JCPSLP Vol 17 No 3 2015

discussed the substantial benefits inherent in access to these technologies but also highlighted the increased demands they place on linguistic, operational, and social competence. They stated that: with the dramatic change in the scope of communication and the explosion of tools through which to meet communication needs, individuals with complex communication needs now have access potentially to a much wider and more diverse audience than ever before. (Light & McNaughton, 2014, p. 9) This means, however, that the communication expectations for AAC users have changed. They must develop the skills required to “independently use these new tools, adhere to their conventions, and communicate with a broader audience that includes those who may have limited or no prior experience with AAC” (p. 9). Challenging myths and misconceptions Despite the increased availability and implementation of AAC within some communities, there continue to be myths and misconceptions about the appropriateness and timing of AAC intervention with infants and young children. A number of highly regarded experts in the field of AAC have written about these issues (Cress & Marvin, 2003; Judge, Floyd, & Wood-Fields, 2010; Romski & Sevcik, 2005; Van Tatenhove, 1987). AAC and speech development One common assumption is that AAC use will impede or prevent speech development (Van Tatenhove, 1987). It is well documented that these concerns are unwarranted (Cress & Marvin, 2003; Johnston, McDonnell, Nelson, & Magnavito, 2003; Romski et al., 2010; Stahmer & Ingersoll, 2004). Research studies have demonstrated that AAC intervention for children below 5 years of age assists with the development of speech, language and functional communication skills (e.g., Drager et al., 2010; Johnston et al., 2003; Dunst, Trivette, Hamby, & Simkus, 2013; Romski et al., 2010; Stahmer & Ingersoll, 2004). Johnston and colleagues (2003), for example, introduced no-tech (Picture Communication Symbols [PCS]) and low- tech (single message voice output device) AAC systems to two children (one aged 3;10 with developmental delay and the other aged 4;6 with athetoid cerebral palsy and developmental delay) across an average of four sessions. Their intervention strategies included (a) creating appropriate and motivating communication opportunities; (b) modelling use of the AAC system by peers and teachers; (c) least to most prompting, and (d) naturally occurring consequences for communication attempts. The children demonstrated a 100% increase in the correct use of unprompted symbolic communication (Johnston et al., 2003). In another study, Stahmer and Ingersoll (2014) explored the effectiveness of an EI service for children with autism spectrum disorder (ASD). The Picture Exchange Communication System (PECS) and modified sign language were implemented simultaneously with students who were described as nonverbal. Not only did the use of AAC appear to assist spoken language development (80% exited the program with spoken language), but by the completion of the intervention, 90% of participants were able to independently use a functional communication system compared to only 50% when the study commenced.

In a final example, Romski and colleagues (2010) investigated the impact of speech generating devices (SGDs) during language interventions. They assigned groups of children, aged 2–3 years old, to three experimental conditions: speech only; aided input (where participants were prompted to communicate using a mid-tech voice output system); and aided output (where communication partners modelled the use of a mid-tech voice output system). The children who received the two aided interventions produced significantly larger amounts of vocabulary (either via speech or their AAC system) than the speech only group (Romski et al., 2010). Timing of AAC implementation Experts in the field of AAC recommend that AAC is introduced as early as possible in order to avoid potential long-term negative outcomes associated with communication impairment (Cress & Marvin, 2003; Drager et al., 2010; Light & Drager, 2007; Romski & Sevcik, 2005; Van Tatenhove, 1987). As Romski and Sevcik stated: “AAC is not a last resort but rather a first line of intervention that can provide a firm foundation for the development of spoken language comprehension and production” (p. 183). Cress and Marvin (2003) suggested that AAC intervention should commence if a child’s communication is difficult for a child’s caregivers or communication partners to decipher. Often one of the reasons for delaying AAC implementation with young children is that the majority of basic wants and needs are generally well interpreted and adequately met by a child’s primary caregiver. The risk in this approach however, is that it teaches young children to become dependent on informed and familiar listeners. This may lead to the development of learned helplessness where the child becomes used to not being able to communicate effectively and ceases to have the motivation to continue trying (Van Tatenhove, 1987). Suggestions for preventing learned helplessness involve coaching communication partners to recognise and support early communication attempts, and demonstrating the power of communication through the use of “core vocabulary” in motivating and functional contexts (Judge et al., 2010; Olive, Lang, & Davis, 2008; Romski & Sevcik, 2005; Van Tatenhove, 1987). Core vocabulary is a set of 400–500 words that feature in approximately 80% of the speech people produce (Banajee, Dicarlo, & Stricklin, 2003; Cannon & Edmond, 2009; Clendon & Erickson, 2008; Clendon, Sturm, & Cali, 2013; Trembath, Balandin, & Togher, 2007). They include words such as: more , again , stop , go , finished , this , that , etc. These words have the ability to hold power over a communication partner by directing an interaction. They also have high utility and thus provide lots of opportunities for modelling and repeated use (Geist, Hatch, & Erickson, 2014). The remainder of words that make up a person’s vocabulary (usually many thousands of words) are referred to as “fringe” or “extended vocabulary”. A further factor influencing the timing of AAC implementation is the reality that many children with CCN have compromised health status. As a consequence, often therapies which are perceived as additional or optional are held back until the child’s health is more stable. This can be a dangerous approach when it comes to AAC implementation as without a functional means of communication, these children run the risk of being unable to express themselves effectively (Cress & Marvin, 2003). It is critical to acknowledge, however, that parents of children with CCN are frequently dealing with considerable

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JCPSLP Volume 17, Number 3 2015

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