Supporting AAC Use for Preschoolers With Complex Communication Needs

Abstract

“An estimated one million children in the United States have complex communication needs (CCN; Binger & Light), defined as having little to no intelligible speech.”

Lucy is a four-year-old in Miss Miriam’s preschool class. She is an extroverted child who loves engaging in play and wants to draw her peers into her favorite activities. She especially likes to work with Play-Doh and pretend play with her toy dog, Lola. Lucy is diagnosed with Down syndrome and uses fewer than 10 words verbally. After a thorough evaluation with a multi-disciplinary team including a Speech Language Pathologist (SLP) and Lucy’s family, Lucy has been provided with an AAC system. Miss Miriam was given support to learn how to use the AAC system. Now, Miss Miriam wants to know how she can help Lucy develop stronger communication skills through the use of AAC in the classroom.

Introduction

An estimated one million children in the United States have complex communication needs (CCN; Binger & Light, 2006), defined as having little to no intelligible speech (Light et al., 2019), including approximately 12% of preschoolers receiving special education services (Binger & Light, 2006). Children with CCN include those with a broad range of congenital disabilities such as cerebral palsy, Down syndrome, and Autism Spectrum Disorder (ASD), as well as acquired disabilities such as a traumatic brain injury (Light et al., 2019). Even though they may present with heterogeneous types of disabilities, young children with CCN have shared characteristics of limited functional communication and verbal language skills. These characteristics make it challenging to participate in everyday activities, share ideas and stories, communicate with peers and adults, make requests, and access knowledge (Romski et al., 2015), all skills and abilities that are critical to success in school and life. High-quality early intervention can enable children with CCN to keep up with their peers and maximize opportunities for communication, language, literacy learning, and socialization (Biggs et al., 2018; Hustad et al., 2008). Thus, supporting children with CCN as they develop communication skills is essential to meet their social needs and engagement in early childhood settings (INS 2, Division for Early Childhood of the Council for Exceptional Children [DEC], 2014; Yoder & Stone, 2006). Teachers and other educational professionals are an important resource to help young children with CCN develop communication and benefit from their educational experiences.

Children with CCN often require alternative means to communicate because they may be unable to use speech as a primary means of communication (Light et al., 2019). Augmentative and alternative communication (AAC) is defined as a method of communication that can replace or supplement speech (and/or writing) for children to communicate (Schlosser & Lee, 2000). AAC can include many methods such as gestures, signs, communication boards, and voice output communication aids (i.e., speech generating devices). Supporting AAC use in preschool classrooms has been demonstrated to increase communication skills, particularly functional communication for children with ASD (Battaglia, 2017; Rabideau et al., 2018). More broadly, AAC use is associated with many positive communication outcomes for children with CCN, including increased quantity of communication with others (Banda & Alzrayer, 2018), increased vocabulary understanding and production (Ganz et al., 2015), and better emergent literacy skills, such as letter knowledge, concepts about print, and phonological awareness (Light & McNaughton, 2012). Although some may worry that AAC use might replace speech and/or interfere with speech development, the opposite occurs: using AAC can support speech development (Millar et al., 2006). Furthermore, using AAC can promote positive peer interactions, an important skill in childhood (Therrien et al., 2016).

“Although some may worry that AAC use might … interfere with speech development, the opposite occurs: using AAC can support speech development.”

Types of AAC

There are many different types of AAC systems ranging in complexity and technical requirements, sometimes categorized into unaided, aided low-tech, and aided high-tech AAC systems. Some examples are shown in Figure 1. Unaided AAC systems are methods that do not require technology, such as signs and gestures. Aided low-tech systems include simple technology such as communication boards, books, symbols, and photos (Hustad et al., 2008). For example, communication boards include pictures to illustrate objects, activities, actions, emotions, descriptors, and so on. New vocabulary can be easily incorporated by printing and adding new pictures. Aided high-tech systems include advanced technology such as digitized speech and allow for the composition of complex messages with the option to customize the use of words, images, and spelling for the individual. No matter what type of AAC the child is using, time and effort are required to most effectively support the child learning to communicate with the AAC system (Soto et al., 2001).

Figure 1

Examples of different types of AAC systems

Challenges With AAC Use

Successfully supporting AAC use in young children with CCN in the classroom can be difficult for teachers, particularly for aided AAC systems, which are the focus of this article. First, there are many types of AAC systems and each has different operational and programming requirements. As such teachers may find using AAC in the classroom to be challenging because of the range of AAC systems (Mellman et al., 2010; Rabideau et al., 2018), lack of knowledge and skills, insufficient technical support, and long decision-making processes (Baxter et al., 2012). Second, a critical challenge in AAC implementation is getting children to use symbolic AAC systems (i.e., graphics or icons to represent object- or action-related vocabulary), especially for preschool children who have little or no previous experience with AAC or knowledge of the symbols that are being used (McNaughton et al., 2008). Children may be comfortable with non-symbolic and idiosyncratic communication methods, such as pointing at objects to communicate a desire to play with the object (Peters-Scheffer et al., 2016), and may show limited interest in using a formal AAC system (Moorcroft et al., 2019). Despite these challenges, the preschool classroom is an ideal place to help children with CCN develop skills for using AAC (Tamakloe & Agbenyega, 2017; Therrien & Light, 2018) with the critical goal of communication with adults and peers and engagement in meaningful learning activities (DeThorne et al., 2014).

“The preschool classroom is an ideal place to help children with CCN develop skills for using AAC with the critical goal of communication.”

Using AAC to Support Communication—A Three-Step Strategy

This article introduces and provides guidance for using an easy, evidence-based, three-step process that preschool teachers can use to support children’s communication using aided AAC. Table 1 includes examples for using the process during multiple learning contexts across the school day.

Table 1

Examples of Strategy Use to Support Communication Using AAC Across Various Activities

Step 1: Preferred activities		Shared book reading	Meal time	Dramatic play
Step 2: Target vocabulary	Necessary	Turn the page, what’s this?	Forks, spoons, more, snacks, done	Feed, drink, walk, water, groom, play, comb
	Meet needs	Read it again.	I want, I don’t want	I want, I don’t want
	Fun	Woohoo, boohoo, llama, pajama, cute	delicious, crunch, smooth, yummy	cute, silly, woof
	Fit the child	Red (favorite color)	Tuna Sandwich (favorite food)	Dog, Lola (name of child’s dog)
Step 3: Interaction strategies	Model	The teacher points to the symbol [turn the page] on the board and says “turn the page”, then turns a page in the book.	The teacher points to the symbol [yummy] on the board, and comments “tuna sandwich smells yummy.”	The teacher asks the child “what is the name of the dog? Lola.” and points to [Lola] on the board.
	Ask the child a question	The teacher says, “who is wearing red pajamas?”	The teacher says, “What do you want for snack?”	The teacher asks the child “Please show me if you want to feed, walk, or groom the dog?”
	Wait	The teacher counts from 1 to 5 to wait for the child’s communication every time she uses any of the strategies.	The teacher counts from 1 to 5 to wait for the child’s communication every time she uses any of the strategies.	The teacher counts from 1to 5 to wait for the child’s communication every time she uses any of the strategies.
	Prompt	The child does not respond to the teacher’s question regarding the pajama. The teacher then provides a physical prompt by holding the child’s hand to point to [llama] and then provides a verbal prompt, “who is wearing red pajamas?”	The child does not respond to the teacher’s question regarding snack choice. The teacher then provides a verbal prompt, “Do you want a tuna sandwich or fruit?”	The child does not respond to the teacher’s question regarding activity choice. The teacher provides a visual prompt by pointing to [feed], [walk] and [groom] on the board while saying each activity name.
	Respond to the child’s communication	The child points to [llama] on the board. The teacher expands on the child’s communication by pointing to [llama] and [cute], and comments “llama is cute.”	The child points to [tuna sandwich] on the board. The teacher responds, “Good job! Here’s your sandwich.” and gives the child a tuna sandwich.	The child pointed to [groom] on AAC and says “goo”. The teacher then respond by expanding the child’s communication by touching [groom] and [comb], on the board while saying, “You can use the comb to groom Lola” and gives the child the comb.

Note. AAC = augmentative and alternative communication.

Step 1: Identify Preferred Activities/Items

To engage children in using AAC, the first step is to find out what activities and objects the child prefers (Keen & Pennell, 2015) to ensure children are interested and motivated to use AAC to communicate. As with any child, children with CCN are more willing to engage in learning new skills (like using AAC) when it supports them in doing something they enjoy. There are three effective ways to identify the child’s favorite activities/items: (1) Observation of the child by taking note of how much time the child spends engaged in different activities and with different items; activities where the child spends the most time are likely favorites (Keen & Pennell, 2010). (2) Providing the child with choices (Tullis et al., 2011); for example, before the child goes to free play areas, the child can be provided with a choice of two or three items or activities. (3) Communication with the child’s family and educational team (Verschuur et al., 2011) about activities the child enjoys at home and educational contexts. Beyond these ideas, a formal preference assessment can be beneficial for identifying favorites (http://ebip.vkcsites.org/preference-assessments/ offers details and instructional videos of how to conduct a formal preference assessment). As the child gains proficiency with the AAC system, more activities can be introduced, especially preschool routines like meals or circle time.

“Vocabulary should be useful for the activity, help meet the child’s current and future language needs, fit the child, and be fun.”

To identify Lucy’s preferred activities and items, Miss Miriam first observes Lucy in free play activities. She finds that Lucy spends most of her time at the pretend play area with a toy dog. She also spends a lot of time playing with Play-Doh. She confirms this observation by offering Lucy a choice between playing in the construction area and in the pretend play area, and then later, between painting and Play-Doh activities. At the end of the day, when Lucy’s father picks her up, Miss Miriam asks Lucy’s father about her favorite play activities. Lucy’s father says she likes to walk her toy dog and loves to play with Play-Doh. Miss Miriam concludes that pretend play with a toy dog and playing with Play-Doh might provide motivating contexts to introduce the use of AAC with Lucy.

Step 2: Identify Vocabulary and Prepare the AAC System

The second step in this process is to identify the vocabulary that is needed for each activity and prepare the AAC system, so that the vocabulary can be used by both the child and the teacher to communicate. Vocabulary should be useful for the activity, help meet the child’s current and future language needs, fit the child, and be fun (Douglas et al., 2013; Douglas & Gerde, 2019). The vocabulary should include the following: (1) Words that are necessary specifically for the activity, such as “tail” and “walk” for playing with the toy dog. (2) Words that children can use to meet their needs. Developing communication skills and useful speech before age five is a strong predictor of the ability to communicate needs at later ages for individuals with CCN (Yoder & Stone, 2006), so words that will be crucial for the child to communicate their needs should be included, such as (e.g., “I want”; “I don’t want”). (3) Words that fit the child’s experience, cultural background, language, and cognitive ability. For example, if the child has a puppy named Lola at home, then the word “Lola” for a toy dog activity can be added. Finally, (4) words to help engage the child (Douglas & Gerde, 2019); for example, in a Play-Doh activity, the words “silly” and “smash” might make the activity more fun. Throughout this process, consultation with the educational team, such as the SLP or paraeducator, is critical to generate ideas of what vocabulary might be most appropriate and effective for the activity.

After identification of the vocabulary, ensure the vocabulary is available in the AAC system. This may involve adding the vocabulary to the AAC system. For example, if the child uses a low-tech communication board for a Play-Doh activity, pictures to represent each vocabulary item can be added to the communication board. For a high-tech device, a new page specific to the activity may be needed, or the child may need help to navigate the AAC system to find vocabulary that is appropriate for the activity. If the child uses an unaided AAC system, such as American Sign Language, whoever is working with the child will need to become familiar with the signs representing the vocabulary selected for the child to model the signs while talking with the child. It is important to prepare the AAC system with the vocabulary before the activity begins, because extensive vocabulary additions can interrupt the play and disengage the child. Early childhood professionals may wish to consider AAC systems that support just-in-time programming: the addition of vocabulary items in response to the child’s interests (for more on Just-in-Time programming, see Holyfield et al., 2019).

“Five evidence-based techniques that can be used to promote communication using the AAC system are modeling, asking questions, waiting, prompting, and responding.”

Miss Miriam is using a low-tech picture communication board with Lucy (Figure 2). She starts by setting up the picture communication board for the Play-Doh activity. First, she adds vocabulary important for the activity: red, green, blue, Play-Doh, cut, squish, and roll. Then, she makes sure the board has vocabulary Lucy can use to make her needs known: I want, I don’t want. Next, she adds some vocabulary that fits Lucy’s interest in walking a toy dog, such as walk, dog, and park. Finally, she adds some fun vocabulary that allows Lucy to comment about the activity and supports her motivation to use the AAC system: silly, cute, soft.

Figure 2

Miss Miriam creates a communication board for the Play-Doh activity

Step 3: Use Interaction Strategies

After identifying the child’s preferences and preparing the AAC system with necessary vocabulary, helping meet the child’s needs, fitting the child, and making the activity fun, it is important to encourage the child to use the AAC system during the activity. Five evidence-based techniques that can be used to promote communication using the AAC system are modeling, asking questions, waiting, prompting, and responding (INT 2, DEC, 2014). The next section briefly describes each of the techniques and illustrates the technique in action. Examples of a teacher using each technique in different activities are included in Table 1.

Model the AAC System for the Child

Modeling involves the teacher showing the child how to use the AAC system by using it himself. This might include signing to the child to show the child how to sign, or touching the AAC system while talking to show the child how to use the AAC system. Modeling will help the child learn that the AAC system is an effective way to communicate (Biggs et al., 2018).

Miss Miriam models the AAC system to request the red Play-Doh. Miss Miriam points Lucy to a piece of red Play-Doh on the table. Next, she points to “red” on the communication board, says “Red, I want red,” and picks up the red Play-Doh on the table. To reinforce the modeling, she points to “red” again and says “red.”

Ask the Child a Question

During the play, a teacher can ask the child a question that requires the child to use the AAC system. Providing the child with two or more choices when asking the question can also be valuable. This strategy is especially useful to encourage the child to engage in the activity (Watkins et al., 2017) and use new vocabulary, such as learning to use “I want” to make a request (Yosick et al., 2016). Avoiding simplistic questions that can be answered by a simple “yes” or “no” is important, because these questions do not require extended child responses (De Rivera et al., 2005).

“Providing expanded wait time helps the child recognize that it is their turn to communicate and allows the child time to form the response.”

In the pretend play activity, Miss Miriam holds Lucy’s preferred item, a toy dog, as well as several other items, including a toy car, a toy cat, and a doll. Miss Miriam shows Lucy pictures of different items on the communication board and says, “What does your dog want to play with? A car, a cat, or a doll?”

Wait for the Child to Communicate

Children who use AAC systems need extra time to respond. Providing expanded wait time helps the child recognize that it is their turn to communicate and allows the child time to form the response using the AAC system (Douglas & Gerde, 2019). An effective approach is to wait 5 s or more for a child response when in a conversation by counting silently: “1 Mississippi, 2 Mississippi, 3 Mississippi, 4 Mississippi, 5 Mississippi.” If the child does not respond after five seconds or more, a prompt can be provided (see below), followed by again waiting for the child’s response.

Miss Miriam models the AAC system to comment on the shape of the Play-Doh

Since Lucy indicated that she wants to take the dog on a walk, Miss Miriam asks Lucy “Where should we take the dog on a walk?” and waits five seconds for Lucy’s response by counting silently to five. Lucy points to the picture “park” on her communication board.

Prompt the Child

If the child has difficulty using the AAC system, an effective strategy is to provide a verbal, visual, or physical prompt to assist the child in acquiring or engaging in the use of the AAC system (Yosick et al., 2016). A verbal prompt can be provided by giving a direction of how to communicate (e.g., “You can point to triangle if you want the triangle”). A visual prompt can be provided by pointing to a picture of the target vocabulary. A physical prompt can be provided by holding the child’s hand to point to a picture on the AAC system. A prompt serves as a stimulus of a target behavior and is effective in helping children achieve their communication goals, especially as children learn to produce multi-symbol messages with their AAC system (Finke et al., 2017). Prompts should provide only the amount of support the child needs; an effective approach is to start with a natural hint or reminder and then gradually provide more intrusive prompts until the child uses the AAC system properly (Finke et al., 2017).

After offering Lucy a choice of squish or roll the Play-Doh, Miss Miriam notices that even after waiting, Lucy is not answering. To help Lucy understand that pointing to pictures can be used to communicate with others, Miss Miriam provides a visual prompt by pointing to “squish” and “roll” on the communication board. After 5 s, Lucy still does not answer the question. Miss Miriam then provides a physical prompt by guiding Lucy’s hand to point to the picture of “squish,” and then guides her hand to squish the Play-Doh.

“Always responding to the child’s communication is critical, no matter what form the communication takes and even if the child’s communication is unclear.”

Respond to the Child’s Communication

Always responding to the child’s communication is critical, no matter what form the communication takes and even if the child’s communication is unclear. For example, the child’s communication can be acknowledged by fulfilling an expressed request (e.g., give the child the toy dog if the child asks for a toy dog using the AAC system), which can help children learn and practice appropriate communication using AAC (Douglas et al., 2013). The early educator’s response can also expand on the child’s communication. For example, if the child has learned how to point to one symbol using the AAC system, the child’s behavior can be expanded by a response that models pointing to two symbols. Expanding helps the child create more complex messages (Kaiser & Wright, 2013).

Miss Miriam creates a communication board for the Mr. Potato Head activity

Lucy is playing with the blue Play-Doh but points to “red.” Miss Miriam recognizes this communication and expands on her message by saying “Oh! You want the red Play-Doh.” While saying this, she points to “I want” and “red” on her board. Miss Miriam then provides the red Play-Doh to Lucy.

Conclusion

This article described ways for early educators to support communication of young children with CCN in classrooms through a simple three-step process. First, identify the child’s preferred activities and items. Second, identify vocabulary and prepare the AAC system. Third, use interactive strategies like (a) modeling, (b) asking a question, (c) waiting, (d) prompting, and (e) responding. These strategies help support the communication of children with CCN. These three steps can be used in activities throughout the day so the children with CCN in the classroom can build young children’s communication and obtain the most out of their learning opportunities.

Footnotes

Authors’ Note

You may reach Tiantian Sun by e-mail at suntiant@msu.edu.

ORCID iD

Tiantian Sun

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