One Easy Way to Increase Vocabulary on AAC Devices

How do we add vocabulary when a child is physically limited to a few keys on a screen?

In the world of AAC, conflicts and compromises abound. We sacrifice battery life for weight, screen size for portability, budget for specialized access modes. We sacrifice the size of the vocabulary set for the number of buttons a child can access.

When children begin to use an AAC device, motor or cognitive challenges may limit them to just a few words on a screen. How in the world are we going to help them transition smoothly into a larger vocabulary accessed with more—and smaller—keys?

The secret is to use motor automaticity to our advantage.

Let’s step back and take a look a motor automaticity. Motor automaticity is the ability to carry out motor patterns without thinking about the movement. We all do this, all the time.

For example, walking is a skill many of us can do successfully without thinking about. Many of us can even complete other tasks at the same time as walking, such as talking to a friend, carrying objects, or looking for a misplaced coffee cup.

But someone recovering from a brain injury or stroke who has lost that motor automaticity must concentrate hard on the movements needed to walk. All their cognitive energy must focus on moving their legs correctly; carrying on a friendly conversation or looking out for that missing coffee mug is too demanding during the task of walking.

Another example of motor automaticity at work is touch typing. A typist can concentrate on forming words on the page without having to think about which finger to move to spell out the words. Remember this example; we’ll come back to it again.

When kids rely on AAC to communicate, motor automaticity allows them to access symbols on a screen without having to think about movement. This greatly enhances their rate of expression and makes conversation much more accurate and fluid. Kids can focus on the meaning of what they are trying to say rather than the motor mechanics of finding and targeting a symbol on the screen.

Without motor automaticity, locating a target and touching or eye-dwelling on it can be very demanding work. Communication is slow, exhausting, and creates a frustrating number of mis-hits.

We support motor automaticity by keeping buttons in the same location as much as possible. Just as we keep letter keys in a consistent arrangement on a QWERTY keyboard, symbols located in consistent arrangements are easier for kids to retrieve. They can find the symbols and letters they want easily, without having to scan through many keys.

To maximize motor automaticity...

Introduce screens with the end result in mind.

How many buttons on a page will a child be able to access in the future? No one has a crystal ball, so you’re just going to have to make an educated guess based on your child. With semantic compaction vocabulary sets, it’s hard to access a full vocabulary in less than 45 or 60 keys. Category-based pages might allow you to communicate with 30 to 42 keys on a screen, but fewer than that is going to mean a whole lot of tedious page flipping. The more buttons per screen, the fewer hits are needed, whether you are accessing words through categories or semantic compaction.

“But,” you say, “my child can only handle 8 buttons on a screen right now...”

You could offer eight buttons that fill the screen. However, what happens in the future when your child is ready to add more vocabulary? You would have to shrink the buttons and shake up their order to make room for more words or categories. Remember motor automaticity? Your child would have to learn their locations all over again. How discouraging is that?!

How naturally do these 8 buttons...

...become this? (Sono Lexis 9 x 6)
Not very!

Instead, take the screen that is your end goal and hide all buttons except the eight starter words/categories your child is using. He still has access to the same eight selections as the large keys filling the screen. Yes, these buttons will be smaller, but they are surrounded by plenty of null space that won’t activate if he hits it. You might be surprised how fast he can learn to target the smaller button size.

With this end goal in mind (Unity 45, full hit)...

...we start with these few word combinations.

When it is time to add vocabulary, you UN-hide hidden words or categories. They won’t change anything your child has committed to motor memory; they simply begin to fill in void space.

Child begins with these words and category...

...and ends with this 9 x 6 Sono Lexis display over time.

Remember learning to touch type in your keyboarding class? You started with the home row of keys:  asdf jkl;. It wasn’t much; you were limited to words like “fad,” “ask” and “lass.” But after a few days (weeks?), the teacher introduced “e” and “i,” and that opened up a huge new world of words! Now you had command of “alike” and “fleas” and “skidaddle!” The good news is that you didn’t have to relearn where the home row keys were located; they stayed consistent while new keys were added. Eventually, you mastered all 26 letters of the alphabet, along with some punctuation and formatting keys. That’s at least 40 keys...more for the kids who mastered the number row and got an A in typing.

This same concept is what I am asking you to try.

·        Start with the board set you think your child might be able to manage in a few years.

·        Select a few important buttons—the same ones you would have made up into a smaller set with large buttons.

·        Hide all the buttons around these select few.

·        Give your child time to learn to target these smallish buttons in the middle of large null spaces; it may take awhile, but trust that it will happen.

·        Then, when it is time to reveal a few more buttons, your child will be able to move forward with great confidence.

Want more information on hiding keys to support motor learning? Check out this comprehensive training material from Prentke Romich Company or sign up for one of their Language Acquisition through Motor Planning trainings. Although these are geared towards Unity's semantic compaction, the principles can be applied to most other language access software programs as well.

Knowing When to Back Off

Barbara at TherExtras asked us to participate in a blog carnival on the topic of recognizing readiness. It’s a happy and forward-looking topic. You are invited to take a look at my response here.

Some disorders that include loss or regression find us struggling to accept when our kids are not ready to move forward. In fact, they may be losing ground. It’s a difficult thing, but it’s important to acknowledge honestly.

How do we know when it's time to keep “pushing” forward and when it’s time to back off? Pull up a cup of coffee and let’s work through this.

Please allow me to share a little background.

A seasoned special needs parent shared a platitude shortly after our daughter was diagnosed with Rett syndrome. No doubt it was offered with the best of intentions. But I took it much too literally and ended up taking on tremendous guilt and self-depreciation. Back then, without the perspective of time or experience, how was I to know to question this “wisdom?”

That awful cliché was this: “Use it or lose it.”

By association, you can also conclude that if your child does lose a skill, it must be because you didn’t push your child hard enough to continue using it. Any loss she suffers, then, is obviously all your fault. At least, I made that connection.

Wrong direction to push an already wounded parent.

Rett syndrome is not the only disorder to cause skill loss or regression. There are others. But it’s the one I’m personally familiar with, and so that is the perspective I speak from.

In Rett syndrome, toddlerhood is an age in which loss of skills is the hallmark symptom of the disorder. These losses simply are. They are not within the child's control.

Like any parent crazy with grief and fear about the outcome of the diagnosis, of course I pushed my child harder than I ought, to do more than she was capable of doing. I certainly didn’t need trite platitudes haunting my every waking moment and robbing my sleep at night.

How much better all our lives would have been during that difficult period if someone had gently taken my hand and said, “Do your very best to help her keep all she can. That which she cannot keep, let go.”

So how do we do that? How do we know when to do our best to encourage her to move on? How do we know when to let go?

Our kids are our best leaders in this. We need to listen and to trust them. They are the ones living inside their skin, knowing when something is too overwhelming or frightening or painful. Toddlers may not have the best judgment at ALL times (for instance, the toddler who tearfully refuses a nap is probably the toddler who needs one the most), but we need to trust their perceptions of their abilities. Especially when their responses are consistent over time.

The most poignant story from our experience discredited the “Use It or Lose It” theory and eventually taught me to trust my daughter’s lead.

I was terrified watching her losing her ability to eat by mouth. She had been a great little eater up until her first birthday, picking up Cheerios or green beans with the finest pincer grip. She nibbled on grilled cheese sandwiches cut into long “fingers.” Homebaked chicken nuggets were an easy favorite protein. She had even begun feeding herself using a spoon.

Slowly, her ability to chew began to deteriorate. I found myself cutting her bites smaller and smaller. Large bites merely got mashed into globs that she struggled to swallow. It alarmed us that her eating skills were getting worse.

She stopped using her spoon and threw it instead. I also noticed that her amazing pincer grip, the one that allowed her to pick up dust particles from the floor, had regressed into palming. She’d try to shove fistfuls of food at her mouth and sometimes missed completely. She was hungry and acting out in frustration. I interpreted this as being naughty.

Enter her diagnosis:  Rett syndrome. I was terrified reading about the losses she might experience. When that older, more experienced mom cited the “Use It or Lose It” theory, I thought that maybe, if I worked hard enough to keep her using what she still had, she wouldn’t lose anything more.

I pushed. Five hours a day I pushed her to eat. We devoted one day a week to oral motor therapy and the lengthy drive to get there. I pushed her when her reflux told her to stop eating. I pushed her when she felt threatened by swallowing. I pushed and she cried. We both cried. No amount of forcing her to “use it” was keeping her from losing her chewing and swallowing.

After a year of pushing, a swallow study revealed why she resisted eating. She had been aspirating the bites I forced her to eat. The medical test explained what she did not have words to tell me.

Can you spell g-u-i-l-t?

How must I have made her feel, cheering her and pressuring her to do something she physically could not coordinate?

That test told us it was time to back off. She was no longer ready to eat by mouth. She had known all along, and she was trying to tell me. I hadn’t listened to her. While listening is certainly the first and best step, medical tests can also provide helpful information to let us know when it may be time to back off.

Medical tests can confirm bone or joint issues that cause a child to suddenly stop walking. They might confirm an illness that causes a child to stop swallowing food or saliva. They may confirm an inner ear infection that causes dizziness, impacting a child’s gross motor skill. Before we jump to panic mode over difficulties with a skill, we need to explore the possible medical explanations.

To be fair, when kids can’t use a skill because they are sick and bedridden, it can take a tremendous amount of work to recover a dormant skill. But we don’t need to immediately panic that the skill is permanently lost. There is a possibility it may be gone. But it may just as well be waiting to return.

While our daughter has yet to walk independently, she has come seriously close about four times in her life. Each of those periods of progress were interrupted by setbacks, whether illness or seizure. Those setbacks did not stop her from trying hard to regain her previous level of skill.

Many families can share similar stories.

Generally, especially for seasoned parents, there’s a lot to be said about trusting your intuition. Deep in your heart of hearts, you probably know if it is reasonable to push your child to practice a skill or not.

In the case of my daughter’s loss of oral motor skills, my intuition was no help at all. At other times, such as continuing to look for sparks of readiness for independent steps, my heart said to keep right on encouraging her to keep trying. Right now my heart does not say that; she battles issues that prevent her from being ready right now…but maybe down the road she will be ready again.

And that is the place of hope where I’d like to wind things up. We may not see readiness for a new skill today. In fact, it may be time to put a frustrating skill to rest. At least for awhile. Because maybe, with prayer and faith and hope, there may come a day when that readiness again raises its little head.

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We prepare the conditions. We ready the opportunities. We pray. We wait. Just as faithfully as the crocuses push their way out from below the soil in the spring, readiness for that skill may re-emerge.

But pressuring, fussing, forcing will not make the crocus bloom. Neither will this ready the soil for that tender skill.

Is your coffee cup is empty now? Mine is. I hope this has helped. It has helped me tremendously. Thanks for sharing this time. I appreciate it. “Do your very best to help her keep all she can. That which she cannot keep, let go.”

* * * * * * * * * * *

Be sure to check out Barbara's blog carnival at TherExtras!

You might also want to read 3 Signs Your Child is Ready to Tackle a New Skill

3 Signs Your Child is Ready to Tackle a New Skill

How do we know when our kids are ready to move on to a new skill?

Since I deal daily with Rett syndrome, a land of ever-shifting terrain, this question is close to home. Rett syndrome, along with so many other disorders with a neurological component, presents an ongoing ebb and flow of skill gains. And skill losses. But for today, let’s look at how our family has recognized that our daughter was ready for greater challenges. The cues she gave weren’t always the standard ones we look for in typically developing kids.

1) Increased interest in new areas. Sure, this sounds pretty typical. But we have to look past the situation at hand to see the broader implications of readiness.

For example, our girl was a diehard Wiggles fan. The bright colors, the catchy songs, the silly humor, the MEN were all attention grabbers for her.

But when she began to show interest in documentaries about penguins, she indicated readiness to take in information in new ways. We could see that she no longer needed the multisensory input of bright colors or music or MEN to keep her interest. She showed us that her attention span exceeded the 60-second vignettes that made up the Wiggles show.

She was ready to enter a new world of information input, one which was supported by the general education classroom and age-appropriate learning venues. Even if it meant being taught by a woman.

Might I add this was a joyful time at our house? While my husband and I are indebted to all the Wiggles men and their Big Red Car for the smiles they brought our girl, Henry the Octopus was enough to make me hurl. We were not sad to see Henry or Dorothy the Dinosaur exit from our lives.

2) Boredom. Particularly for kids confined to wheelchairs, boredom is often expressed as shut-down. Sleep. Faking sleep. They escape from a boring situation by checking out.

The other option for them is tantruming. Screaming. Doing anything loud or aggressive that will get them removed from a horribly boring situation.

I suspect the route a child chooses has much to do with personality. Our daughter shuts down when she is bored.

When a child is bored, they are ready to move on. They may not have mastered a skill in its entirety, but they may be ready to generalize it to new situations.

Take, for example, an occupational therapy activity that was suggested to us. We were to assist my daughter, with as minimal assistance as possible, to scoop a walnut out of a bowl, carry it in her right hand across midline, and drop it into a second bowl. Repeat for 30 walnuts. Switch bowls and repeat for the left hand. Ho-hum (I see you yawning!).

After the second or third time I brought out the bowls of walnuts, the poor child would drop her head to her chest and fake sleep. Had she mastered the skill? Absolutely not. But she was ready to apply it to something else that would keep her brain engaged.

So we started sorting plastic letters into piles of capitals and lower case, using the same movements of scooping, crossing midline, and releasing. We did the same to separate consonants and vowels. She never did learn to love the activity, but at least she was able to stay more engaged in it when we brought it into a learning realm she was ready for.

3) Stagnating IEP objectives. This is a huge problem for children who have difficulty expressing themselves. I have seen it not only with my own daughter, but many, many other kids with complex issues. An example is the IEP with the goal for identifying colors (red, yellow, blue, green) from preschool until high school. Unbelievably, this happens in real life. No joke.

When an IEP goal is repeated several years in a row, the child is ready to move on! There are several scenarios that may be at work; each one suggests that the child is ready for new goals.

a. The child has mastered the goal. Move on. So what if the concept is easy and comfortable to teach? The child deserves to be challenged. Move on.

b. The child has internally mastered the goal and either cannot express it or, more likely, HAS expressed it but we’ve missed the responses. Move on.

c. The child hasn’t mastered the goal. Move on. It may not be intrinsically important to the child. It may be that our system for teaching that goal has been inappropriate. It may not be broken down to fit the child’s capability. There are many other reasons a child may not master a goal. But why waste their time doing the same thing that hasn’t worked in the past? Move on.

Granted, there are some situations where maintaining a skill is the objective. We see this with our daughter and physical skills; just keeping what she has is forward progress. I don’t see these as “stagnant” goals. Ideally, her continued goal to “walk 300 feet with assistance” would include fading of the levels of assistance, but for now, just walking 300 feet with as much assistance as she needs would count huge in my book as progress.

4) Bonus:  They just do it! This is the miracle of child development when it happens. While it’s not unusual for typically developing kids to spurt forward without much warning, sometimes our kids with disabilities will also magically sweep us off our feet. Suddenly, everything comes together. It may be out of the blue or it may come after months and months of rehearsal. Maybe they go from standing to propelling forward with steps (don’t pinch me if this ever happens. So far, it has only occurred for my daughter during my REM sleep). Maybe they invite a classmate to join them in play for the first time. Maybe, FINALLY, they reach out to touch fingerpaint after years of tantruming over balking at all tactile sensations.

One instance that has happily etched itself forever in my memory was when the consonant “m” came together for our daughter after she’d lost her ability to speak. Her sister, then a toddler, had been rehearsing a nursery rhyme by filling in the word “moon.”

“I see the ____ and the _____ sees me,

God bless the ______ and God bless ME!”

Little sister was reciting the rhyme for Grandma, filling in with the word “moon” (and “me!”) at the correct pause. Our non-verbal daughter started to get agitated, so Grandma asked her if SHE wanted to recite the poem. Happy smiles; that’s an affirmative, Captain.

Oh great, I thought. She’s going to be so disappointed when the word doesn’t come out.

BUT IT DID! Well, close.

“I see the MMMmmmmm,” she fills in, right on cue. Timing is another part of our daughter’s apraxia that is impossible for her to control. BUT SHE DID IT!

“…and the MMMmmmm sees me.

God bless the MMMmmmm and God bless MMMmmm!”

Grandma and I could hardly see her for the tears puddling in our eyes, but the look of pride on her face was priceless! Everything just WORKED!! This so rarely happens for her, but when it does, it is a monumental occasion. And I’m happy to report that “mmmm” continues to be a consonant sound she has been able to maintain, especially because it makes up the bulk of that most important word—mom. What mother could ask for anything more?

Barbara at TherExtras has launched a blog carnival to discuss the topic of readiness. I hope you will check out her post and join in the fun!