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Dr. Caroline Ramsey Musselwhite

Tuesday, April 24, 2018

Building Augmentative Communication Skills in Homes Where English and Spanish are Spoken: Perspectives of an Evaluator/Interventionist

(Hopefully this will turn in to an article for the ASHA Special Interest Groups Perspectives)

Deanna K. Wagner, MS/CCC-SLP, is a speech-language pathologist with over 25 years experience providing consultations and training in the area of assistive technology with an emphasis on augmentative communication. Through Southwest Human Development Easter Seals she has participated in many projects related to balanced literacy and AAC.  She is one of the founding members of Out & About, a local AAC in the Community special interest group.  She has presented at local, national, and international conferences.
Financial Disclosures:  She is contracted to work with educators and families to achieve goals in the area of AAC selection and implementation through NAU and TherapyOne, as one of few evaluators/trainers who can support families who speak primarily Spanish.  She also provides ongoing AAC training to adults at Valley Life Adult Day Treatment Program.
Non-financial Disclosures:  She has been invited to provide feedback and input as vocabulary files and apps were being developed for a number of vendors: Alexicom, Assistiveware, Prentke Romich Company, Semantic Compaction, TobiiDynavox.

AAC users (and their families) receiving services from Deanna have varied tremendously over the past 25 years, the youngest barely two years old and the oldest in her sixties.  Almost all have qualified for long-term care assistance, which means that they have autism, cerebral palsy, or developmental delays that result in reliance on others throughout their lifetime for daily care.  Arizona (AZ) Medicaid provides devices to these individuals through a managed care system.  Evaluating agencies are awarded contracts to pay for assessment as well as 12 hours of training with each new device.  Evaluations must indicate a medical need for a communication device, along with goals for implementation. 

Environments for assessment/intervention through the AZ Medicaid contract have included homes, communities and schools.  Perspectives offered in this article were also gained through five years working as a school speech-language pathologist in Phoenix, AZ, with an AAC caseload.

Bilingual Considerations
Some individuals who require augmentative communication have intact language systems and impaired articulation, but these are the exception.  It is our intention to reach young people who need communication supports way before they are teenagers.  The result in many cases is that once a communication device is introduced, expressive language learning will be mediated through that system. 

Since expressive communication skills are built through experiences, it is only logical that individuals who come from homes where Spanish is spoken by at least one caregiver will have some knowledge of how words are used in that language, particularly as they relate to home routines.  As they develop, children move from using non-symbolic systems of communication (e.g., gestures and vocalizations) to symbolic means (primarily spoken or written words, but may also include sign language).  The website www.project-core.com can be very helpful when discussing this concept with families and professionals alike.  Language is an agreed upon set of symbols and rules that enables a community of people to interact and communicate with each other.  Therefore, each language and each community will have some symbols and rules in common and some differences.  Bilingual speech-language pathologists will be able to identify delays and disorders based on knowledge of the home language and compare that to delays or difficulties that present themselves when the child enters school and is expected to interact with others in English.  In cases where the child is completely nonverbal it can be more challenging to identify receptive communication delays or disorders, particularly if they have had little experience with augmentative communication (symbols and rules that are mediated through sign language or images).

Creating a Shared Vision
Before initiating a plan for using/learning an AAC system, those who will be supporting the individual need to have some agreement about what AAC looks like when families speak more than one language.  In addition to the myths and misconceptions of AAC that were dispelled by Romski & Sevcik in 2005 (http://depts.washington.edu/isei/iyc/romski_18_3.pdf), we also have to deal with misinformation that families may have received regarding bilingual language development.  Some families were told by their pediatricians or other professionals that using a second language will be confusing and they should try to speak only English at home in order to make it easier on the child when he/she goes to school.  Therefore some children receive misinformation twice: once by being told they should only use one language, and again when they are told that it is best to wait to introduce AAC until a child has demonstrated certain pre-requisite skills (such as knowing/using a few signs or matching pictures to objects).  We need to help parents understand that learning a language involves experiencing that language, and that conceptual knowledge can be mediated through Spanish (L1) to English (L2) or by both languages concurrently (multiple sources, referring primarily to the Revised Hierarchical Model).  The greatest hope we can impart to parents is the belief that their children can learn language.  In order to do so, we must recommend a robust communication system and work on strategies to teach the child about the symbols and rules that make up that system.

Robust AAC Systems
Any robust AAC systems must include an organizational framework for categorizing words as well as rules for syntax/morphology.  Some categories will be very similar in both English and Spanish, particularly with regards to nouns (e.g., people, places, toys, foods).  More differences will be seen based on word use, word order, and morphology.  When we provide AAC intervention, we need to think about the first words that our students will be using, and how they will learn to combine or modify words to express their own thoughts and intentions. We also need to keep in mind that everybody communicates, and to offer opportunities and experiences that help support a variety of communicative intents/functions (www.vantatenhove.com).

Implementation with Beginning Communicators

Carol Zangari’s “Year of Core Words” can be an invaluable resource. Each month the words that are provided cover a range of communicative functions, so we can practice asking questions, directing others, requesting, etc.  The first month also includes cessation and negation.  Here is a link to the smart charts for
The WordPower Basic 60 SS (SymbolStix) version: https://saltillo.com/chatcorner/content/31.   The smart charts for icon sequences (Unity, Unidad, Words For Life) can be found at www.aaclanguagelab.com. Each month interventionists can practice a set of core words with the parent(s) in English.  Talk about how the English words/concepts could be translated into Spanish, and practice on the device in both languages. So, for example, during the month of January the following words are suggested:  what, that, mine, you, want, don’t/not, different, more, again, all done, stop, help, and different.  After some practice finding the words, talk about family goals and brainstorm ways they can use the words throughout the month.  Focusing on just five core words during an activity, especially at first, gives more opportunities to practice.  

Many families have already had experiences with early intervention and the use of the sign “more” and will use the same sign when saying the word “más” in Spanish.  So start there and talk about many ways they can teach and use this word throughout daily routines.  Then look at the word “all done” and do the same thing.  For some families, this word is most often used in English, so talk about how to switch languages on the device, to model the English version with more frequency.  Share Let’s Teach Core resources from Saltillo with teachers, therapists, and other family members who speak English.  Here is a link for “Let’s Teach More:”  https://saltillo.com/downloads/chat/lets-teach-core/Let%27s%20teach%20more.pdf

In January particular attention should be paid to “want” and “don’t want” in order to address the assumption that a communication device is for making requests.  Encourage the parents to model asking “what” on the device.  This gives them more experience using words on the device, not just for requesting, but for asking and negating, as well.  It is important that the interventionists and families agree that grammar is not important on the device and that it is appropriate and should even be encouraged to model phrases on the device such as WHAT WANT and WHAT YOU WANT or NOT WANT.  At the same time, encourage them to verbally use appropriate grammar.  They can say a word or two while pointing to one symbol (on the device or on a printed display).  This method of aided language input has been described by multiple clinicians, including Jill Senner.  She recently offered a recorded webinar for Saltillo (https://saltillo.com/videos/communication-partner-instruction-in-aac).  In addition to pointing to symbols on the device, interventionists can provide families with printed and laminated versions of the device home page.  That way they can point to a symbol and say the word in either language.

When speaking with the speech/language pathologists who serve these students, provide additional ideas for activities to practice core words.  Great resources for activities with identified core words include: Assistiveware’s Core Word Classroom and the AAC Language Lab.  Although there is a fee for the Language Lab, the first year is included with purchase of one of the devices from Prentke Romich Company. 

Erin Sheldon and Caroline Musselwhite do a great job introducing their first set of four core words in their communication video series for Angelman Syndrome Foundation

The words for February include “like,” and interventionists can show families how to do a little charting activity of things their child likes or doesn’t like.  This is also an idea from Saltillo’s Chat Corner.  During the second month of intervention with a new device, talk more about customizing and personalizing the vocabulary so that the “About Me” page includes something about what the child likes.  Then talk about categories of words for eat/drink/play and what they watch on TV or videos.  Watch YouTube videos.  If appropriate for the child’s age, use Super Simple Songs, such as “Do You Like Broccoli Ice Cream?” https://www.youtube.com/watch?v=GOCroTBFlFw&t=6s.  For older students, show them how to use Tarheel Reader.  Here is a link to a story using “don’t like” and “do like”:  www.tarheelreader.org/2014/06/03/like-not-like/.   

It is important to share the words of the month with the teacher or speech therapist and talk with them about core word strategies, including recommending that they use Realize Language (www.realizelanguage.com) to collect data.  Whether the child is using English or Spanish (or both), the beginning communicator needs experiences with highly functional words throughout their day.

Implementation with Expanded Communicators

For those families who are able to join us, we offer additional experiences to use core words during our Out And About activities in the community.  A guide for starting this type of group can be found for free at www.teacherspayteachers.com.   Some of our most important communicative functions that we practice are social greetings/manners, commenting (including giving opinions) and requesting.  We also try to design activities where we can practice with words used to describe or tell about the event or items we are using.  Many families include parents with limited English proficiency and siblings who are bilingual.  We encourage the families to practice in both languages so that they are developing schema related to the concepts being expressed, not just pushing a button to say a word or phrase. 

Some of our participants who have had more experience using their devices will be able to model expanded utterances.  We talk about language patterns and differences between English and Spanish.  One of my SLP colleagues, Sharon Hendrickson-Pfeil, also does bilingual community-based intervention (in addition to working in schools in Tucson, AZ).  She suggests the use of books on Raz Kids (www.raz-kids.com)  as a way to share interactive videos with families and practice early sentence structures.

Finally, keeping in touch with others who use AAC can also build more confidence and foster self-advocacy.  I work with Adult Day Programs and the members there are always looking for ways to connect with others and share what they have learned (and are continuing to learn).  We use e-mail, YouTube channels and Facebook groups.  Look for us at www.closingthegap.com!


ASHA collection of resources from the Office of Multicultural Affairs offers policy documents, guides and tips for addressing the needs of CLD students in schools, titled “Working with Culturally and Linguistically Diverse (CLD) Students in Schools.” © 1997-2015 American Speech-Language-Hearing Association. http://www.asha.org/slp/CLDinSchools/

ASHA Practice Portal on “Cultural Competence.” © 1997-2015 American Speech-Language-Hearing Association. http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935230&section=Key_Issues#Developing_Cultural_Competence

Gerber, S., Brice, A., Capone, N., Fujiki, M. & Timler, G., (2012). Language Use in Social Interactions of School-Age Children With Language Impairments: An Evidence-Based Systematic Review of Treatment. Language, Speech, and Hearing Services in Schools, 43, 235-249.

Goldstein, B.  (2012).  Bilingual Language Development & Disorders in Spanish-English Speakers.  Baltimore: Paul H. Brookes Publishing.

Goldstein, B. (2011). Cultural and Linguistic Diversity Resource Guide for Speech-Language Pathologists.  NY: Delmar, Cengage Learning.

Gutiérrez-Clellen, V. F., & Simon-Cereijido, G. (2009). Using language sampling in clinical assessments with bilingual children: Challenges and future directions. Seminars in Speech and Language, 30(4), 234.

Kohnert, K., Yim, D., Nett, K., Kan, P. F., & Duran, L. (2005). Intervention With Diverse Preschool Children: A Focus on Developing Home Language(s). Language Speech Hearing Services in Schools, 36(July), 251–263.

Kroll JF, Van Hell JG, Tokowicz N, Green DW. The Revised Hierarchical Model: A critical review and assessment. Bilingualism: Language and Cognition. 2010; 13:373–381.10.1017/ S136672891000009X

McCord, M. S., & Soto, G. (2004). Perceptions of AAC: An Ethnographic Investigation of Mexican-American Families. Augmentative and Alternative Communication, 20(4), 209–227.

Perozzi, J. A., & Lourdes Chavez Sanchez, M. (1992). The Effect of Instruction in L1 on Receptive Acquisition of L2 for Bilingual Children With Language Delay. Language, Speech, and Hearing Services in Schools, 23(October), 348–352.

Pickl, G. (2011). Communication intervention in children with severe disabilities and multilingual backgrounds: perceptions of pedagogues and parents. Augmentative and Alternative Communication, 27(4), 229–44.

Robinson, N.R. & Solomon-Rice, P.L. (2009). Supporting collaborative teams and families in AAC. In G. Soto and C. Zangari (Eds.) Practically Speaking: Language, Literacy, and Academic Development for Students with AAC Needs, (pp.289-312). Baltimore: Paul H. Brookes Publishing.

Sheng, et al (2013). Semantic Development in Spanish-English Bilingual Children: Effects of Age and Language Experience. Child Dev. 2013 May ; 84(3): 1034–1045. doi:10.1111/cdev.12015.

Soto, G., & Yu, B. (2014). Considerations for the Provision of Services to Bilingual Children Who Use Augmentative and Alternative Communication. Augmentative and Alternative Communication, 30(March 2014), 83–92.

Soto & Zangari (2009).  Practically Speaking:  Language, Literacy, & Academic Development for Students with AAC Needs.  Baltimore: Paul H. Brookes Publishing.


Saturday, March 3, 2018

AAC Modeling: Making It Fun And Easy - WISH, Los Angeles, 3-14-18

WHAT:  Workshop on AAC Modeling:  Making It Fun and Easy

WHO:  Presenter is Dr. Caroline Ramsey Musselwhite
Target audience is parents, but other people who work with students who use Augmentative and Alternative Communication (AAC) are welcome to come

WHERE:  Auditorium, Wish Charter School / Orville Wright Middle School
6550 W. 80th Street, Los Angeles, CA  90045

WHEN:  Wednesday, March 14, 2018, 6:00 - 8:00 pm

FLYER:  Download the flyer at the link below

WISH AAC Modeling Flyer

Wednesday, February 28, 2018

Laugh and Learn

WHAT:  This is just a reminder to take time in your busy classroom or therapy or home schedule to make learning FUN.  While this seems entirely obvious, I don't always see it in action.

WHY:  Consider the latest UDL Guidelines.  You can find them at the link below:


High interest, fun, and engaging activities can support both recruiting interest and sustaining effort and persistence.

HOWBelow are a few ways to up the Fun Factor, while still maintaining task focus and purpose:
1) Add an App! A few examples:
a) Supporting students in asking simple yes/ no questions with their devices?  Use a 'magic 8 ball' type of app, such as:  Your Magic Crystal Ball
See more ideas here:  
Asking Questions
b) Asking students to find items on their device or answer rote questions?  Present them from a 'name picking' app such as:  Random Name Selector Starter

c) Celebrating Writing?  Use an app with fun audio or video presentation such as Auto Rap or Word Salad or PicCollage or Path On Swipe to Type

2) Use a Highly Targeted Video
Too often, videos are used for 'babysitting' - that is NOT what I'm talking about.
Try 'Wordless Videos' stopping often for comments, questions, etc.
See the Tip # 3, 2018 at:  www.aacintervention.com 

3) Read a Clever Book
For young children through adults, you're never too old to enjoy a fun book.  Use these books for Shared Reading, modeling language on the student's AAC device and having opportunities to make connections:  Text to self, Text to text, and text to world.  So many books, so little time!  A few samples:
That's Disgusting by Pittau & Gervais

Little Critter Books

Story of the Little Mole

Have fun!  You might just catch your students laughing.  And learning!

Thursday, February 22, 2018

Paper-Based AAC FlipBooks: When, How, Why do they matter?
Interactive 60 min Session, ISAAC 2018, Gold Coast, Australia
Deanna K. Wagner, MS/CCC-SLP and Gretchen Hanser, PhD

There are a number of resources for printed displays that are available for purchase or download.  Page-turning options that flip up or down are often a part of these systems. We have found that using paper-based displays helps slow down the process of selecting a message and provides the communication partner with additional time to talk about what the symbol may represent and clarify the intent of the message.

Use paper-based displays at the pool, in brightly lit rooms, and in darker rooms with a flashlight.  Use them when the high tech device is low on battery, or when the user doesn’t want to share his/her high tech device for aided language input.  Use with overlays and cut-outs for target with complete access to the full vocabulary when needed – faster than using hide/show in TouchChat and much like turning on/off Vocabulary Builder, Exploring vocabulary in Proloquo2Go when Progressive Language is turned on, and Babbling with SpeakForYourself.

AAC Flip Books – Where can I find some?
·       https://aaclanguagelab.com/resources/free - LAMP WFL and Unity
·       www.project-core.com - Universal Core Displays (These are not flip books, just core)
Pixon Project Kit
·       https://saltillo.com/chatcorner/content/29 - NOVA Chat and TouchChat (PCS and SS options)
Speak For Yourself (with category indexes, make your own flip book from device screen shots)

  • o   AAC-Communication-Flip-Book-and-Boards-2431089 by Super Power Speech
  • o   Motivate, Model, Move Out of the Way: How to implement AAC by Kate Ahern
  • o   AAC Picture Communication Book with Core and Fringe Vocabulary by Susan Berkowitz
  • o   AAC Flip Communication Book BUNDLE by RosieBeeSLP
  • o   AAC Communication Book by Speech Me Maybe
  • o   Core Vocabulary Binder Ring - Core Board Binder Ring AAC by Mrs Ds Corner
  • o   Low-Tech, Core Vocabulary Based, AAC Flip Boards by Speechy Musings

Ahern, Kate. http://www.slideshare.net/teechkidz/bringing-aac-home-fcsn
·       This PowerPoint slideshow, aimed at parents and caregivers, explains why and how aided language works in the home.

Enders, Lauren.  Moving beyond a Common roadblock to Successful AAC Implementation. June/July, 2016 edition of Closing The Gap Solutions

Farrel, Jane.  http://www.janefarrall.com
·       Why We Do Aided Language Stimulation - And You Should Too! - This guest blog, written by Mary-Louise Bertram, clearly explains why modeling is so important for those beginning to use AAC.  

Hatch, Geist, Erickson, Greer, & Erwin-Davidson.  ATIA, 2017. Using Core Vocabulary in Emergent Literacy Instructional Routines.  www.project-core.com Professional Development Modules

Mirenda, P. (2008). "A back door approach to autism and AAC." Augmentative and Alternative Communication. 24, 219-233.

Sennott, Light & McNaughton (2016).  AAC Modeling Intervention Research. 
       Vol 4, Issue 2. Research and Practice for Persons with Severe Disabilities. http://journals.sagepub.com/doi/pdf/10.1177/1540796916638822

Zangari, Carol http://praacticalaac.org