Revisiting the Adapted AAC Prompt Hierarchy:

Seven Years Later

Seven years ago I wrote about and created a new prompt hierarchy, designed for use with those who have apraxia.  Soon after Shelane Neilsen collaborated with me to create a visually more appealing Adapted Prompt Hierarchy. Quickly translations began appearing, at first with or Shelane's my consultation and, eventually, without it.  Eventually new versions appeared, usually copying my premise, and often times my exact language, sometimes with credit or consultation and most times not.  Sometimes these were sold by others.  They are making money off of work I have deliberately only offered for free.  Work I've only offered for free because it is so vital to what we do as AAC caregivers and practitioners. 

The Adapted Prompt Hierarchy came into being because of my experiences observing a traditional, ABA based hierarchy used with AAC learners.  Those prompt hierarchies always started with an adult who had something specific that they thought the user should say.  It was assumed the adult was always correct in their choice of what should be said and no other response was acceptable.  As a means to that end the prompts had the end goal of encouraging, and if that didn't work, forcing the individual to say what they adult wanted them to say.  Such procedures ignored the humanity and human rights of the AAC user to be in charge of if, when and what they communicate.  These procedures, especially physical prompting, could create learned helplessness.  Furthermore, AAC users are taught that the AAC system doesn't belong to them, it is merely a tool that someone else is in charge of, that they can be pressured or forced to use to say anything someone else wants, regardless of their desires.  This may make the AAC system aversive, which will limit the success of it's use.

The major ways this Adapted Prompt Hierarchy for AAC is different from other prompt or cue hierarchies are the following:

• Aided Language Input (aka Aided Language Stimulation, Partner Augmented Input, modeling) is the umbrella under which all other intervention occurs.  It is a setting event for learning AAC. 
• This model focuses on maintaining the humanity and autonomy of AAC users.  It safeguards AAC and communication as a choice.  
• It suggests use of a pause of a minute or more.  Many prompt hierarchies suggest mere seconds.  This is often not enough time for AAC users to process language, formulate a response and use their AAC system to say that response.  The amount of wait time should be based on the individual AAC user.  Data can be collected to determine the average wait time needed for many different types of responses to determine how long to wait. 
• This prompt hierarchy completely eliminates hands on prompting - including partial, full physical, hand over hand and hand under hand.  No one should be touching an AAC user or their system while they are communicating.  Ever. There is a myth that hand under hand prompting is acceptable if the user consents and can withdrawn at anytime.  However, any physical prompting sends the message that the adult knows better than the child what to say and teaches the child to accept being physically manipulated to communicate.  This is what we want to avoid.  There may be some exception for Deafblind AAC users, but even then physical prompting is discouraged. 
• Other prompt hierarchies focus on getting an AAC user to say what the adult wants them to say, but this prompt hierarchy focuses on helping the AAC user figure out what THEY want to say. 

​As well as their being a plethora of research supporting Aided Language Input as a primary intervention in AAC and a recommended best practice, there is also research indicating passive observation is better than using physical prompting in individuals with intellectual or developmental disabilities. 

Additionally, seven years ago I had begun to work with a number of individuals who had been assaulted at school.  I had to wonder how being forced to communicate specific messages using hands on prompting (be it hand over hand or hand under hand)  created an easier target for abuse. Especial since these individuals were also subject to hand over hand prompting for other tasks, physical restraints and they were given rewards for allowing others to do things they found invasive or for allowing their bodies to be manipulated.  Certainly, hands on prompting, compliance based education and therapies and the inherent ableism in forcing a disabled person to do undesired activities was grooming disabled children and adults into being easier targets for abuse. 

In my original post, I went into great detail about the studies that show that individuals with disabilities are abuse at exponential rates compared to non-disabled individuals.  The statistics have not gotten any better in seven years:

• Adults with developmental disabilities are at risk of being physically or sexually assaulted at rates four to ten times greater than other adults. (From Sobsey, Dick (1994). Violence and Abuse in the Lives of People with Disabilities The End of Silent Acceptance? Maryland: Paul H. Brookes Publishing Company.)
• Sixty-eight (68) to eighty-three (83) percent of women with developmental disabilities will be sexually assaulted in their lifetime, which represents a 50 percent higher rate than the rest of the population (Pease & Franz 1994, Warick, Jason (1997).
• According to one study in 2000, approximately five (5) million crimes were committed against persons with developmental disabilities in comparison to 1.4 million child abuse cases and one (1) million elder abuse cases. (From Joan Petersilia, Ph.D., When Justice Sleeps: Violence and Abuse Against the Developmentally Disabled.)
• More than ninety percent (90%) of people (both male and female) with developmental disabilities will experience sexual abuse at some point in their lives. Forty-nine percent (49%) will experience ten or more abuse incidents. (Valenti-Hein, D. & Schwartz, L. (1995). The Sexual Abuse Interview for Those with Developmental Disabilities. James Stanfield Company. Santa Barbara: California)

        (https://shorturl.at/rwyV7)

Certainly, when the hierarchy was first shared seven years ago there was a backlash.  Some caregivers, but mainly paraprofessionals and professionals, could not conceive of a world where what an AAC user communicated was up to the AAC user.  Talking about abuse against those with complex communication needs and developmental or intellectual disabilities caused great upset.  There was a lot of push back about the rates of abuse reported being untrue, despite experts saying they were actually low.  Many practitioners doubled down on using hands on prompting. Slowly, but certainly some practitioners have begun to see the risk in using physical prompting and compliance based programming.  Most and more parents and other stakeholders are demanding their child's interventions NOT be based in compliance training and instead support neurodiversity.  Using the Adapted Prompt Hierarchy supports neurodiversity in many ways.  It supports communication autonomy by allowing the child to decide if, when and how they communicate.  It supports physical autonomy by avoiding any hands on prompting.  It allows for extended wait times of a minute or more to allow neurodiverse brains time to process what is happening and form a response.  

The Adapted Prompt Hierarchy for AAC is designed to create autonomous communicators who make their own choices surrounding what they wish to communicate, while offering them supports in choosing what to say,  

Please contact us if you wish to translate this into another language.  We will be happy to assist.

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