Sustainable AAC Practices in Low-Resource Areas

Jessica Gormley

5/13/2017 3:38 AM

This is the final post of the current collection exploring augmentative and alternative (AAC) services in low-resource areas.

Once the impact of poverty is assessed, team collaborations are formed, and the strengths, needs, and goals of all stakeholders are assessed, it is time to implement sustainable AAC instruction and intervention! It is vital to integrate the knowledge obtained above with evidence-based practices to implement culturally meaningful intervention with children with complex communication needs (CCN) and their partners.

As in the previous posts, case examples will be provided to describe how these topics were addressed within an interdisciplinary team during service trips to Port-au-Prince Haiti.

AAC Instruction in Low-Resource Areas:

Regardless of setting, many families and professional possess limited awareness that AAC strategies can optimize communication effectiveness (Light & McNaughton, 2012). If these individuals are unaware that AAC techniques have the potential to improve communication function, they may be reluctant to participate in activities that train AAC strategy use (Kent-Walsh & McNaughton, 2005). Many students with CCN in low-resource nations may never have attended schools let alone participated in speech therapy before. It is essential that SLPs allow families times to acclimate to interacting with professionals, if for the first time. Furthermore, SLPs should also address the basic principles of communication, AAC options, and demonstrate the power of communication strategies to ensure commitment to long-term use of AAC strategies (Muttiah, McNaughton, & Drager, 2016). As in any instructional program, commitment is an integral first step in the learning process (Kent-Walsh & McNaughton, 2005).

Muttiah and colleagues (2016) found that AAC experts who provide services in low- and middle-income nations report that focusing on foundational AAC principles (e.g., use of multiple modalities) and integrating AAC into daily routines (e.g., using communication boards in a religious activity such as singing or praying) can be a key to success. The International Classification of Functioning, Disability and Health: Children & Youth Version (ICF-CY; World Health Organization, 2007) can also be a resource to assist SLPs in making decisions to select intervention areas to maximize a child's community participation while considering impact of culture and current level of function (Fannin, 2016).

Sustainability:

When SLPs from high-resource nations participate in short-term service trips, it is important to remember that they will be present for a minute portion of a child's daily life. This fact should not necessarily lead to discouragement but, instead, a solemn reminder about the necessity of efficient, high-quality AAC services for long-term positive impact on the lives of children who have CCN. McConkey (2005, p. 148) recommends that SLPs should intentionally select AAC interventions that are essential, feasible, and meaningful in low-resource settings instead of "striving to emulate what happens elsewhere" (i.e., high-resource nations). This is not to claim that AAC specialists should have lower standards of care, lower expectations for individuals, or try less in these low-resource settings. Instead, SLPs should be realistically evaluate what can be accomplished in the allotted amount of time, identify powerful interventions to maximize intervention and instruction time, and use an assets-based approach (Alant, 2005) to deliver high-quality, efficient services.

Partner Instruction: High-quality AAC partner training consists of obtaining a partner's commitment to learning AAC strategies, strategy demonstration and explicit instruction by the SLP, and multiple opportunities for the partner to practice the strategy in real-world settings given a gradual fading of feedback and training supports by the SLP (Kent-Walsh & McNaughton, 2005). When time is of the essence, it is essential that partners are able to quickly practice newly trained AAC strategies (e.g., providing aided AAC modeling, using shared storybook reading strategies) in natural settings to have opportunities to receive feedback from SLPs to boost confidence and long-term implementation. These key communication partners may be selected as future trainers of AAC strategies once SLPs are no longer available (e.g., Bornman, Alant, & Lloyd, 2007) and to do so effectively,must be confident in this role.

Social Validation: Throughout the intervention process, use of social validation procedures with all stakeholders in the communication process can be critical to evaluation of the meaningfulness, relevance, and usefulness of the AAC instruction used (Light & Binger, 1998). Recall in the discussion of cultural humility that professionals are encouraged to maintain openness to the opinions and perspectives of others. When stakeholders, including families and individuals with CCN, are able to provide feedback to professionals, AAC instruction, systems, and techniques can be changed to better suit the unique needs of a community and make future AAC interventions more efficient.

Case Example:

On the short-term trips to set up classrooms in Haiti, the American team was able to provide services for a maximum of one week. The major focus of the trips were to provide training opportunities for the teacher so that she can be empowered to confidently run her classroom and incorporate basic communication, positioning, and learning strategies. I have found that parents and teachers quickly observe the successes of therapy when observing our physical and occupational therapists provide mobility and positioning devices to children who have significant motor and communication challenges. Although this may seem unrelated to communication, it helped demonstrate to communication partners the power of therapy on helping a child better participate in the classroom. Seeing successes helped to foster a spirit of commitment to learning additional strategies (e.g., AAC techniques).

Once they were able to observe children with significant needs become active participants in the classroom, I could better engage with teachers about specific AAC techniques that could further optimize participation in class activities. For example, when in a group training, I created challenges for the teachers to think of a student in their classroom who could not speak and brainstorm at least one way the student uses to communicate without using words (e.g., eye pointing, smiling, crying). In the classroom context, I worked directly with a teacher to use "think alouds" to describe the current communication attempts of a child and then describe techniques to expand the child's current communication skills. Many of the techniques discussed were seemingly basic; however, it allowed the teacher to quickly implement strategies (e.g., use of expectant delay, offering additional communication opportunities to children with CCN), create materials (e.g., draw pictures, create name and word cards), and integrate these within natural and culturally appropriate activities of her choice (e.g., group singing activities).

References:

Alant, E. (2005). Intervention issues. In Alant, E., & Lloyd, L.L. (Eds.), Augmentative and alternative communication and severe disabilities: Beyond Poverty (pp. 9-29). Philadelphia, PA: Whurr Publishers Ltd.

Bornman, J., Alant, E., & Lloyd, L. (2007). A beginning communication intervention protocol: In-service training of health workers. Education and Training in Developmental Disabilities, 42, 190-208.

Fannin, D.K. (2016). The intersection of culture and ICF-CY personal and environmental factors for alternative and augmentative communication. SIG 12 Perspectives on Augmentative and Alternative Communication, 1, 63-82.

Kent-Walsh, J., & McNaughton, D. (2005). Communication partner instruction in AAC: Present practices and future directions. Augmentative and Alternative Communication, 21 195-204.

Light, J.C., & Binger, C. (1998). Building communicative competence with individuals who use augmentative and alternative communication. Baltimore, MD: Paul H. Brookes Publishing Company, Inc.

Light, J., &McNaughton, D. (2012). The changing face of augmentative and alternative communication: Past, present, and future challenges. Augmentative and Alternative Communication, 28, 197-204.

McConkey, R. (2005). Service delivery in low-income countries. In Alant, E., & Lloyd, L.L. (Eds.), Augmentative and alternative communication and severe disabilities: Beyond Poverty (pp. 131-154). Philadelphia, PA: Whurr Publishers Ltd.

Muttiah. N.A., McNaughton, D., & Drager, K.D.R. (2016). Providing instructional support for AAC service delivery in low- and middle-income (LAMI) countries. International Journal of Speech-Language Pathology, 18, 341-53.

World Health Organization. (WHO Workgroup for development of version of ICF for Children & Youth). (2007). International Classification of Functioning, Disability and Health Children and Youth Version (ICF-CY). Geneva: WHO.

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