Augmentative and Alternative Communication: The right enhancement to the way we communicate

We all communicate everywhere and at (almost) any time. But this makes participation difficult for people who have other ways to communicate than most of us. Augmentative and Alternative Communication (AAC) helps people who are unable to use normal spoken language to interact with their environment. What available communication options are there? And why is the most advanced technology not necessarily the best alternative?

When we hear the term communication, many of us only think of the spoken or written language. But communication is so much more. The WAY we speak, meaning the tone and volume we use is also important. And then there is non-verbal communication through body language, that is to say, facial expressions and gestures. Communication comes in many different ways, is reciprocal and takes places between two people or more. Sometimes, this makes communication difficult and complex, because it also means that we interpret what the other person is saying and how he/she says it. In turn, interpretations are subjective and affected by us and our own mood and disposition at the time. To cut a long story short, communication is essential and takes many forms but is by no means easy and simple.

But what about those people who have lost their ability to communicate verbally thanks to an illness, accident or disability or who never developed this ability in the first place? After all, without the spoken language, those affected have only restricted ways to communicate and thus hardly any opportunities for participation in today’s society. Only those with a voice are heard.

Augmentative and Alternative Communication (AAC) can help to promote better communication. The aim of AAC is not to replace one’s own communication channels, but to supplement and enhance them. That’s why choosing the right auxiliary means is essential, if the affected person is meant to really use it. Personal and individual consultation with experts with the inclusion of future users, as well as relatives and the family, is vital. Information about motor and language skills is just as important as knowledge about the interests and preferences of the user. In addition to specially trained therapists in speech-language pathology, physical therapy and/or occupational therapy, families or relatives can also "refer to a number of different places for an initial assessment, which include Autism Treatment Centers, Social Pediatric Centers, and Augmentative and Alternative Communication Facilities," says Nina Hormes, medical device consultant and rehabilitation educator (B.A.) at RehaMedia. The Duisburg-based company specializes in communication devices.

Who benefits from augmentative and alternative communication? "Augmentative and alternative communication is suited for different target audiences. AAC can be an expressive means of communication for people who are able to understand the spoken language, but are unable to express themselves – this refers to children or adults with dysarthria for example. AAC can also support people whose verbal speech is only comprehensible if they apply an additional resource as needed - children with developmental verbal dyspraxia for example. What’s more, AAC can be used as an alternative method of communication by people for whom the spoken language is too complicated a communication medium and who need a suitable replacement – this applies to children or adults with a so-called intellectual disability, "explains Hormes.

Regardless of whether it is a congenital disability or progressive disease, the result of an accident or merely a temporary limited speech impairment - the target audience for AAC is vast and not limited or tied to any specific age. To make sure that augmentative and alternative communication is able to develop its full scope of support, it is important that the communication resources provide age-appropriate content. As Heike Köhler, marketing director of REHAVISTA, a company that also specializes in communication resources, explains: "Whereas children highlight their 'favorite toy' as a category, adults emphasize communication contents such as partnership, sexuality or work and career. If the communication tool does not represent the user’s living environment, it very likely goes unused in everyday life."

But what exactly are AAC devices? As aforementioned, communication is more than just the spoken or written language. Anything our bodies can communicate, be it through certain gestures or facial expressions, posture or even breathing, is a type of body language. This includes sign language since it is not considered a spoken language. Everyone knows that communication actually works without understanding the spoken language from when you vacation abroad and can’t speak the country’s language. Intercultural communication typically works quite well through nodding or shaking your head or by using your hands and feet if necessary. Needless to say, this doesn’t really compare to a more extensive type and scope of communication. In this setting, people who want to use AAC apply modes of communication that are no longer limited to their bodies. Those resources can be non-electronic methods such as text or picture cards or symbol boards. "Electronic communication aids include resources such as keys or buttons to initiate communication," says Nina Hormes. But there are also communication devices featuring symbols and/or word input. Most people are probably more familiar with so-called talker and speech-generating devices. However, according to Heike Köhler, it should be noted that "AAC does not just refer to electronic communication devices. 'Multimodal communication' should always be the goal, that is, a mix of different approaches to facilitate the best possible communication in every situation. "

That being said, the user’s acceptance of the resource is the most important aspect. And that partly depends on when or whether language acquisition was affected. For example, people who have initially learned the spoken language naturally and then lost this ability due to an accident or illness often have a completely different level of acceptance of electronic means of communication than people who have suffered communication impairments from birth or before any language acquisition. "Many ALS patients state that AAC or their eye-tracking speech generating device is their 'gateway to the world': they can foster social contacts by writing emails or are able to work and live an active and self-determined life," says Heike Köhler. Meanwhile, finding the right tool for people who have had a different way of communication from birth requires more finesse. "They are usually quite inexperienced when it comes to the basic functions of communication since their own communication strategies have often been ignored, misinterpreted and/or where not accepted. Empirically, these people often have low expectations compared to same-age peers who are able to verbally communicate." That’s why when it comes to AAC integration, "a sensitive way of dealing with and introducing 'communication' itself - such as experiencing one’s own effectiveness – is the key to success." In a nutshell, it’s never too late to use AAC.

That being said, users of communication devices differ greatly and have developed different strategies to master everyday life. However, most of them have in common that they are restricted by society. Nina Hormes says that "due to the different user groups and the many options in the field of augmentative and alternative communication, there are numerous strategies and solutions for everyday use. One’s personal obstacles are very unique. One obstacle that every user encounters is how the environment and society deal with a person who uses an augmentative and alternative communication device."

1988 saw the publication of "A Brief History of Time" by Stephen Hawking - a man who was diagnosed with ALS (Lou Gehrig’s disease) at age 21, and had last used his own voice to speak three years before that date. A computer program helped him to write the book. The software allowed the famous physicist to select letters and commands on his computer at the touch of a button, which were then output by a speech generator. His "new" voice became his trademark. His speech-generating device received several updates. Hawking not only had a mobile version mounted on his wheelchair but was also able to control it using an infrared sensor and the movement of his cheek muscle since 2008. In 2013, he required new software because he started to have difficulties operating his computer using his cheek muscle. Similar to a smartphone’s voice recognition, the software recognized what Hawking wanted to say, but was more efficient since it was based on the contents of his books. If he entered the beginning of the word "black," his software suggested the word "hole" to him. This enormously increased the speed of his voice generator, allowing the physicist to being interviewed again.

You might say that the Brit who passed away in the spring of this year is arguably the most famous user of augmentative and alternative communication. His case demonstrates the many new possibilities that are a result of advancements in technology in recent years. Hawking was able to surf the internet, skype or write e-mails. Even though Hawking relied on using his cheek muscle, typically all AAC users today, who are unable to operate their speech-generating device via pressing a button or by using a touchscreen, control their computer via eye tracking. Nina Hormes agrees that "eye tracking is a great example of how technology advancements enable more and more people to have access to technical assistance." Generally, assistive technology devices vastly expand the options of participation. "Eye-operated speech-generating device technology doesn’t just offer many new benefits from a user perspective. From the perspective of the environment, in particular when it comes to medical routine care, eye tracking offers more targeted and extensive diagnostic options for physicians and therapists, especially in the area of persistent vegetative state for example," says REHAVISTA’s Marketing Director Mareike Köhler.

In addition to facilitating participation, the new technical assistance systems also offer another advantage. They are hip and modern. Most notably tablet-based communication devices are an interface between AAC and the socially accepted use of tablet computers. Resources signaling to the outside world that a user requires a communication device are especially unpopular with young adults or adolescents according to Köhler. That’s why today’s golden rule is that "the best technological resource is only effective and useful if it is accepted and being used. As a result, further developments always involve close cooperation with the actual users." What’s more, "AAC always needs a customized approach and adaptation of communication strategies" according to Köhler. Nina Hormes agrees. RehaMedia's medical device consultant and rehabilitation educator cautions against defining the speech-generating device as a blanket solution for all AAC users. "All AAC users should choose the right communication system with the help of experts."