A child whose speech is not developing within the realm of what is considered normal, or is not likely to develop normal speech due to a pre-existing condition, is a potential candidate for AAC. (See Risk factors for a communication impairment.) Even when it is unclear whether or not a child will eventually develop normal speech, and this is frequently the case, the child may still benefit from an AAC program. (See Does AAC impede natural speech?—and other fears.) The following are some of the reasons why AAC should be considered for a child with a communication impairment or delay.

• Much of a child's cognitive, social and academic progress depend on communication. AAC has been shown to enhance a child's ability in all of these areas (Abrahamsen, Romski, & Sevcik, 1989; Blackstone, 1989; Silverman, 1980).

• A child with severe disabilities is often unable to learn the early cognitive and social skills on which conventional communication is based. An AAC program can tackle these related areas while teaching functional communication at the same time (Van Tatenhove, 1987).

  OTHER RESOURCES: "AAC Demographic Information" by David Beukelman at aac.unl.edu/AACdemog.html.

• Caregivers are often unable to interpret a child with disabilities' early attempts at communication. This results in a distorted relationship between caregivers and child, and the extinguishing of further attempts at communication by the child. An AAC program helps caregivers become more sensitive to the communicative behaviors of their child, in addition to giving the child a more decipherable means of communication (Van Tatenhove, 1987). (See Normal speech and language development.)

• A child with a communication impairment is at risk for learned helplessness. Because adults do not expect the child to inform them of his or her needs and wants, they anticipate, and often misinterpret, the child's needs. As a result, the child may relinquish any attempt to make his or her desires known and become extremely passive. AAC provides the means for the child to make choices and indicate desires and dislikes. In fact, giving the child more control over the environment is often one of the first goals of a communication program (Schweigert & Rowland, 1992; Van Tatenhove, 1987). (See Basic communicative functions.)

• Besides learned helplessness, a child who becomes frustrated due to the inability to communicate may resort to problem behaviors in order to get his or her way. AAC provides the child with socially acceptable ways of communicating needs and desires. (See Children with severe behavioral issues.)

• Finally, since the ability to communicate represents a quality-of-life issue, it is important to observe the overall level of satisfaction and sense of fulfillment that the child derives from his or her life. There may be a need for AAC when a child's communication disability is preventing him or her from engaging in the quality and quantity of participation in activities and routines that would be characteristic and expected if he or she did not have a communication impairment. In other words, if a child is unable to participate meaningfully in day-to-day activities and events just because of difficulties communicating, he or she would probably benefit from AAC. The implications of this definition of need are:
  • Every child must be assessed individually and in the context of his or her environment, lifestyle and culture. (See The ecological approach: Focusing on participation.)
  • No standardized tests can in and of themselves determine whether a child will benefit from AAC. (See The comprehensive AAC assessment.)
  • Children with severe and multiple disabilities, including profound cognitive impairments, can still increase their level of participation with AAC. (See A historical perspective on AAC.)

    Help me—and everyone who reads this site—by mailing your suggestions, criticisms and personal experiences to Ruth Ballinger at yaack@iname.com

  • AAC goals and objectives should be functional, that is they must have purpose and meaning to the child and/or to significant others in the child's life. They should be primarily aimed at increasing the quality and quantity of the child's participation in activities and routines. (See The ecological approach: Focusing on participation.)

Although it becomes obvious that a child needs AAC when he or she already exhibits learned helplessness, behavior problems, or cognitive or social delays as described above, the trick is to intervene prior to their appearance. (See b4.html#b4aContacting an organization for services and support.) Van Tatenhove (1987) outlines the following risk factors as precursory evidence of a communication disability.

• Prior to age one: "...feeding difficulties, irregular breathing...lack of oral play...overall abnormal gross motor development..."
• Twelve to twenty-four months: "...presence and persistence of primitive oral reflexes, development of compensatory abnormal oral movements, overflow of muscle tension or movements to the mouth when the child moves his body, lack of disassociated movements between the child's mouth and body, vocal or laryngeal blocking, poor coordination of respiration with feeding or vocalizations, and emerging speech abnormally unintelligible...continued reliance on nonlanguage systems to communicate when speech should be assuming more dominance..."
• Twenty-four to thirty-six months: "...continued poor oral-motor coordination; limited intelligibility; and difficulties with the processes of respiration, phonation, resonation, and articulation...evidence of communication frustration, learned helplessness, and a widening receptive-expressive language gap..."

Learned helplessness occurs when a child does not attempt to ask for or do things for him- or herself due to repeated experiences in which the child has not been able to have an effect on other people or the environment. This is a likely result for a child who is unable to act or behave in expected or conventional ways due to a disability. Because family members are not able to interpret or respond to the child's communicative attempts, the child does not discern a relationship between his or her own actions and a response from people or the environment. Learned helplessness is associated with excessive dependence and lowered self-esteem. Children with severe disabilities are at risk for learned helplessness due to:

• Motor, sensory or cognitive impairments that impede their ability to effectively act on the environment, or to understand the results of their actions.
• Lack of opportunity to make choices or otherwise be able to determine one's own life.
• Communication impairments that prevent them from being understood by others.

In intervening with young children who have communication difficulties, it helps to understand the normal sequence of development of children's speech and language. In simplest terms, children go through three main stages. Initially, an infant's behaviors are reflexive and random; the child is not actually trying to communicate to another person. Nevertheless, adults typically interpret the infant's behaviors as communication. For example, in response to an infant's crying, a mother may say, "She's letting me know she is hungry." (Researchers call this the "perlocutionary" stage. It is also referred to as unintentional communication.) (See Assessing intentionality, and the understanding of means-end, causality and symbols and The first goal: Intentional communication.)

The next stage occurs when the child realizes that his or her actions do have an affect on others. This usually occurs at around eight to ten months of age. The child begins to attempt to control what is happening or to interact socially by communicating through nonsymbolic means, such as gestures and vocalizations. For example, the child may reach toward a cookie as a way of getting the adult to hand it over. (This is called the "illocutionary" stage.) (See Basic communicative functions.)

Finally, the child develops formal, symbolic communication—usually speech—and is able to communicate increasingly complex and abstract information. (This is the "locutionary" stage.) Each of the three stages are made up of many cognitive, social, motor and oral-motor developments, all of which proceed, more or less, in a set order (Bates, Renzaglia, & Wehmna, 1981; Goetz, Guess, & Stremel-Campbell, 1987).

Frequently, a child with severe disabilities is at a serious early disadvantage in the developmental process. Although this infant may be exhibiting a repertoire of early communicative behaviors, due to the child's motor, sensory, cognitive or other disabilities adults may not be able to, or know how to respond. Furthermore, when adults do attempt to respond, the child may not be able to take advantage of the input. As a result, the child does not gain the understanding necessary to make the cognitive leap from unintentional to intentional communication. In these situations, caregivers and others may benefit from professional assistance in learning how to become sensitive and responsive to the child's attempts at communication. (See Contacting an organization for services and support.)

There is a controversy over whether a child with disabilities develops communication in the same fashion as a child without disabilities, albeit at a slower pace, or progresses in a different order or skips steps altogether. The implications of this debate extend to the content of and the manner in which the child with disabilities should be taught communication. The specific question is: Should the child be taught steps in order, and not allowed to proceed to the next one until previous ones have been mastered, or should a highly individualized communication plan be developed, one that focuses on the child's unique strengths, abilities and needs? It is probably safe to say that the extent to which a child with disabilities follows or deviates from the normal sequence of communication development is unique to a specific child. Whether a child is assisted in mastering the sequence of developmental skills in order, or is provided with an individualized intervention plan that deviates from normal development, should depend on the personal characteristics and individual circumstances of the child. In general, however, infants and very young children are more likely to benefit from a developmental approach than older children who frequently require a more individually adapted program (Goetz, Guess, & Stremel-Campbell, 1987). (See The ecological approach: Focusing on participation.)

OTHER RESOURCES:

Help me—and everyone who reads this site—by mailing your suggestions, criticisms and personal experiences to Ruth Ballinger at yaack@iname.com

• "Communication—It's all in the way you move" by Desleigh de Jonge looks at the impact of cerebral palsy. It is at curriculum.qed.qld.gov.au/lisc/ articles/therapy/thart2.htm.

• "Speech and language characteristics of children with down syndrome" in "Total communication options for children with down syndrome in the context of Hanen programs for parents" by Claire Watson, Senior SLP at www.hanen.org/downsynd.htm.

• "Starting Early with AAC....WHY?" edited by Caroline Musselwhite and Pati King-Debaun "is a summary of research on brain development, language, communication and it's relationship to early symbolic development" at www.creative-comm.com/topicset.html.