Wednesday, April 6, 2016

Yes, And?

I am just sitting here thinking about how random some AAC device activations can seem when they aren't. Two examples from a child today:

1) at the park the child pointed at her friend and then said "win basketball". No basketballs in sight. It took me a minute and I never would have figured it out if I didn't know the friend and her mom. My student's friend's basketball team had recently won the championship.  It would have been easy to ignore or tell her that there weren't any basketballs around. And though this student has some excellent and emerging AAC skills she doesn't yet know how to repair. So, had I dismissed her comment she would have just gone along with it. It terrifies me a little how much power the communication partner, in this case, me, has in interacting and learning with an AAC user.  "Win basketball"? Spot on. 

2) later we were tired and sitting in the student's living room, she had just asked for her one of her favorite AAC activities - FaceTime. Luckily my relatives, a few friends and the student's grandmother are very willing to oblige her desire for a sometimes very distracted video chat. So we reached my cousin on the FaceTime and at the end of the conversation the student says "dishcloth" twice. I told her I didn't understand and it was time to say bye, essentially dismissing her comment as a random activation. We hung up and the student hands me something she had accidentally put in her mouth while her aide hands her, you guessed it, a nearby dishcloth! The student wiped her hands and I felt like a jerk. It wasn't obvious or anything, I didn't feel like a jerk for missing what she might of meant. 

I felt like a jerk for forgetting the first rule of improv, which is also the first rule of chatting with an emergent AAC user as well - "yes, and?" In improv you always go with what is said, you don't shoot anything, down you are flexible and you go with it. Now your improv partner is barking like a dog? You don't say "Wait, we were pretending to be in a bank" you say, "Oh no! The bank robber hypnotized you! I knew I recognized him!" Or just about anything else to keep the exchange going. And in chatting with an AAC user you don't say "Dishcloth? I don't know what that means." (And then change the subject.) Instead you say, "Oh, a dishcloth? What about a dishcloth?" Yes, and?

P.S. All of the rules of improv, especially the first five, are powerful in working with early, beginner and emergent AAC users:

1) Say “yes’and!”
2) Add new information.
3) Don’t block.
4) Avoid asking questions- unless you’re also adding information.
5) Play in the present and use the moment.

Thursday, March 24, 2016

Rethinking the AAC Prompting Hierarchy in Severe Apraxia

Prompting Hierarchies have been a staple in special education, behavioral methodology andcommunication therapy for some time. However, when it comes to children with severe apraxia, with or without coexisting anxiety, (Rett Syndrome, Angelman Syndrome, ASD, etc) the commonly used prompting hierarchy can complicate instead of simplify teaching augmentative and alternative communication.

Many studies now support aided language stimulation or direct modeling as a primary intervention that should be ongoing and intense with child who are learning to use AAC. Given this knowledge we should move modeling from a step in the hierarchy to the umbrella that covers all of the other steps in AAC teaching.

Another flaw in the commonly used prompting hierarchy in AAC is the use of direct verbal/requesting a response/giving a command as a "cue" or "prompt". Telling a child what to "say" with their talker isn't a cue or prompt. It is a command and usually it is testing. When we equate communication with testing we lose out on what drives communication (and humanity, when it comes down to it) - an inherent desire to connect with another person. Sometimes that connection is about meeting a need or want and sometimes it is about sharing information, being polite or socially being part of an interaction. But we negate that when we command child to say something specific. Furthermore, such demanding/testing type interactions increase anxiety (fear of getting it wrong, fear of disappointing, etc), oppositional behavior (the child's desire to prove that the he or she has power) and apraxia.

Apraxia is a neurological disability that impacts the child's ability to follow a direction in spite of the directive being understood, a desire to follow the directive, the physical ability to follow the directive and sometimes, a previously shown ability to follow the directive. In short, the more the child WANTS to do something the more apraxia stops them. This is neurological, NOT a behavior. Anxiety and demands increase the apraxia. So the child might still be working through the previous levels of cues you have given but then you make the demand "show me_______" or "say_________" and all bets are off! It will be nearly impossible for the child to do as you say at this point. Creating a amicable bond, sometimes even an almost conspiratorial connection is much more likely to enable a child with severe apraxia to be able to communicate. Non-directive and non-confrontational is the way to go in apraxia if you want results!

Finally there is the issue of "hands-on" cueing. What does "hands-on" cueing really mean? It basically means we MAKE the child press or activate buttons on their devices. (The child actively taking your hand is different than you taking the child's hand.  Yet, this should still be faded as soon as possible.)   Hand-over-hand and hand-under-hand both are hands-on.

What does a hands-on, full physical "cue" this tell the child? It tells them that A) we have the right to manipulate their bodies or make them touch or do things whether they want to or not and B) that we have the right to force them to say things just because we want them to say it. It teaches them that if they don't comply with a directive (regardless of if they understood it or if apraxia stood in their way) we will make them comply with the directive.

Our students are some of the most vulnerable human being anywhere. Consider this statistic:

More than 70 percent of those with disabilities polled said they had been abused and over 60 percent of family members indicated that their loved one with special needs had been mistreated. (

Or this one:

More than ninety percent (90%) of people (both male and female) with developmental disabilities will experience sexual abuse at some point in their lives. Forty-nine percent (49%) will experience ten or more abuse incidents. (Valenti-Hein, D. & Schwartz, L. (1995). The Sexual Abuse Interview for Those with Developmental Disabilities. James Stanfield Company. Santa Barbara: California)

Now tell me again how is it ok to teach children who have significant disabilities that they should allow others to make them do things with their hands and that they should allow others to "put words in their mouths"? We have almost a sacred duty to do everything in out power as educators, therapists, caregivers, parents to prevent abuse of our students - now and in the future. And this starts with teaching them that they have the right to be respected in what they do (and don't do) as well as what they say (and don't say). It might be the most important thing we do. We must take it seriously. We must make it a priority. And that means finding new ways to teach and "cue"/"prompt" (it definitely isn't a prompt if it is hands-on). We are an intelligent, creative and compassionate field, certainly we can find other ways?

Additionally a "full physical" or hands-on situation, where we make the child "say" something with the device, teaches the child that language/words are something put upon them by others.  If we want our students to see the power of their AAC systems we must let them see, in both our modeling and in how we teach and respond to their AAC, that the power of language/words is that it comes from INSIDE us and can affect those OUTSIDE us.  Children can't learn that if we are constantly putting them in a position where the words come from someone else who is physically making them access their communication system.  In teaching AAC we are setting the child's attitude about using their speech system for the rest of their life.  It is so much better that we teach them the value of their system from the beginning instead of having to combat a negative attitude about their communication system that is created by how we taught them in the first place.

So we must rethink the prompt hierarchy. We make modeling a setting event that happens ALWAYS. Then we use the expectant pause, indirect gestural cue (body language), direct gestural cue (pointing), indirect and partial verbal cues (phonemic cue, hinting) and then we return to modeling and move on.

Why don't we force the issue until we get the device activation we want? Because communication isn't a test and nothing is so important that we put our hands on and make them say something. Instead we increase the motivation of the child (through preferred activities, child led sessions and our own demeanor), we increase the modeling of the AAC device or system and we move out of the way and let the child come to an understanding of their communication system and the power it has through repeated meaningful experiences.

Tuesday, March 1, 2016

Rare Disease Day

February 29th is Rare Disease Day
So many of the children I work with and adore have rare diseases. I hope today doesn't just increase awareness of those who rare diseases and the need for research into improving their quality of life today and finding treatments and cures in the future but also the potential in each of these amazing individuals. I learn far more for the children I work with than they learn from me. They all have something to offer the world and we all have something to learn.

The children I work with have many syndrome and disorders among them Rett Syndrome, Angelman Syndrome, Cockayne Syndrome, Pitt-Hopkins syndrome, forms of muscular and leukodystrophies, various Mitochondrial Diseases and more recently identified rare genetic disorders with only genetic names CDKL5, GRIN2B, FOXG1 Many of these disorders are life limiting still for many a cure may be on the horizon. Our job as educators is to keep our students ready educationally, emotionally and physically for that cure, whenever it may come. Our jobs are vital, to see in each rare child the potential that is inherent but hidden to many.

Sunday, December 20, 2015

Wearing Your Words

Jabber Jas Harness

Custom ChatBag
Wearing your words is essential when you are an ambulatory AAC user.  You need to be able to access your AAC at all times and you can't do that if gets left in another room or is in your backpack.  AAC users who also use wheelchairs or strollers face different issues in terms of mounting their AAC systems but sometimes it is even more of a challenge if the user is running around and active.

Parents or schools should implement a means to carry/wear AAC systems at the same moment they acquire the "talker" itself.  However, it is never too late if you are already using a mobile talker.  Some children do just fine with a shoulder style carry bag that is open to the screen and allows the talker to be flipped up and used without removing.  Others will try to remove or throw such a system and need a harness style carrying system that is more tamper proof.  The goal is to find the least invasive system that allows full access without risk of losing or throwing the talker.  Custom designs can increase appeal and "buy in" where as off-the-shelf, commercial solutions may look more "typical" and be less expensive.  The draw back to commercial solutions is that they may not be fitted for children or teens and may not be as durable.  It might be important for certain features to be available for example the ability to attach a bluetooth speaker, to block access to various ports or to charge without removing the carrying case.  Another consideration is any orthopedic issues or potential for future orthopedic issues from carrying 1-2 pounds over the shoulder or in a harness. If this is a possible issue consult your OT or PT. A waist belt with flip up attachments can be created in a DIY manner if over the shoulder(s) is not a good solution.
Please see this list to assist with feature matching.
Jabber Jas

If you are starting off you child in wearing his or her words and you need to help them understand how important it is some ideas include: you wearing his or her words as well, social stories about wearing your talker and using pictures of other children wearing their words such as in this Pictello book in PDF form (or get through sharing server with this  code which is good for 100 days 9658-4211).  You can also check the #seemeseemyaac find photos. 

Custom Made

Shoulder Strap Style

Harness Style
Commercially Made

Shoulder Strap Style
Harness Style
 *has one handed use option

Thursday, December 17, 2015

The Real Cost of Premium AAC Apps

This blog post from October 2014 has been updated.

Some prices have changed, some apps added and some removed.  The premise of this post is that in making all things equal in terms of assuming customers need a robust vocabulary, a premium TTS voice and a means to back up and share files we can compare the real cost of premium AAC apps over time. 

The most expensive app both for one and five years remains TouchChat/TouchChat HD.  Some app companies have realized that schools and health insurance reimbursement requires apps without add-on purchases and have started offering all inclusive versions of their apps.  Perhaps the most interesting development in the field is some apps offering premium TTS voices included in the cost of the app (Proloquo2Go and Clicker Communicate, for example) or for a minimal price and others have higher price points for the same voice (TouchChat and Go Talk Now offer a premium voice for $11.99, while Speak for Yourself offers the exact same premium voice for $24.99).

Of course price point isn't the only  reason to choose an app, which is why this chart seeks only to compare oranges to oranges price-wise and not to examine any of the other reasons why you would choose one app over another for your student, client or child.
Direct Link
PDF Version 

Contact Me at:

Contact Me at:

Visit our advertisers:

Fujitsu Computer Systems Corporation, LLC Try Nick Jr. Boost FREE for 7 Days ... Label the things you love !! Build-A-Bear HearthSong - Toys Outlet