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Revisiting the Adapted AAC Prompt Hierarchy:

11/10/2023

3 Comments

 
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.

​Download file here.
3 Comments

How Many Buttons?

11/4/2023

0 Comments

 
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One of the frequent things we see in the field of AAC is a struggle to determine how many buttons per page to start with on a new AAC system.  Though there is a myth that one should start small and have a very limited system at first this is no longer best practice, best practice is to consider the users ability to  "Perceive and Access" the buttons on the system.

Perceive and Access
Start with as many buttons, the maximum, the user can perceive and access (often times called "see and touch", a brilliant approach from the folks at AssistiveWare, but perceive and access is more accurate as it includes visual needs, fine and gross motor needs, memory and working memory needs, alternative access and more).

This means determining the skills needed to perceive the buttons including vision and visual scanning for most users, but also memory and working memory (especially for those using indirect selection like switches) and hearing for those using auditory supports for access.  

As perception issues are considered, access is also considered.  How will the individual make selections?  Will they use direct selection like their finger, a stylus, a joy stick, eye gaze or head tracking? Will they use switches?  What supports will be used for the selection method? Do they need the button they are about to select to enlarge or change color? Do they need an auditory preview or auditory scanning? If switch scanning will be used how many options are they able to recall during a scan?  Can they do row/column or group/item scanning? Are they able to use their cognition and executive function to make selections while they hold their whole message in their head? Overall, how many buttons per page can they access - remembering that less is not necessarily easier! Less buttons per page means more navigation.  More navigation increases the need for executive function skills, working memory, attention span and patience of both the user and communication partner.

(One place to start is watching the individual use other technology or do other activities.  Can they navigate YouTube? Find the X to close the video? Visually scan over selections and make a choice? Yes? Then chances are you can go pretty small with the buttons, which means more buttons per page.)

When you base the size of the system on what they can perceive and access you meet visual and fine motor needs because you chose based on criteria that includes what can be seen and what can be selected.  Once all these factors have been considered and tried a decision should be made to use as many buttons as they can perceive and access WITHOUT considering if they know the words and symbols on the buttons, if they can combine words or anything else beyond perception and access.  They will learn the symbols, words and the system as a whole because we will teach it to them.

​Like all children the AAC user must be exposed to exponentially more words than they can currently "say" as they learn to communicate.  In the case of AAC this is done using aided language input (aka modeling). They need words to prove they can use words.  This is important to understand as the old belief was that they have to prove they can use words to get more words added to their communication system.  That myth's time has passed.  You also need words to model. You can’t model what’s not there! We might hide/mask words, use "progressive language" features or similar during learning activities (though I don't), so that we can have a smaller number of words during the activity, but then return the system to full access. Using these features ensures the buttons stay in the same location as buttons per page changes and a new motor plan doesn't have to be learned for each increase. 


There are some other things to think about when you decide to give a user a limited number of buttons per page:
  • you limit the language they can use and since language is about connection there is less to use to connect with others which minimizes motivation
  • you are attempting to mind read to know what they might need and since no one can mind read you will be wrong
  • you make assumptions about their ability and, worse, others seeing the limited vocabulary start to perceive the user as unable to use more language and doubt their cognitive abilities, stigmatizing them
  • you cause them to need to learn a new motor plan everytime you increase the grid size, limiting progress
  • you make words transactional as the student must earn the right to have words
  • “proving ability” becomes next to impossible since you need words to prove you can use words
  • you are allowing the needs of the caregivers/stakeholders to outweigh the needs of the user as often concerns about "too many buttons" are based on the erroneous idea that if the stakeholder is overwhelmed then the user must be

​Remember, when you choose how many words someone "deserves" you are choosing the size of their world.  Choose carefully!
See also:
AAC through a Language Lens
https://blog.mycoughdrop.com/aac-through-a-language-lens/
​
Choosing a Grid Size by AssistiveWare
https://www.assistiveware.com/learn-aac/choosing-a-grid-size
Grid Sizes by Liberator AU
https://shorturl.at/eoFW9   
Prepare for AAC Use by Fluent AAC
https://www.fluentaac.com/prepare-for-aac-use 
What is beginning AAC? by Jane Farrell 
​https://www.janefarrall.com/what-is-beginning-aac/
0 Comments

    Kate Ahern, M.S.Ed.

    Accessible education teacher focusing on students who communicate using AAC.  

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