Augmentative communication

      For Anjana, learning is a continuous process. Talking about her college days, she says, back then, the word neurodiversity meant little to her. But now she looks at things differently. She strongly advocates a neurodiversity affirming practice. Professionals, like her, who are curious and empathetic, add great value to the families they work with. Anjana is an SLP, based out of Bengaluru. Having studied at All India Institute of Speech & Hearing, Mysore, she firmly believes in multi-modal communication and the power of AAC.

                                Anjana is also working with a team to build Subodha, into an institution working towards the vision of ‘making communication accessible for all’.

1. How would you do you define as your role as an SLP?

By profession, we must work on communication, speech, and language. This is our forte. For me, it is both an obligation and a privilege. Communication is a basic human right. We built all other skills on it, and one needs it all the time. My job is to facilitate communication.

                 The concept of communication can't be seen in isolation. It's interwoven with many factors - empathy, radical acceptance, and a connection with the other person. One can work on teaching skills, grammatical aspects of language, and producing some sounds. However, one cannot achieve meaningful communication without factoring in the factors I mentioned.

2. As you had mentioned, as an SLP, it is important to delineate language, speech and communication for parents. Can you elaborate on it?

      Yes, this is absolutely important. Speech is predominantly the way people express themselves. We don't think of other modes of communication. When you have to work on communication for a person with a disability, one should look at it as these three basic clusters and identify it as areas to build on. 

                        Communication can be through signing, gesturing, writing, typing… There are many modes. Language is the formal code we use, English, Kannada, Hindi…,It has grammar rules, vocabulary. Speech is the motor part of communication where the muscles have to work to communicate. It is important we explain these differences because, at least initially, parents perceive speech as communication.

                              Everything starts with a thought, an idea, a feeling. The person has the urge to communicate the thought. It starts as a cognitive process. Words are then used to express the thought, which is the language part. The speech muscles will then program themselves for every alphabet or phoneme. It is a very complex motor process. A child can have difficulties in any of these areas or all. There might be a bright mind, but the motor process impedes speech. Like Tito once mentioned, “My lips don't move”. There is a mind-body disconnect, and it leads to a lot of frustration. When they have the competency to communicate, but cannot do so, the AAC can help.

3. There are also children having difficulty processing language/information, and this affects their communication? 

                                   As I mentioned, speech is a very complex function. Since we can do it easily, we do not realise the difficulties involved. There is the processing of language, executive functioning skills of communication, such as working memory, word recall, and so many other things. We call it the cognitive-linguistic function of speech. All of this happens so quickly and synaptically in a neurotypical brain, we cannot separate these and look at them individually. That is why accommodations should be provided to enable communication.

4. Most children don’t go beyond communicating needs while using AAC. Parents get discouraged in that process. Language has a much larger scope than merely stating needs. How can parents improvise on this?

                                 Food is a huge motivator. Initially, we start with food items. Communication has many functions. We communicate to express opinions, protest, preferences and then there is a linguistic side to it to narrate a personal experience, describe something, storytelling, express feelings, tell a joke. We have to look into each of these communicative functions, and think about how we can facilitate it.

                  A lot of it has also to do with presuming competence. Some of us think, why should I ask for their preferences? They don't have any. Will they really be able to give an opinion? I advise parents to involve them in real-life situations. For example, the tap is not working. Use AAC to talk about these problems, model the right behaviour, and show them how you are solving the problem. their vocabulary also expands. And slowly start asking them. They get to see how you are communicating and, importantly, why we communicate. Rather than merely transactional communication. A lot of it has to be understood and modelled by parents. That is not happening. Parents also need guidance. The SLP will be able to work with the child and the parents on these issues.

5. An accountability partnership is the way to go forward...

                         Yes, it is more of a collaboration between the child-parents- therapist. It immensely helps in expanding the language of the child. When parents talk to us, we can make suggestions saying try it this way, or introduce something new in the vocabulary. For example, a child saying NO is a protest; we should provide them with vocabulary to say No, Don't, I don't like, etc.

                 Communication has value only when we justify all the reasons the person is trying to communicate. And this partnership is a good way to facilitate communication. There are subtle things you see in a child’s communication. One can always attribute meaning to these actions. For example, a child is turning away. What language can you use there? Don't you want this? Shall I put it away? That is how we include language at any point in time. These are some thoughts that we share with parents.

6. What thoughts must be given  when we choose an AAC? 

   There are three types of AAC-Low tech, mid tech and High tech. High tech is more dynamic and robust. One can add more words on the go. It also has some grammatical features, like changing tenses. If you are working on literacy, then there is word prediction, a keyboard… It gives auditory, visual and symbolic representation of the words. It helps a child to pick up and learn language much faster and easier. The high-tech models in India include Avaz and Jello. 

                     If ‌you cannot use a high tech AAC, a low tech can also be put to good use. A low tech AAC would mean having printed, laminated word boards, communication boards. I strongly recommended a combination of both as one cannot carry the device everywhere. A low tech can help familiarize the child with the vocabulary in different situations. Sometimes, one doesn't feel confident sending the device with the child to school, or the child needs to go for swimming, then a low- tech laminated board would serve the purpose. Another factor is affordability. Mainly, the idea would be to involve the child and get participation in every situation. 

        The mid-tech is usually buttons with recorded messages. We don't have it in India. There is GoTalk. The Go Talk is a tablet with a few buttons and recorded messages. It gives you access to quick communication. Suppose the child is in a sports event, and the child has to express himself, like choosing a particular sport, or saying my turn. Mid tech is never robust and used in combination with low/high tech.

                 Some of the AAC supports are available on the browser as well. There are popular assistware apps like Proloquo2go. Then, there are texts to speech apps. As awareness is increasing, people are trying more of these options.

7. How do we implement AAC at home?

                           Home is where the heart is. Home is where we have our routines. Many rituals, such as "Me time," "Bath time," "Meal time," "Evening time," and "Bedtime”. The child has its own activities. There is a lot of language that can be facilitated through these routines. From the time the child wakes up to go to bed, there are many things happening at home.

                        What I suggest to parents is to pick up two routines that happen every day. And one activity to start with. For some it could be craft or for another a physical activity. Our minds turn to language that we can facilitate during these interactions.

              For example, during mealtime, bringing the cutlery, placing the plates, serving the food, asking do you want more? “Stop”, “I don't want more”, “I dont like this”...How is the taste?. “I need water”, “I feel thirsty”. There is a lot of language one can model. One of the key things is to provide access to words, to vocabulary. Either have a low- or high-tech device, readily available is important. I suggest putting up a chart near the dining area or fridge, as these words are always easy to access. As these are daily routines that the child follows, it consistently provides the inputs. Eventually, we create a situation when something is missing or not given, and the child is motivated to ask for it. There is a hierarchy in modelling, initially modelling with no expectation and then slowly backing off and encouraging communication from their end. Likewise, with an activity. The interactions become spontaneous over a period.

                  One another piece of advice would be to start with concrete, experiential things that you can touch and feel. Language, then, becomes real and meaningful to the child. Asking them to recall something that happened in the morning, or “What did you do in school”? is vague and demanding. Many children cannot answer these questions. Start with closed questions, then make it more open-ended. 

      

8. How can an SLP help in a classroom setting?

             The SLP- Special Educator collaboration is really important. The goals and line of work of a spl-ed is more academic. Even if it is academic, there is language to be used, be it a mathematical problem or science project. If there is a lesson on photosynthesis, we expose the child to the words they must know. The core words. Getting them to understand and use these words. When we have enabled them to use core words to explain a concept, our job is done. 

                                 Additionally, I work on an individual level to determine what supports the child needs, as well as the counselling parents need.

9. Quickly your views on:

           a. Moving towards neurodivergent practises:

                       When we started practising, fresh out of college, we knew little about neurodiversity. If the child was autistic, our efforts were driven to make the child “normal”. The thought process was to make them sit and give us eye contact. We thought this was the right approach. But then, as we learned about neurodiversity, and differently wired brains, it was a paradigm shift for me and others. So, now believers of neurodiversity affirming practices work differently. We don't want to change them into neurotypical ways of behaving or ‌communicating. If they want to use a wobbly seat on their chair, we are now ok with it. 

                               Many of us continue to teach our children to take turns during a conversation, which is very neurotypical. Many young adults cannot do that and find it difficult. Autistic adults, speaking for themselves, say they cannot quickly change their focus from talking about the weather, to the dinner they had or the plans for the weekend. Many of them have expressed that this kind of conversation makes no sense to them. They prefer a topic-based conversation, preferably a topic of interest to them. They prefer this to doing “Small Talk”. These are the things that the practice needs to refine. Rather than getting them to do things our way, we need to take their lead. We really need to understand what they want, how they process information? Do they really want to make friends? We need to go through a checklist to see their preferences. If they are keen on developing friendship, what kind of friendship, and with whom? Are they comfortable developing in-person or virtual interactions? At least with adolescents and young adults, we must go through this checklist. These approaches would be more neurodivergent aligned. An autism diagnosis doesn't mean that one gets to work on their social skills immediately, teaching them to say hi and bye. 

2. No ableist conversation goals:

                               Right, like the small talk I mentioned. Mostly, these are things we neurotypicals do. Feigning concern, appreciation…  Many of them prefer direct language. Things can be put forth straightforwardly, “I want an ice cream” instead of “An ice cream would be lovely!”. Neurodivergents have difficulty deciphering this ambiguous language. Teaching them self-advocacy skills or strategic competencies like, “Can you please repeat this”? “I do not understand this”, “Can you please be direct with me”?” Can you give me options”? Teaching children all this right from the beginning really helps to make them feel more confident.

 

Thanks, Anjana, for this interview, which  has helped us rethink communication.