Proportion of Nonverbal Children with ASD AAC Definition - FINAL.pdf · Wendt & Studebaker: AAC in ASD ISHA 2013 1 Evidence-based Interventions in Augmentative and Alternative Communication

Wendt & Studebaker: AAC in ASD ISHA 2013

1

Evidence-based Interventions in

Augmentative and Alternative

Communication (AAC) for

Autism Spectrum Disorders

Oliver Wendt, Ph.D.

Emily Studebaker, M.S.

Department of Speech, Language,

and Hearing Sciences

Purdue University

Indianapolis, IN

April 4, 2013

Program

Prominent AAC Strategies for ASD

Picture Exchange Communication System

(PECS)

Speech-Generating Devices (SGDs)

Moving from PECS to SGDs and iPads

Using iPads and AAC apps for augmented

language interventions (E. Studebaker)

Case Examples

Discussion

Proportion of Nonverbal

Children with ASD

Autism includes a “delay in, or lack of the

development of spoken language” (American Psychiatric Association, 2000)

14-25% of children diagnosed with an autism

spectrum disorder (ASD) present with little or no

functional speech (Lord & Bailey, 2002; Lord, Risi, &

Pickles, 2004)

Autistic disorder only: 50% of children are functionally non-verbal

no sufficient natural speech or writing to meet their daily communication needs (Light, Roberts, DiMarco, & Greiner,

1998) Candidates for intervention in augmentative and alternative communication

AAC Definition

Augmentative and Alternative

Communication (AAC):

(1) The supplementation or replacement of natural

speech and/or writing. (Lloyd, Fuller, & Arvidson,

1997, p. 1)

(2) The area of research, clinical and educational

practice … to compensate for temporary or

permanent impairments, activity limitations, and

participation restrictions of persons with severe

disorders of speech-language production, and/or

comprehension. (ASHA, 2005, p. 1)

AAC and Autism (cont.)

AAC strategies particularly used in ASDs:

Manual signs and gestures

Pictographic symbols sets/systems

High technology speech generating devices (SGDs) for synthesized and/or digitized speech output

Practitioners face difficult task selecting a suitable approach

Evidence-based practice (EBP):

Using research outcomes as a major basis for clinical and educational decisions (Lloyd, 2001)

EXCHANGE-BASED

GRAPHIC SYMBOL SETS

Evidence-based Interventions in AAC for ASD


2

Picture Exchange

Communication System (PECS)

Structured behavioral intervention program to teach

use of visual-graphic symbols for communication

(Bondy & Frost, 1994)

Teaches to make requests by handing/ exchanging

symbols for desired items

Picture Exchange

Communication System (PECS)

Picture Exchange Communication System (PECS) protocol (Bondy & Frost,1994)

Phase I: Physical Exchange

Phase II: Expanding Spontaneity

Phase III: Picture Discrimination

Phase IV: Sentence Structure

Phase V: Responding to “What do you want?”

Phase VI: Responsive and Spontaneous Commenting

Why Choose PECS?

Requires very few prerequisites Only prerequisite individual can clearly indicate wants

and needs

First skill taught in PECS is requesting Often targeted in early instruction of individuals with

developmental disabilities due to motivational considerations (Reichle & Sigafoos, 1991)

Systematically targets spontaneous communication acts, a particular deficit in autism

PECS graphic symbols are highly iconic Can be easily recognized by the learner and are more

recognizable by communicative partners

Study N Phases DV PND-

Mean

PND

Range

Apprai-

sal

Ander-

son

6 I-III Requesting-PECS 67(Q) 29-100 Con-

clusive

(2001) Requesting-Signing 0 (I) 0-0

Tincani

(2006-2)

1 IV Word vocalizations 0 (I) 0 Con-

clusive

Word approximations 100 (H) 100

Anger-

meier

(2007)

4 I-II(III) Requesting-high iconic

67 (Q)

47 (I)

0 (I)

67

0-72

0

Con-

clusive

Requesting-low iconic 100 (H)

72 (F)

31 (Q)

100

Tincani I (II as Requesting-PECS 92 (H) 83-100

(2004) best Requesting-Signing 75 (F) 72-78

2 treatm.) Words/approximations

elicitation-PECS

100 (H) 100 Pre-

ponderant

Words/appr.-Signing 100 (H) 100


Mean

PND-

Range

Appraisal

Ganz 3 I-IV Words imitation 4 (I) 0-8 Suggestive

(2007) Word approximation

imitation

4 (I) 0-8

Marckel

(2006)

2 IV Requesting

generalization

(untrained items)

100 (H) 100 Suggestive

Tincani 2 I-II/IV Requesting 100 (H) 100 Suggestive

(2006-1) Word vocalizations 0 (I) 0

Word approximation 6 (I) 0-11

Charlop-

Christy

3 I-IV Eye contact, joint

attention or play

100 (H) 100 Suggestive

(2002) Requests and

initiations

87(F) 60-100

Elicited vocalizations 44 (I) 25-90

Speech imitation 34 (I) 25-50

MLU 31 (I) 17-50


Mean

PND-

Range

Appraisal

Lund

(2007)

3 I-III, I-II,

I

Requesting

(Independent)

60 (Q)

42 (I)

100 (H)

54-71

23-60

100

Suggestive


3

Study;

N; CA

Phases DV: # of OUTCOMES STATISTICAL

RESULTS

AP-

PRAISAL

A Mean

(SD)

B Mean

(SD)

Coh.

d

d

L (H)

Hedges’

g (p)

Yoder &

Stone

(2006a);

38

subjects

1 PECS -

(I-IV if

within 6

months)

2 RPMT

non-

imitative

spoken

acts

1T2a:

3.6 (4.8) 1T3:

5.5 (3.2)

2T2:

0.6 (4.8) 2T3:

5.4 (3.2)

.63

.03

-1.53

(2.91) -1.41

(1.55)

.61(.03)

.03 (.96)

Conclusive

33 mo different

non-

imitative

words

1T2:

2.4 (3.6) 1T3:

3.1 (2.4)

2T2:

0.6 (3.6) 2T3:

2.9 (2.4)

.50

.08

-1.12

(2.21) -1.00

(1.22)

.49 (.04)

.08 (.93)

Yoder &

Stone

(2006b);

38

subjects

1 PECS -

(I-IV if

within 6

months)

2 RPMT

Genera-

lized

turn-

taking

1T2:

4.0 (.81)

2T2:

7.1 (.81)

.97 .22

(4.29)

.92

(.019)

Conclusive

33 mo Genera-

lized

joint

attention

initiation

Pretreatment joint attention skills predict

response to treatment:

> 7 initiating joint attention acts: greater benefit

from RPMT

Only 1 initiating joint attention act: greater

benefit from PECS (ΔR2=.36, p<.001)

Study;

N; CA

Phase

s

DV OUTCOMES STATISTICAL RESULTS AP-

PRAISAL

A Mean B Mean z p r

Carr &

Felce

(2007a);

41

subjects

PECS

I-III (A)

vs.

control

(B)

Child-to-

adult

initiations

T2:

61.4

T2:

10

5.3

< .00003

0.83 r 0.69 r2

Elemen-

tary age

Child-to-

adult

linguistic

initiations

T2:

50.8

T2:

1.3

6.93

< .00003

1 r 1 r2

Child-to-

adult

initiations w

adult

response

T2:

96.7

T2:

76.9

2.8

< .0026

0.44 r 0.19 r2

Suggestive

Adult-to-

child w no

opportunity

for child to

respond

T2:

13.3

T2:

21.1

-1.65

< .0495

-.26 r

0.07 r2

PECS Summary

Considerable empirical support for using PECS as a

beginning communication strategy

Overall shows strong effectiveness for teaching initial

requesting skills

Some evidence to indicate: more effective than

manual signing in terms of requesting

Effect is less clear for other outcome variables such as

speech production, social or challenging behavior

When treatment goals is speech production no

sufficient evidence to inform practice in favor of PECS

or manual signing

In general, mixed results on this outcome measure

PECS Summary (cont.)

Methodological issues in PECS studies

Often lack investigation of maintenance

Skill generalization sometimes reported, but what

counts as generalization varies greatly

Participant descriptions lack detail

Sparse reports of treatment integrity

PECS appears as a promising intervention

that presents with emerging empirical support,

but critical questions are still to be answered

SPEECH-GENERATING

DEVICES


Speech-Generating Devices

(SGDs)

LightWRITER

BIGMack

Portable, computerized devices producing synthetic or digitized speech output when activated

Graphic symbols are used to represent messages, activated by finger, switch, head stick, etc., selecting a symbol from the display


4

SGDs (cont.)

SGDs (cont.)

Fixed Display

Graphic symbols

located in separate

squares of a grid,

organized into rows

and columns

Limited vocabulary

Dynamic Display

• Selection from a

display results in a new

array of graphic

symbols

• Larger vocabulary sets

SGDs (cont.)

Visual Scene Displays

• Language concepts are

embedded into contextual

scenes

• Objects and events within

the photograph are then

used as symbols for

communication

• May be used in a dynamic

display system

Not ideal for learners

with severe autism due

to sensory processing

difficulties

SGDs (cont.)

Example of a child with ASD using an SGD:

http://www.youtube.com/watch?v=s4GAX-

IXE_k&NR=1

Example of synthetic speech output:

http://www2.research.att.com/~ttsweb/tts/demo.ph

p#top

Why Choose SGDs?

Allows composing more detailed messages

Enable user to communicate very precise requests and

prevent communication breakdown

Voice output (aka speech output) may facilitate

acquisition and maintenance of communication

skills

Producing speech can be perceived as more

natural

Better intelligibility

Easier to get attention

Higher likelihood of receiving a listener response

Why Choose SGDs? (cont.)

iPads and other tablet devices are

Lightweight and portable

Cost-efficient compared to dedicated SGDs

Easy to program

Highly motivating to use

Socially appealing (peer acceptance)

http://www.youtube.com/watch?v=s4GAX-IXE_k&NR=1



http://www2.research.att.com/~ttsweb/tts/demo.php

http://www2.research.att.com/~ttsweb/tts/demo.php


5

SGDs: Empirical Evidence

Ganz, J. B., Earles-Vollrath, T. L., Heath, A. K., Parker, R. I., Rispoli, M. J., & Duran, J. B. (2012). A meta-analysis of single case research studies on aided augmentative and alternative communication systems with individuals with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42, 60-74.

Van der Meer, L. A. J., & Rispoli, M. (2010). Communication interventions involving speech-generating devices for children with autism: A review of the literature. Developmental Neurorehabilitation, 13, 294-306


Van der Meer, & Rispoli (2010), systematic review: Found 23 studies with a total of 51 children aged 3-16

years

Positive outcomes reported for 86% of studies, most commonly targeting requesting skills

Potentially effective option for teaching communication skills in ASD

Ganz et al. (2012), meta-analysis: Included 8 studies on SGDs, 9 studies on PECS, 7

other graphic symbols

Effect size estimates were 99% each for SGDs and PECS, 61% for others

SGD or PECS use yields significantly higher effects


(cont.)

Schlosser et al. (2009): “…SGDs represent a viable and effective AAC option for individuals with ASD”

Empirical evidence speaks a clear message, effectiveness of SGDs no longer a question

Wendt and Golinker (2012): “SGDs are one part of the standard of care to improve the functional communication and other outcomes for clients with ASD”

important when applying for SGD funding from insurance agencies

MOVING FROM PECS TO

SPEECH-GENERATING

DEVICES


SGD Advantages Additional provision of speech output presented

as (a) antecedent auditory stimuli (a.k.a.

“augmented input”), and/or (b) consequence

auditory stimuli (a.k.a. “feedback”) may benefit

learners with developmental disabilities

Gains in receptive and expressive language

skills in adolescents with intellectual disabilities

using SGDs (Romski & Sevcik, 1993, 1996)

SGD may allow more independent form of

communication (voice output understood by

variety of familiar and unfamiliar comm.

partners)

Research Questions

Practitioners/parents: after successful mastery of (initial) PECS

phases, can the child move on to a SGD? (Grether, 2007)

“…research into innovations to the PECS protocol is a

laudable direction and should be continued using rigorous

methodologies” (Schlosser & Wendt, 2008)

Project goals:

- Modify traditional PECS protocol for implementation and

transition to an SGD

- Evaluate the effects of such a modified PECS protocol on

increasing requesting skills, social-communicative behaviors,

and emerging speech

- Evaluate effectiveness of a particular device for such purpose

that is built upon PECS principles


6

Experimental Design Multiple Baseline Design across participants

(Baer, Wolf, & Risley, 1968)

Intervention phase split into PECS phases and SGD

phases, followed by maintenance phase

3 children, 9-11 yrs., severe autism and non-verbal

Dependent measures:

Requesting skills: number of correct requests during

20-trials session

Social-communicative behavior: number of responses

including eye contact, physical orientation towards

comm. partner, positive affect via smiling/laughter

Emerging speech: word vocalizations or word approx.

Materials and Setting

Traditional PECS book with PCS symbols for

desired items

Proxtalker -“sentence strip that actually speaks”:

picture card is put on ProxTalker display speak out the

symbol referent in form of prerecorded digitized speech

- several picture cards can be

combined to speak sentences

- symbols used were identical to

PECS symbols

Departmental Speech Clinic,

3 sessions per week

Modified PECS Protocol

(Preference Assessment)

Phase I: Physical Exchange

Phase II: Expanding Spontaneity

SGD Implementation

Phase III: Picture Discrimination

Phase IV: Sentence Structure

Phase V: Responding to “What do you want?”

Phase VI: Responsive and Spontaneous Commenting

(Original PECS protocol by Bondy & Frost, 1994)

Baseline Video Clip PECS Phase I Video Clip End


7

PECS Phase II Video Clip End

ProxTalker Phase II Video Clip Beginning

ProxTalker Phase V End

Moving from Mid-Technology (ProxTalker) to High-

Technology (iPad)

Ipad Phase End

Effects on

Requesting

Skills

Effects on

Social-

Communi-

cative

Behavior


8

Effects on

Emerging

Speech

SpeakAll!© The purpose is to help teach the process of

constructing sentences

Customizable to each child’s specific needs

Allows the instructor to use recorded audio and custom

images

Seamlessly connects with PECS or ProxTalker intervention

Selection Area on top replaces

PECS book

Sentence Strip at bottom speaks

selected graphic symbols

“Shuffle button" randomly regroups

graphic symbols

DOWNLOADABLE ON ITUNES (free app)

Appstore>Education>Purdue>SPEAKall!

Research on iPad-SpeakAll© Multiple Baseline Design across settings (Baer,

Wolf, & Risley, 1968)

Intervention repeated across clinic, home, and school

environments following PECS instructional phases

iPad with SpeakAll replaces ProxTalker, intervention

starts immediately with iPad

Dependent measures:

Requesting skills: number of correct requests during

20-trials session

Emerging speech: word vocalizations or word approx.

Participant 1 - Requesting

Ph 4

1 attr. 2 attr.

iPad fade out

1 attr. 2 attr.

Baseline Ph 3 Ph 5

Home

School

Clinics

Participant 2 – Requesting

Baseline Ph 3 Ph 4 Ph 5

1 attribute


9

Participant 3 - Requesting Clinic

Home

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

1 smbl

2+ smbl

2 attr.

iPad fade out

School

Baseline Ph 3 Ph 4 Ph 5

1 attr.

iPad gone Speech only

1 attr.

1 attr. 2 attr.

iPad fade out

iPad fade out

iPad gone

iPad gone

Speech only

Speech only

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

1 smbl

2+smbl

School

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

Participant 4 - Requesting

Home

Clinics

Baseline

Ph 3

Ph 1 Ph 2 Ph 3

Ipad and SpeakAll!© Participant 2 - Beginning

Ipad and SpeakAll!© Participant 2 – End

Ipad and SpeakAll!© Participant 3 - Baseline

Ipad and SpeakAll!© Participant 3 – Middle Stages


10

Ipad and SpeakAll!© Participant 3 – End

Conclusions

Findings provide support that AAC can have

facilitative effect on natural speech development

There may be a particular role for shaping echolalic

utterances

Refute myth that AAC prevents speech

Confirm augmented input may enhance

expressive and receptive communication

development

Confirm PECS principles (behavioral) hold true

regardless of modality

Conclusions (cont.)

• All participants mastered iPad intervention, but

varied in ability to complete later protocol

phases; effects are replicable across settings

• Gains in speech production most notable for

echolalic child able to request in spoken

sentences after fading out iPad

• Other participants varied in effects on natural

speech production

• Pre-treatment speech skills and degree of

cognitive impairment likely moderator variables

AUGMENTED LANGUAGE

INTERVENTIONS


Using AAC to Supplement Speech

and Language Intervention

Aided Language Stimulation: clinician highlights a

symbol on the child’s communication board while

providing verbal stimuli (Goossens’ et al., 1992)

Augmented Communication Input: similar to Aided

Language Stimulation but SGD instead of board,

communication partners learn to activate symbols on the

SGD to augment their speech input (Romski & Sevcik,

1993; 1996)

Aided Language Modeling: use of language boards to

implement aided language intervention during interactive

play activities (Drager et al., 2006)

Watch the following cases!

Acknowledgements

This project is supported by a Project

Development Team within the ICTSI

NIH/NCRR Grant Number RR025761

Thanks to ProxTalker.com, LLC for providing

devices

Thanks to the families who agreed to

participate in our research


11

Questions ??? Contact Information

Oliver Wendt, Ph.D.

Phone: 765-494-2462

E-mail: [email protected]

Emily Studebaker, M.S.

Phone: 765-496-3192

E-mail: [email protected]

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Lloyd, L. L. (2001, March). Evidence based practice. Why and what with an

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References (cont.)

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mailto:[email protected]

mailto:[email protected]


12

References (cont.)

Romski, M., & Sevcik, R. A. (1993). Language comprehension:

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References: PECS Studies

(cont.) Charlop-Christy, M. H., Carpenter, M., Le, L., LeBlanc, L.A., & Kellet, K.

(2002). Using the picture exchange communication system (PECS) with

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and have autism to make requests using a variation on the picture

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