie reports that his doctors now talk TO him when he comes in.  They no longer talk exclusively to his mother ABOUT him.  Chad tells all his doctors “do not put a band-aid on me,” and they don’t.  Katie’s nurses move slower and explain themselves much more clearly to her before touching her. After the fact, all of our patients look back over their pictures with their families and friends.  They have the ability to share their experiences and a place to go when they feel sick again and need to talk about it.

None of this could have occurred without active and engaged families…now how do you think THAT impacts communication?

Earlier this month, we shared some ideas for making communication boards using color coding and also for creating boards geared to different communicative purposes. Making the communication board according to some basic principles is a good thing, of course, and it takes a decent amount of thought and planning. Even more important, though, is developing an intervention plan so that the augmentative communicator learns how to use the board effectively. Here are some of our thoughts on how to teach someone to use a new communication board.

Model It

We’ve talked about aided language input so many times that I’m almost embarrassed to mention it. Almost. The truth is, it is a ‘must do’ strategy when we’re first introducing a communication board, book, SGD, or AAC app. Incidental learning is important for just about all of the people with whom we work. It is never the only strategy we use, but it’s almost always the one we start with.

Create Frequent Opportunities for Use

When tools are easy for us to use and don’t require a lot of thought, planning, or effort, we tend to use them readily to meet whatever the need is. The same is true for people who use AAC, but getting them to the point where they feel sufficiently competent with the AAC tools we’re introducing takes time. It takes less time if we load them up with lots and lots of teaching and practice opportunities.The task here is to work with the learner’s team to infuse opportunities to learn about and use the communication board all day long. There is no separate ‘communication time.’ Rather the communication board gets used at every possible opportunity. Whenever I see the client, the communication board should be right along with him/her. If it is rich in core vocabulary, then the communication board has pronouns, verbs, descriptors, prepositions, interrogatives, and other words that are as appropriate in the classroom as they are on the playground, bus, bathroom, therapy room, bedroom, kitchen, backyard, store, restaurant, doctor’s office, waiting room, gym, park, library, clinic, Grandma’s house, porch, car, etc. Communication boards work everywhere: Don’t leave home without ‘em!

Give an Orientation

When we got a new car last year, the dealer spent a view minutes orienting us to the dashboard. When I got a new app recently, I watched a video that gave an overview of the features. When I introduce my AAC class to an SGD for the first time, we go over the parts and review the ‘anatomy’ of a communication device. Explanations matter. They may not be the only strategy we need to learn a new tool, but they sure help get us started. For some reason, though, SLPs tend not to do this when we provide our clients with a new AAC tool. We’d like to advocate for a brief period of orientation when we introduce communication boards and other tools so we can explain the basic layout. It’s standard procedure with adult clients, but for some reason we tend not to use this strategy with kids, particularly if there are intellectual disabilities. We’ve found it to be useful, though, for at least some children.

Use your best clinical judgment for how to do this in a way that facilitates understanding by your client. Generally, that means brief, simple, direct, and with visual input. Most times, we use a slower rate of speech to give time for the learner to look, listen, and process the information we’re sharing. This is not an appropriate strategy for beginning communicators who are just getting started with their AAC systems, particularly if their receptive language skills are extremely impaired. However, for people who are beginning to combine words into sentences, we try to presume competence by explaining how their communication board is set up.

Teach the Patterns

Human beings are pattern-seekers. We use patterns to help us make sense of things and to remember them. Why not use this to our advantage when teaching people to use communication boards effectively? If we used color coding to create a board with pronouns that have yellow backgrounds or borders, for example, then it makes sense to teach that strategy to the learner. Here are some thoughts on how to do that. Not everything works for every learner, so choose the ones that are best-suited to your particular situation.

1. Create a visual support: Having a visual representation of the color-coding schema available to look at and refer to during the therapy session makes teaching clearer. We can reference this as we talk about the words, their part of speech, and the color coding strategy. You can download an example of the ones we made for both the Modified Fitzgerald Key and the Goossens,’ Crain, and Elder schemas. 

2. Use a think-aloud strategy: “Hmm. I want to say ‘go’ and I know that’s an action word. Those are green. Let me look through the green ones. [scanning down the board] Get…give…GO!”

3. Model with aided language input and draw attention to the colors as you do

4. Use activities designed to highlight the patterns: We might do a scavenger hunt, for example, where we look for all the blue adjectives or pink prepositions on our board. We might adapt a board game where we draw cards with different colors and then use the communication board to say a word from that part of speech (color category).  We could develop a word sort activity where we look at a word or picture and decide whether it belongs in the green/verb pile or goes with the orange/nouns. We might develop a fill-in-the-blank worksheet with colored blanks so that the learner has to pick a word from that part of speech/color category to complete the sentence. Once you start thinking about your learner and the materials you have at hand, it’s pretty easy to come up with activities that match the goal.

5. Highlight it in sentence-building activities: Activities that give specific instruction on creating sentences using color patterns can be very beneficial to some AAC learners. Those of us who have (ahem) been around awhile remember using the Fokes Sentence Builder, a color-coded template for creating sentences that have a predictable pattern (e.g., The noun is verb+ing. The noun is verb+ing + prepositional phrase). Marcia Sterner and the AT Team at OCPS have created Boardmaker templates for the basic schema, who/what doing, which/where using a modified Fitzgerald Key. There are commercially available programs and apps that do this sort of thing, such as Alien Talk and Colourful Semantics, but this can be a bit confusing if the color-coding system used in the app differs from the one that the AAC users have on their communication boards/books and/or SGDs.

Many of the strategies that work for introducing SGDs, AAC apps, and other communication tools work perfectly well with communication boards, too. You can read some of Robin’s suggestions for building skills with a new communication book here. There are lots of ways to do it; The main thing is to teach, rather than just provide access to the new tool and ‘hope’ the person uses it. Any teaching strategy is better than none at all.

Finally, manage your expectations. Teaching your client to use the new communication board will take time. It’s not going to happen in a week, or maybe a month. It takes time. As our friend, Jane Farrall, said recently, “The road to great outcomes can be so much longer than the road to poor outcomes.” Help the team understand that by doing the things mentioned above, they are laying a solid foundation and that takes time. We all love to get immediate results, but the more realistic scenario is slow and steady gains. If the team knows to expect this, it’s easier for them to stay the course. When we expect big changes to happen quickly and then they don’t, we tend to lose enthusiasm for the approach. Gear the team for success by preparing them that using good teaching strategies will allow the AAC learner to use the communication board, but it takes time.

For more tips on making and teaching ‘no tech’ AAC tools, check out some of our earlier posts on communication books. Do you have tips or thoughts on teaching people to use communication boards? We’re always looking for input and would love any comments you’d care to leave.

Fokes, J. (1976). Fokes Sentence Builder.  Boston: Teaching Resources Corporation.

The First 5 Questions to Ask:

• How Does the Learner Communicate? It is important that everyone has a way to communicate their own wants, needs, ideas, interests, and more. It is NOT good enough to just ‘know’ what someone wants. Even though some learners are beginning communicators or may seem to only request items, communication involves much much more for EVERYONE. Do not underestimate the power of a communication system to decrease challenging behavior. 

• How Does the Learner Understand Language? Comprehension of language and predictability of experiences is often not as good as it might ‘look’. It is hard when you do not fully understand what is happening, what people are saying to you, or how to predict what will happen next. Sometimes even if we know what is going to happen, we still need to ‘see’ it for it to make sense. Again, it is NOT just good enough to know the schedule, or know what individual words mean.  A visual language environment can help with language and experience understanding and thus decrease challenging behavior.
• How Often Are There Choices Offered? We All like choices. If we have the appearance of choosing ourselves, we are much more likely to participate and cooperate. Sometimes we even like to communicate that we do not like any of the offered choices. This is also true for learners with special needs, maybe more true because they often can not communicate their own choices the way children/adults without communication problems do.

• Are you expecting Compliance vs Communication? This is a big question and often one that poses a big problem.  Typical language users negotiate their way out of doing things by changing the subject (distraction), offering alternatives (“in a minute”), arguing (“No Way, Not Today”), complaining (“but… I am so tired”), or just venting (“agh come on, not again”). Negotiation happens about 70% of the time for typical learners (from small children to graduate students and beyond).  Learners with communication problems can only negotiate by using their behavior.  We have found that learners with communication problems often are more compliant than others but they are not given the chance to negotiate.

• What Has Been Done To PREVENT the Challenging Behavior? We need to make sure the basics are in place to help with structure, understanding, communication, and organization. We need to use positive behavioral supports rather than tell learner’s what not to do. Schedules, mini-schedules, calendars, first-then boards, and environmental organization supports (labels, boxes, bins, borders, etc) are just a few of the supports that should be in place for many learners with communication difficulties. Are they?

After asking, answering, and making some modifications, you will see a decrease in challenging behavior. There is A LOT we can do to prevent and minimize challenging behavior. Be careful not to fade the supports when the behavior improves (would you want your schedule taken away or the labels on your file folders removed…. we think not).

 Other Resources for Learning About Strategies to Help Decrease Challenging Behavior 

•  PrAACtical AAC Thoughts on Behavior
• PrAACtical AAC Thoughts on Challenging Behavior
• Self Calming Strategies
• 3 Communication-Behavior Visual Supports
• 5 Sites for Tools & Tips on Self Calming & Behavior Regulation
• Ted Carr on Challenging Behavior  
• Positive Behavioral Support on Pinterest