AAC Devices: Augmentative and Alternative Communication Considerations

The American Speech-Language-Hearing Association (ASHA) defines augmentative as adding to someone’s speech and alternative as being used instead of speech.

Augmentative and Alternative Communication (AAC) methods allow people who need communication support to communicate with others. The American Speech-Language-Hearing Association (ASHA) defines augmentative as adding to someone’s speech. ASHA defines alternative as being used instead of speech. Both children and adults can use AAC for a limited time or throughout their lifetime. AAC use can change based on a user’s age, needs, and environmental demands.

Recommended course: AAC Devices: One Size Doesn’t Fit All

Successful AAC use is based on matching the method with the potential user's skill set. Speech and Language Pathologists (SLPs) have expertise regarding appropriate AAC recommendations, and occupational therapists (OTs) can assist with determining the person and environmental factors that will support or hinder a person’s AAC use.

AAC benefits

The renowned physicist Stephen Hawking, often called the greatest scientist of this time, used an aided device to communicate after losing most of his body control and his ability to speak. At 21, Hawking was diagnosed with the progressive disease Amyotrophic lateral sclerosis (ALS), ultimately resulting in the need for a wheelchair, a caregiver to assist with his daily living skills, and an AAC device for communication.

Hawking lived until age 76 as an AAC user. Hawking’s cheek movements, executive function, and expressive and receptive language skills were strengths he used to facilitate his AAC use. Hawking used his cheek muscles to activate an infrared switch connected to a speech-generating computer.

This successful AAC use allowed him to share his brilliance during interviews, presentations, and a TED Talk questioning the universe. Hawking’s device even allowed him to make cameos on popular TV shows, where he engaged in dialog with regular characters.

Multiple types of AAC

Unaided and aided are two types of AAC. An AAC user may utilize more than one type of AAC device for communication. Environment, length of anticipated use, and communication circumstances can determine which type of device is needed. Unaided methods of communication do not require external support.

However, unaided methods can require sufficient motor control. They also require that communication partners are skilled in interpreting the intended message. Aided AAC devices require some external support.

Unaided AAC includes:

• Gestures
• Facial expressions
• American Sign Language (ASL)

Aided devices include:

• Tablets
• Communication boards with symbols
• Computers
• Handheld devices

Recommended course: iPad’s and AAC: Getting the Most Out of Your iPad

User’s skillset and types of AAC

The recommended AAC should allow the user to use the communication method as independently as possible. Therefore, understanding a user’s strengths and abilities is essential.

Expressive and receptive language skills

Understanding how the AAC user understands and utilizes images, words, and symbols is essential for determining what type of AAC will help them communicate accurately. If a user uses gestures or symbols that their communication partners don’t understand, the AAC will not be effective.

Executive function

Hawking’s intact executive function supported his ability to use his AAC device. Consider the complexity of the AAC, what setup is required for the AAC, and how many steps need to be sequenced to activate it successfully. Additional considerations may be necessary to support users with intellectual and developmental disabilities.

Fine motor skills

Finger isolation, finger strength, and finger coordination impact how a user physically accesses an aided device like a tablet. It also impacts how users express themselves using unaided AAC, such as hand gestures and ASL. Fine motor skill impairment can decrease AAC accessibility.

Visual-motor skills

Visual motor skills involve interpreting visual information and responding with body movements. For some types of AAC, such as using a communication board with symbols, hand-eye coordination is needed to accurately point to the items on the board. Impaired coordination can lead to over or undershooting the targeted symbol when using the device.

Visual tracking and visual scanning

Intact visual tracking and scanning skills will allow a user to scan a device for the correct symbol to choose. Decreased ability in either of these areas can make it difficult to locate the desired symbol needed for communicating.

Visual perception

Visual perceptual abilities allow the user to interpret the information they receive through their eyes. Figure-ground and visual discrimination are two areas of visual perception needed when using some AAC devices. Impairments in either of these areas can make it difficult for a user to select the correct letter or word on a device.

Visual acuity

An AAC user with decreased visual acuity may require modifications to the device that include enlarged font, images, or symbols. It can also mean repositioning the device, bringing it closer to the user. Users that have prescription glasses or contacts may need encouragement to use them while engaging in AAC activities.

AAC tailored to the user’s skillset

Color contrast

High-contrast colors can increase the device’s visually accessible for all users. An optimal visual contrast is a light background with a dark font or a dark background with a light font.

Device size

The device's size must be manageable for the person using it if they are expected to transport it independently.

Device durability

For long-term use, a device needs to be durable or easily replaceable so the user can utilize the device for communication consistently. A temporary aided method such as paper and pencil may be more appropriate in some settings, eliminating the need for durability or ease of replaceability.

The evolution of AAC devices

A 2022 neuroscience article published by the National Institute of Health (NIH) discusses brain-computer interfacing (BCI) that allows language expression direct from the brain. The current research has been limited to studying people with severe and permanent communication impairments. BCI requires continued in-depth research but may be a viable option in the future.

BCI has implications for those most in need of AAC. This scientific breakthrough would have eliminated the need for cheek movements to activate the infrared switch for the late Hawking. A brain-computer interaction would also make a device more accessible to those with executive function impairments, visual impairments, and sparse motor movements.

Supporting AAC users across settings

Although brain-computer interaction is revolutionary, an additional article published in 2022 by the NIH discusses the ethical, legal, and social aspects of decoding speech directly from the brain.

As advancements with AAC devices continue, healthcare providers need to continue their professional education to ensure appropriate recommendations for AAC devices. Healthcare providers also benefit from learning to support AAC users in healthcare settings and in the community for increased health and social outcomes.