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
Wendt & Studebaker: AAC in ASD ISHA 2013
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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
Study N Phases DV PND-
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
Study N Phases DV PND-
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
Wendt & Studebaker: AAC in ASD ISHA 2013
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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
Evidence-based Interventions in AAC for ASD
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
Wendt & Studebaker: AAC in ASD ISHA 2013
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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)
Wendt & Studebaker: AAC in ASD ISHA 2013
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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
SGDs: Empirical Evidence
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
SGDs: Empirical Evidence
(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
Evidence-based Interventions in AAC for ASD
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
Wendt & Studebaker: AAC in ASD ISHA 2013
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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
Wendt & Studebaker: AAC in ASD ISHA 2013
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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
Wendt & Studebaker: AAC in ASD ISHA 2013
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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
Wendt & Studebaker: AAC in ASD ISHA 2013
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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
Wendt & Studebaker: AAC in ASD ISHA 2013
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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
Evidence-based Interventions in AAC for ASD
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
Wendt & Studebaker: AAC in ASD ISHA 2013
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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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