Recognizing Difference: Augmentative and Alternative Communication in Natural Contexts
11 September 2017 (online)
We are all different.
There is no such thing as a standard or run-of-the-mill human being, but we share the same human spirit.
Augmentative and alternative communication (AAC) is a set of procedures and processes that seek to maximize communication for individuals with complex communication needs. AAC approaches include aided (e.g., photographs, line drawings, words) and/or unaided (e.g., natural gestures, sign languages or systems) means to supplement or replace natural speech or writing. The field of AAC has a relatively short history of research and clinical practice as a formal discipline. Within the last four decades, research results have armed us with a wealth of discoveries leading to systems, evidence-based interventions, and principles to address the communication needs of those who cannot rely on speech to communicate in all situations.
One of the challenges of both AAC research and clinical practice is the high degree of variability that exists among individuals. There are multiple methods for addressing the heterogeneity that exists within a population of individuals who require AAC. These include using research designs that take advantage of the uniqueness of each participant, such as case studies and single-subject designs, as well as the development of systems and interventions that can be customized. However, when reviewing and summarizing past research, and considering how to apply these findings to clinical practice, it is all too easy to lose sight of the impact of the distinctiveness of each individual and run the risk of a “one-size-fits-all” approach.
Professor Stephen Hawking, in the 2012 Paralympic Games Opening Ceremony in London, stated, “We are all different. There is no such thing as a standard or run-of-the-mill human being, but we share the same human spirit.” This declaration was in recognition of the success and creativity of the participants of the games. But it is also a reminder of the diversity of the population of individuals who require AAC. We are all different, not only from basic biology and DNA, but from the unique experiences that contribute to who we are. Just as no one person can be an adequate representative for his or her race, religion, gender, or country of origin, no one person who requires AAC can be an adequate representative for all others. Therefore, it can be somewhat difficult to generalize the findings of research studies. Although this has the potential to paralyze clinicians and researchers in determining how to adapt systems and approaches, it also provides us with an interesting challenge. Nowhere is the challenge more apparent than in the real world, outside of the laboratory.
The World Health Organization, in creating the International Classification of Functioning, Disability and Health, recognized that “disability is always an interaction between features of the person and features of the overall context in which the person lives.” Multiple factors influence the functioning of an individual, including health factors (diseases and disorders) and contextual factors (external environment and internal personal characteristics). The International Classification of Functioning, Disability and Health classifies human functioning at the levels of the body or body part, the whole person, and the whole person in a social context. Thus, it is a useful construct to developing an understanding of how an individual may function within a natural context. It takes into consideration the dimensions of body functions and structure, the level of activities and participation of the individual, and the environmental factors contributing to functioning.
Each of the seven articles included in this issue of Seminars in Speech and Language has approached this challenge in a different way. The authors were tasked with providing an overview of recent research in AAC, with a particular focus on intervention and issues encountered in real-world contexts. All of the articles address barriers and supports influencing performance in activities and participation, as well as environmental factors that impact an individual's functioning.
This issue begins with a focus on skills that present a barrier to participation, specifically literacy skills. The ability to generate novel language provides powerful access to an increased social network. However, as Barton-Hulsey describes, several challenges exist for individuals who require AAC in reading instruction. She presents an overview of these challenges, the available literature, and considerations for increased access to instruction. Next, Boyle and colleagues present a technological approach to providing access to digital texts, which has the potential to foster early language and literacy skills.
The next two articles focus on system features that present a barrier to participation. In the first, Johnson et al describe the critical need for individuals who communicate via AAC to have access to appropriate vocabulary and specifically vocabulary that allows for communication about sensitive topics. They suggest a model for selecting vocabulary for sensitive topics, using pain-related vocabulary as an example. Then Boster and McCarthy discuss the use and limitations of touchscreen access on AAC technologies and the potential for mainstream innovations to unlock barriers for individuals for whom touch access is not feasible.
The remaining articles shift the focus to the environmental factors, while still addressing activities and participation. O'Brien et al provide an overview of available “just-in-time,” or in-the-moment, supports to individuals to increase independence and language. They propose the use of repurposed commercially available products and present illustrative examples that capitalize on providing supports “just in time.” Then O'Neill and colleagues describe the role of family-centered approaches to support individuals who use AAC in integrating communication into daily life. They discuss AAC intervention within the context of family leisure activities, a rich environment that brings both benefits and constraints. Finally, Bornman provides a discussion of the role of AAC in preventing abuse and providing access to justice for individuals with complex communication needs. This article considers larger societal implications of communication as a basic human right.
The diversity of topics in this issue is broad, reflecting the range of human experience as well as the heterogeneity of individuals for whom AAC can provide critical supports. Each article presents a summary of the research in an area, while acknowledging the necessity of supporting individuals with unique skills, backgrounds, and needs. More work is needed to break down barriers and enable access to language and communication, to facilitate participation in society, and to capitalize on the human spirit that we universally share.