Naturalistic Augmentative and Alternative Communication Instruction for Practitioners and Individuals With Autism

Abstract

Using speech as an effective communication method is a challenge for many individuals with autism spectrum disorder (ASD). Research suggests aided augmentative and alternative communication (AAC) used with young individuals with complex communication needs (CCN) can result in improved communication quality and frequency. The effectiveness of AAC with individuals with ASD and CCN is in part due to its visual nature and utilization of concrete representations of abstract concepts, making it manageable to use. Teaching in natural settings integrates learning into their routine and benefiting individuals with ASD who tend to have difficulty generalizing learning to new situations. Blending naturalistic techniques to teach AAC with behavior techniques is an innovative way to integrate an individual’s ability to generalize with his or her need for direct teaching. This paper offers methods of implementing naturalistic techniques as a tool for practitioners to engage in communication development with individuals with ASD.

Keywords

autism spectrum disorder aided AAC naturalistic instruction

Individuals with autism spectrum disorder (ASD) experience significant challenges with social communication. Some individuals with ASD are unable to use conventional, verbal speech as an effective communication method; that is, they have complex communication needs (CCN) that must be considered (Binger & Light, 2007). Students may lack skills to interact with peers in natural contexts due to deficiencies in communication generalization and low rates of reinforcement from peers (Cosbey & Johnston, 2006). Using language in a natural context is helpful for increasing verbalizations and initiations while engaging in motivating activities for the individual (Warren, McQuarter, & Rogers-Warren, 1984).

Augmentative and Alternative Communication

Augmentative and alternative communication (AAC) is designed to increase communication competencies for individuals with CCN (Lund & Light, 2007). Communication competencies refer to proficiency in communication quality and quantity, not only clinical treatment improvements (McNaughton & Bryen, 2007). AAC is defined as an expressive or receptive communication method that replaces or enhances spoken communication for individuals with disabilities who cannot communicate using age-appropriate speech. Local education agencies are obligated to evaluate for and address communication needs of students who qualify for special education, including consideration of assistive technology, such as AAC (Individuals with Disabilities Education Improvement Act, 2004).

A common type of AAC is unaided AAC, such as sign language or gesturing, which can be performed without supplementary devices (Sennott & Mason, 2016). Aided AAC requires using external communication tools, such as low-tech picture cards and communication boards, or high-tech computer tablets with apps that incorporate pictures and speech generation (Sennott & Mason, 2016), or a dedicated speech-generating device (SGD). AAC has the potential to be a socially valid communication method for those with ASD who also have CCN.

The benefits and barriers to AAC use vary across communication modes. Sign language may be preferred by some due to the fluency of forming words and phrases compared to aided AAC. Difficulties include finding partners who know how to communicate via sign language, encountering motor difficulties in some people with disabilities that limit the ability to accurately form signs, and the difficulty of understanding the signs between communicative partners (Bailey, Stoner, Parette, & Angell, 2006). Low-tech aided AAC is portable, fairly easy to teach, and understandable to target a broad listener audience (Ganz, Rispoli, Mason, & Hong, 2014). Some limitations to low-tech aided AAC are that it can be difficult to interpret the symbols, some learners with ASD may not have the motor skills to select messages, vocabulary may be limited, they may not be portable, and creation of materials and vocabulary may be time-consuming (Light & McNaughton, 2012). An SGD provides access to a greater range of language and just-in-time programming, is easily individualized, is typically socially valid, and is broadly understood across audiences (Light & McNaughton, 2012). However, some can be costly, require basic motor skills to operate appropriately, require teacher and parent training, are time-consuming to program, and are not always used consistently by implementer or individuals with disabilities (Ganz et al., 2014). These considerations, user and family preferences, and learner symbolic understanding are critical when selecting a mode or modes of communication to target.

Individuals with ASD tend to associate what they learn with specific contexts, hindering generalization of their communication abilities (Koegel, 2000). Individuals with ASD often learn behaviors in structured settings. Such learning environments lack enough variability for the child to apply those behaviors in less structured settings (e.g., what is learned with a speech pathologist in a clinical setting may not be translated into behaviors at home). One teaching alternative is to use naturalistic methods that integrate learning into the individual’s daily routines, across all contexts and with all individuals with whom the person with ASD needs to communicate.

Scenario

Zoe, a 7-year-old with ASD and CCN, learned to use her tablet computer-based speech generating app as an AAC system to request a variety of her favorite materials and snacks. An SGD was selected based on teacher and parent preference, Zoe’s physical capabilities using tablet computers, and results of her recent evaluation and the functional needs of the child. Zoe’s IEP goals included, “Zoe will use communication skills, including an AAC device, to ask for help and label items, during one-on-one or small group activities that allow open-ended communication.” Improvement will be measured using daily observations to determine the rate per hour at which Zoe independently, without prompts, requests help and labels items spontaneously and when asked (see Note 1).

Anna, a behavioral specialist, worked with Zoe and her parents in their home. As Zoe was sitting on the rug, Anna, held up Zoe’s favorite book and Zoe spontaneously tapped the book’s picture in the app. The app played the recording of a voice saying “BOOK” after which Anna handed Zoe the book and said, “yes, you want the book.” Zoe opened it and began to flip through the pages. After approximately 20 seconds Anna said, “my turn” and gently took the book from Zoe. Repeating the sequence, Zoe quickly tapped the book’s picture again. Zoe and Anna took several more turns, and as she paused to record the data, Anna thought to herself that Zoe was making progress. Soon Anna noticed that Zoe never spontaneously asked for her favorite book from others, in different locations, or if other items were on the rug with the book.

This was puzzling to Anna because when given the choice of multiple items, Zoe chose a book almost every time when she played on the rug or used her communication app with Anna. At their next appointment, Anna set the tablet computer on the rug next to Zoe, showed Zoe another favorite book that was not identical to the picture on the app, and asked, “what is this?” Zoe studied the book cover, but did not answer. Later that day as Anna was eating lunch with Zoe’s teacher, Anna expressed her concern. “She just doesn’t ‘get it’ unless we’re playing on the rug and with limited materials!” Anna sighed. Zoe’s teacher encouraged Anna by explaining, “We need a strategy to teach her to communicate in different contexts for varied communicative purposes. It is time for a consultation with our AAC specialist.”

Naturalistic Instruction

Naturalistic instruction involves strategically planning and implementing instruction so that it takes place in natural settings, with natural communicative partners, with materials that are typically available, using naturally available reinforcement (e.g., social praise), and following the learner’s lead as much as feasible. The recommended practices of the Division for Early Childhood (2014) support the use of inclusive settings and natural settings with children to address diverse abilities. Much of the research regarding naturalistic instruction to teach AAC to date was conducted with people who have developmental disabilities, rather than ASD, and primarily with children under the age of about 10 years. This requires readers to make inferences from these studies to generalize to individuals with ASD, including older ones (Binger & Light, 2007; Cosbey & Johnston, 2006; Lund, Quach, Weissling, McKelvey, & Dietz, 2017). Implementation of naturalistic aided AAC has been demonstrated to result in increased communication from preschool, elementary aged children, as well as adolescents diagnosed with developmental delay, ASD, and intellectual disability. Positive outcomes include individuals initiating and engaging in communication more frequently, as well as acquiring more vocabulary (Light & McNaughton, 2012). Furthermore, the research supports the use of naturalistic strategies, including modeling of AAC use (McMillan, 2008). Many studies have demonstrated the effectiveness of verbal modeling coupled with AAC modeling and included behavioral techniques, such as time delay, prompting, and errorless learning (Cosbey & Johnston, 2006; Sennott & Mason, 2016; Weitzman, 2013).

Incidental Teaching

Incidental teaching is an approach to language instruction that focuses on individually selected reinforcers and natural consequences (Hart & Risley, 1978). When an individual appears interested in a stimulus in the environment such as an activity or object, the desired stimulus becomes a self-selected reinforcer for the individual, which may lead to communicating, via speech or AAC, to obtain the reinforcer. The individual learns that communicating in natural environments results in realizing the individual’s goals of obtaining preferred objects and participating in desired activities (Charlop-Christy & Carpenter, 2000). Hart and Risley (1992) found that aspects of parental interaction correlated with higher child IQ. This includes parents remaining in the vicinity of their children for a longer time period, thus creating more occasions to model language and respond.

Multiple aspects of interaction quality were also correlated with better outcomes (Hart & Risley, 1992). The frequency with which parents repeated and elaborated on their children’s comments including repetition, confirmed parental understanding of their children’s statement. Elaboration also modeled new content for the children. Parental questions posed to their children encouraged them to participate in the conversation, which was rewarding, and increased more thorough exploration of their environments (Hart & Risley, 1992). These parent behaviors can be adapted for use by natural communication partners to encourage individuals with ASD to learn communication skills within natural contexts.

Naturalistic Strategies to Incentivize Communication

Individuals with ASD, like most people, learn best when learning is rewarding (Karsten & Carr, 2009). There are a number of strategies that can be used to provide people with ASD with incentives to learn new communication skills. Natural communication partners, especially parents, are critical informants with regard to what communication skills are needed in what contexts, identifying natural environments and materials that are motivating to the target individual, determining items and actions that the target individual finds regarding (e.g., specialized topics of interest for conversation, verbal praise), and selecting daily routines that lend themselves to communication instruction (Lund & Light, 2007). Reinforcement is another behavioral technique available for communicative partners. This entails presenting a consequence to a behavior, thus encouraging the individual to continue or increase engagement in the behavior. Naturalistic AAC interventions use natural positive reinforcers, like handing the child a preferred food after the child requested it by selecting a symbol on the AAC device (Cosbey & Johnston, 2006). AAC can also use reinforcement by removing a difficult task when the individual learns to select symbols communicating that a break is needed.

Naturalistic instruction is not about using teaching opportunities that arise; it is about planning and arranging motivating communication opportunities in the individual’s environment (Cosbey & Johnston, 2006). The following describes how to implement incentivizing communication.

Interview and use preference assessment with parents and service providers who know the individual well to determine contexts and materials that the target individual finds reinforcing or motivating and identify needed communication skills across all possible natural contexts (Koegel, 2000; Leaf et al., 2015). This may involve the use of checklists by which parents may indicate their children’s preferred items and activities and may involve informal observation of the individual to determine what he or she seeks in natural contexts, such as at home.

Pair communication instruction with praise and other positive reinforcement. Provide access to items and topics of conversation that are reinforcing or preferred to use as anchors for learning new conversation skills. For example, Sam enjoys talking about sports cards with his teacher during the school day. The teacher would use this motivating topic to entice and create opportunities to ask questions about cards, label car parts, ask him opinion about cars in photos, and provide opportunities for him to ask for or work on model sports cards.

Interrupt routines or disrupt access to preferred materials to provide opportunities for which communication would be required (Ganz & Hong, 2014). For example, communication temptations (Wetherby & Prutting, 1984) may include joining the individual in a preferred activity with key items missing, playing with an interactive toy together and then turning it off, showing a desired food without providing it to the individual, or placing preferred items in containers the individual cannot open. These communicative temptations should elicit a response from the child and provide opportunities for communicative partners to model using the AAC device and teach new vocabulary. For older individuals, this may involve setting up situations for which he or she might need assistance, such as shoe tying, problem solving, or homework.

Ensure that communication instruction is enjoyable to the target individual and requires a reasonable response effort. That is, avoid frustration, punishment, and boredom and end instruction on a positive note. If communication instruction becomes aversive to the individual, he or she will not willingly engage in planned activities or spontaneously use new skills. For example, a teacher repeatedly prompts the individual to say, “We went to the park and climbed on a jungle gym with our friend Roger,” selecting each photo on the AAC device one at a time instead of praising the student and accepting the response, “We went to the park,” then asking follow-up questions. The effort may be too high for the target individual in terms of ratio to desired rewards (e.g., attention, social praise). Similarly, instructors should avoid promoting requesting for items or activities that the individual does not appear to want. Socially based communicative functions like conversation may be more difficult to teach a child with ASD. Consequently, conversation may be about a topic in which the child has special interest.

Scenario

After discussing Zoe’s daily routine with her parents and observing each situation, and as a result of consultation with and some training from the school district’s AAC specialist, Zoe’s IEP team chose the following communication objectives in the following initial contexts:

Requesting help (Sample contexts: cannot reach book on shelf, favorite snack in a container Zoe cannot open, remove toothbrush and wait for Zoe to notice).

Labeling items (Sample contexts: throughout Zoe’s day, label and ask Zoe to label items and preferred snacks, respond to questions about items in Zoe’s environment).

Working with Zoe’s parents, Anna created a list of all the things Zoe uses from practical things like toothbrushes to toys with which Zoe plays. Then, for each room in Zoe’s house and for each of her daily activities, Anna programmed the vocabulary symbols into the communication app on Zoe’s tablet computer app.

She also included a HELP symbol and a WHAT’S THAT symbol for each page of the app. The first day implementing Anna’s new teaching strategy, she placed Zoe’s favorite book on the shelf where it was too high for Zoe to reach. She then stood by the bookshelf with Zoe when Zoe walked over to it and tried to get her book.

Modeling Use and Verbalizations in Natural Contexts

Modeling use of AAC, along with modeling speech, is a means of providing AAC instruction in a similar manner to the way typically developing individual learn language, by hearing others speak and by trying to speak themselves. Modeling also provides students with variety of language models (Binger & Light, 2007). Thus, AAC experts recommend constantly exposing individuals learning to use AAC to adults and peers modeling how the individual is expected to communicate via verbal (i.e., speech) and nonverbal communication (e.g., AAC, facial expressions, tone) (Binger & Light, 2007; Drager et al., 2006). The following strategies illustrate how to implement modeling within natural contexts.

Prepare the AAC device or communication book in advance, including symbols for key vocabulary that is needed for the upcoming activity. Simultaneously model language use via speech and AAC (Drager et al., 2006). Speak while selecting symbols on the individual’s AAC device or communication book (Binger & Light, 2007). For example, during playtime when the child is using crayons, the teacher might say “you are drawing with a green marker,” while touching the symbols for DRAW, GREEN, and MARKER.

Model the key targeted vocabulary for a given activity (Drager et al., 2006). The communicative partner can select a symbol on the individual’s AAC device while verbally labeling it, and then verbally expand on the selected words (Binger & Light, 2007). If, for example, a child places a baby doll in the toy crib, the child’s communicative partner could name the symbols for BABY and CRIB while touching or pointing to the pictures on the child’s AAC device, and then expand on the verbal model by stating, “the baby is sleeping in the crib.”

Scenario

When Zoe stood on her tiptoes and stretched her arms up toward her favorite book, Anna tapped the HELP symbol on Zoe’s communication app and said, “I need help reaching my book.” Zoe raised her eyebrows and looked at the app on the tablet screen, but she did not attempt to touch the symbol.

Prompting and Prompt Fading

Behavioral techniques, such as prompting, are derived from applied behavior analysis and are comprised of direct, strategic skill teaching. Prompting is defined as providing instructions or demonstrations that are arranged to help individuals increase the likelihood of correct responses or behaviors (MacDuff, Krantz, & McClannahan, 2001). For example, a teacher may provide a physical prompt, or hand-over-hand prompt, to help a student measure with measuring cups until the student can do so independently. Directly teaching new skills to individuals with ASD is necessary because they are less likely to learn from observation and may learn at a slower pace than their peers (MacDuff et al., 2001). Prompts teach behaviors an individual with ASD either does not display, or displays infrequently. One way of prompting is to guide an individual’s hand to the correct AAC symbol if he or she selects the incorrect symbol or fails to select a symbol. It is important to fade prompts as soon as possible so the individual does not become prompt dependent, or reliant on prompts to perform a new skill (MacDuff et al., 2001). The following strategies are recommended to incorporate prompting and prompt fading into AAC instruction in natural settings:

Errorless learning is a strategy that increases the likelihood an individual will master a new skill more quickly. Undesired behavior, or errors in performing a skill, can be self-reinforcing and increase the likelihood that the error will occur again (Fillingham, Hodgson, Sage, & Ralph, 2003). Errorless learning requires that the learner is fully prompted to perform the correct response, and then reinforced for that behavior, while preventing an incorrect response (Fillingham et al., 2003). In this way, the individual does not reinforce errors. Errorless learning can also be used when teaching initial AAC by immediately following a stimulus, such as showing the student what kitchen utensils are available, with a prompt, such as providing a hand-over-hand prompt to help the student select the correct picture on his communication board (Reichle, Drager, & Davis, 2002).

As soon as the individual has had sufficient prompted practice, and as soon as possible, prompts should be faded, via time delay or another technique, such as moving from most restrictive (e.g., full physical prompting) to less restrictive prompting (e.g., gesture), and eventually providing no prompts for learned skills. Time delay is a technique that involves providing the individual with ASD time to respond after the communicative partner presents a stimulus (Reichle et al., 2002). The delay may be constant, such as always waiting to provide a prompt for 5 seconds, or may gradually increase (Cosbey & Johnston, 2006). This technique can be used in any naturalistic setting; for example, asking a child playing with a toy farm “what animal is that?” while pointing to the cow, waiting 3 seconds, and then prompting the child to select the COW symbol on the AAC device. When the child already demonstrates the desired behavior, AAC use, but not frequently or at the appropriate time, time delay is useful in increasing frequency and timing. You could also incorporate this with an older individual who is working on more complex communication such as being able to tell events in chronological order.

Communicative partners can pair time delay with an expectant look when the individual has not initiated interaction. A teacher may look expectantly at a student who does not respond or responded incorrectly, and then model or prompt as the situation dictates.

Scenario

As Anna and Zoe were sitting on the rug in the book area, Anna gently reached for Zoe’s hand, shaping her finger into a point, and prompted Zoe to tap the HELP symbol. Then Anna said to Zoe, “you need help” while simultaneously reaching up and getting the book down from the shelf. Zoe flipped through the book for several minutes before Anna placed her hand over the pages and asked, “what’s that?” while tapping the book symbol on the app and then pointing to the book Zoe held. Anna waited 5 seconds before physically prompting Zoe to tap the book symbol, stating “yes that’s a book” as she took her hand off the pages.

Expanding on Previously Acquired Skills

Communicative partners should follow lead of the individual when engaging in naturalistic AAC instruction. Language development may occur more quickly when communicative partners give language use examples frequently, starting with the individuals’ motivators at their current language level and building on what they can do by following their communicative attempts and expanding on the verbal, nonverbal, and AAC-based communications (Binger & Light, 2007; Drager et al., 2006). The following are strategies and examples explaining how to implement expanding on prior learning:

Communicative partners can speak in shortened phrases, speak more slowly, pause to allow the individual to respond, focus on the individual’s nonverbal communication, and model expansion with what he or she says.

Communicative partners can begin with a repetition of what the individual communicates, following with expanding on what was communicated.

Expansion techniques include adding a descriptor, labeling an item the individual named incorrectly, and modeling a slightly longer sentence.

Scenario

In the next month, Anna worked on labeling preferred snacks and toys with Zoe and asking for help. Anna faded prompts quickly when it was possible. When Zoe was able to demonstrate independent labeling and asking for help with new items, Anna began to work with Zoe’s parents and grandmother, teaching them how to implement communication instruction, including how to use the app when interacting with Zoe. Anna added new vocabulary and communication functions like answering personal questions and adding descriptors whenever Zoe mastered vocabulary with her different family members in various settings. Zoe’s mom was pleased to note that Zoe began using her app to greet the mailman and could label “LETTERS” and “MAILBOX.” Anna, along with Zoe’ parents, began to determine what vocabulary and communication skills Zoe would need when she started kindergarten in the fall, and in other settings in the community. Zoe’s family plans to practice social skills and learning new vocabulary at the library this summer, encouraging Zoe to interact with other children there and respond to their basic questions such as Zoe’s name and age.

Conclusions and Future Directions

Naturalistic teaching strategies for AAC are appropriate for ASD populations and are especially relevant in the context of teaching individuals with ASD to generalize using AAC to a variety of settings and a variety of communication situations. Integrating implementation in natural settings, modeling AAC skills, expanding current skills, and behavioral techniques could be a particularly efficient and effective method to address the need for individuals with ASD to develop the generalization skills to communicate in a variety of settings. As this integration is not a widely accepted AAC instruction method no protocol currently exists; however, interested practitioners and family members may find instruction in applied behavior analysis, incidental teaching, and AAC use helpful and informative.

Naturalistic aided AAC instruction is a practical way to incorporate language development into daily routines for individuals with ASD or CCN. Incidental teaching in the context of naturalistic instruction and verbal language instruction is an effective way to teach individuals with ASD (Charlop-Christy & Carpenter, 2000) and the potential communicative functions are numerous, expanding beyond requesting to commenting/labeling, asking questions for information, responding to questions for information, refusing, and taking turns in conversation (Wetherby & Prutting, 1984). In addition, naturalistic instruction can be used in tandem with behavioral techniques such as errorless learning, prompting, and time delay to increase communicative functions. Because naturalistic instruction in AAC has most often occurred while participants engaged in play activities or meals, generalizability to other contexts is limited. Developing a training protocol instructing practitioners and family members in implementing naturalistic AAC instruction is the next needed step in exploring and expanding naturalistic AAC instruction as an effective communication tool for individuals with ASD.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Notes

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