Many learners with CVI have complex communication needs. The visual behaviors and characteristics of CVI must be considered at every turn when designing a communication system. Many parents ask: What Augmentative and Alternative Communication (AAC) system is right for children with CVI? There are no one-size-fits-all systems. Every child with CVI has their own unique needs, and therefore a whole-child, collaborative approach is paramount when designing an AAC system for a learner with CVI.
Here are five essential steps to help teams and families find the best AAC system for a learner with CVI:
- Define the purpose
- Evaluate the learner’s unique profile
- Thoughtfully consider CVI visual behaviors and characteristics
- Monitor progress
But first, let’s define AAC.
AAC stands for alternative and augmentative communication. AAC is any system that supports a child’s communication and is uniquely designed to fit the child’s needs and communication levels. There is no one-size-fits-all AAC system. Options for what AAC can look like fall on a broad continuum. Low tech options can include a picture exchange communication system or making choices using whole objects or tangible symbols. Mid-tech can consist of voice output switches, picture exchange communication books, or leveled speech-generating devices (e.g., GoTalk 9+). High tech is where you see more dedicated, dynamic speech devices, such as Accent, iPads with communication apps like Proloquo2Go, and eye gaze systems.
“AAC includes all of the ways we share our ideas and feelings without talking. We all use forms of AAC every day. You use AAC when you use facial expressions or gestures instead of talking. You use AAC when you write a note and pass it to a friend or coworker. We may not realize how often we communicate without talking.” asha.org
Step 1: ASSESSMENT
Every learner with CVI has unique needs. Assessment is critical in understanding how to design an AAC system and individualize an approach that fosters growth in communication skills.
A Speech-Language Pathologist (SLP) completes a thorough evaluation of a learner’s language skills, including an in-depth parent interview, observation, and direct assessment. How much is the learner able to understand? Can they follow one-step directions? Does the learner understand everything, but they just aren’t talking? Once the SLP completes a series of assessments and has a solid grasp on the learner’s communication skills, they start to pull in all the other factors, including motor and sensory skills (touch, hearing, vision). SLPs look at the functional vision assessment results, CVI-specific assessments (Roman’s CVI Range, Dutton’s Inventory, Tietjen’s 2D Image Assessment), and the Learning Media Assessment. We have to look at all reports from the learner’s providers to design something matched to the learner’s skills and abilities.
There are many assessments available for SLPs to assess speech and language skills, but currently, there is a lack of appropriate assessments for learners with visual impairments. Many speech and language tests include pictures, for example, abstract cartoons, which are often less accessible for children with CVI. On some tests, there is also a visual bias in the questions asked, for example, “When you see someone with their arms crossed and a frown on their face, what does that mean?” Without access to incidental learning and recognition of body language and emotive facial expressions, a learner with CVI will have a challenging time answering that question. Or the assessment relies on milestones only met with visual skills (e.g., eye contact, joint attention). There is a great need for more research on effectively measuring communication in children with visual impairments.
The Communication Matrix and the Functional Communication Profile are both excellent tools to evaluate total communication. Both tools incorporate accommodations for visual impairments. The Communication Matrix includes both interviews and observation and focuses on what the learner can communicate. The Functional Communication Profile consists of a parent interview, evaluates the optimal access method to AAC (vision, touch, auditory), and considers listening comprehension. Beyond these two tools, the Preschool Language Scale (used for children up to 7 years of age) looks at developing language skills and uses real objects and meaningful tasks. This tool allows the SLP to see where the learner is in their development of communication skills, auditory comprehension and oral expression.
Step 2: PURPOSE
Clearly define the purpose of the AAC system. Identifying and recommending an AAC device and approach significantly depends on the individual’s unique needs. There are various reasons why a learner might use an AAC system. Here are five examples:
Suppose a learner is nonverbal and needs a method to communicate functionally. In that case, the team might recommend a simple AAC design to establish the cognitive “building blocks” necessary to learn communicative exchange. For example, learning to request preferred things, to ask for “more” or “all done,” to take turns (necessary for a conversation), and to greet.
Suppose a learner is a nonverbal communicator and needs a universal communication method (more expansive, complex language). In that case, the team might recommend an AAC system that supports the progression of concept development and expressive communication.
Modeling and building language skills
If a learner is a verbal communicator but needs to develop more sophisticated language skills, the team might recommend language modeling using visual supports. Auditory processing may be an issue, so the visual support and modeling done on an AAC device are critical to expanding and building their language skills and, for example, expanding functions of communication beyond requesting and into commenting, directing and greeting.
Modeling motor speech
Suppose a learner has a significant articulation or motor planning issue (e.g., Childhood Apraxia of Speech). In that case, a team might design an AAC device that provides a consistent model that helps them practice and improve their intelligibility of speech, which often helps them build their language skills.
Mending communication breakdowns
If a learner has appropriate language but is relatively unintelligible, the team might recommend AAC to clarify their message to the listeners.
Step 3: UNIQUE PROFILE
After we think about the purpose, then we consider the unique profile of the learner. SLPs must collaborate with the educational team to learn as much as possible about the learner’s skills and abilities.
- Synthesize results of communication assessments. What are their current language skills? What do they understand, and what inventory of vocabulary do they currently use?
- Collaborate with occupational and physical therapists. What are their motor skills? Can a consistent motor plan be easily developed? Will a consistent motor plan augment any deficits in vision and other areas? What are the visual motor skills and fine motor skills? What are the considerations for physical positioning?
- Collaborate with the teacher of the visually impaired (TVI). What are the learner’s visual skills and tactile exploration skills? What is the learner’s functional vision skills? How does the learner use their compensatory skills to access tasks and their environment? How does the expectation of improved vision use factor in developing an AAC system for the learner? What is the impact of the environment and fatigue?
- Collaborate with the teacher of the deaf and deafblind educator. What are the learner’s auditory skills? What are the learner’s functional hearing skills? Is voice output accessible with hearing loss? Does the selection of the AAC device consider auditory accessibility?
All of these considerations factor into determining the most reliable method of access for the AAC system. Is direct contact (touching the screen/symbol) or indirect contact (eye gaze, switches, auditory scanning) most reliable? Is the use of whole objects the most reliable? What are the learner’s strengths? That’s where we build!
Step 4: CONSIDERATIONS FOR CVI
The SLP and TVI must collaborate to design an effective and accessible AAC system for a learner with CVI. There’s a lot to consider with CVI and access. The SLP and TVI must use the recommendations from the vision-based assessments (FVA, LMA, CVI-specific tools) to figure out what is most appropriate to match the learner’s unique profile.
What does the learner mainly visually attend to and recognize? Is the learner able to recognize 3D objects only, or can they interpret some 2D images? What types of 2D images is the learner able to recognize? Matt Tietjen’s 2D Image Assessment is critical in helping SLPs assess how the learner responds to 2D pictures and symbols. Many SLPs are quick to use Mayer Johnson symbols or Symbolstix icons because they are easily accessible and appropriate for other populations (children with ASD, Down syndrome, and more). But these are highly abstract images, which are very difficult for learners with CVI to interpret.
When using 3D or 2D, make sure the icons or visuals are closely tied to the learner’s life experience. Children with CVI miss so much incidental learning, and therefore miss the opportunity to build foundational skills required for concept development. Whole-object interaction within the context of a routine, task, or other experience is where all children, including those with CVI, learn to develop their knowledge and understand new concepts. It’s the multi-sensory exploration of their environment and the world around them that will build the foundational concepts needed for a total communication system.
Consistency of placement on a page or board is important so that the learner can develop a consistent motor plan for access. And it is especially helpful for our learners with CVI to predict the location of the icons/symbols to build more contextual cues and recognition.
Impact of light
What is the learner’s reaction to light? Is backlighting necessary for visual attention and to support visual motor? The use of an iPad could be an excellent option for a high-tech AAC system or the use of task lighting with a low-tech AAC system.
Impact of color
How does the learner use color for visual recognition and visual attention? Does purposeful color highlighting improve the learner’s visual attention? Would a color-coded system work to support visual memory? How does high contrast support visual attention and recognition? For example, black or neutral background for both the communication board and the background of the symbols/icons, paired with symbols/icons with highly saturated colors. Does the learner attend to and interpret symbols in a single color or are they able to discriminate more detailed presentations?
Impact of spacing, object arrangement, clutter
How does the amount of items presented at once impact the learner’s access to the AAC system? How many objects/icons are they able to attend to and recognize when presented together visually? What spacing is required? Consider reducing the number of icons on a page or the number of symbols on a board. This might mean showing the learner one symbol at a time and using a form of Partner-Assisted Auditory-Visual Scanning (PAAVS).
Impact of motion
Does an element of movement need to be incorporated to gain the learner’s visual attention? Can this be done with programming on a high-tech AAC or by gently moving a low-tech symbol?
Visual field abilities and physical positioning
What kind of positioning provides the learner with the most consistent access? Is there a visual field preference? Does the device need to be mounted for optimal visual access? It is critical to collaborate with the PT and OT to best understand appropriate body mechanics in combination with accessing the AAC system.
Consider the method of presentation of the AAC device. What is the amount of wait time required for visual attention, recognition, and response? If vision is the primary sensory channel for accessing the AAC system, present the page/board or symbol/icon first, wait for the learner to process, and then provide a verbal label or request a demand.
What kind of environments will the learner use the AAC system? Does the learner need an environment with reduced noise, visual clutter, distracting lights, or movement to access the AAC system? If that’s the case, then is it the most reliable method for their communication?
AAC systems need to be accessible in any environment. The SLP may need to teach each symbol, icon, or AAC-related skill in isolation in a highly accommodated environment and then gradually scaffold the learner’s use of this skill into more complex and demanding environments. It’s important to have a backup system, a safety net for the learner’s communication. The student is often learning how to use a high-tech device in a quiet speech suite—navigating between pages and the array of visuals on a page. Eventually, the learner will be able to generalize these skills while in different environments. But in the meantime, if they can’t access their device in a busy environment like the grocery store, the family can use a switch with a picture/symbol on it that matches what’s on the device. So if the child starts melting down, they can hit that switch and say, “I need something different,” “I need a break” or “I need to go home.”
Orientation and Mobility
Communication happens everywhere, even when learners with CVI are navigating their environment. Collaboration with Orientation and Mobility Specialists will support expanding communication as the SLP incorporates landmarks for navigating environments in the learner’s communication system.
Step 5: MEASURING PROGRESS
Once an AAC system is in place, an SLP measures progress—what’s working and what’s not—in the following ways:
- Collect data during direct speech sessions—always considering the context, level of support and accuracy.
- Track progress through the IEP goals and objectives.
- Monitor the use of the AAC system throughout the day. Communicate with the team and family, checking in with different service providers to ask how the learner is doing with the AAC system, if anything needs to be changed or added. SLPs often informally check in with all the team members to offer device programming, training, or support as needed. It’s a lot more relational legwork of connecting with everyone and making sure that the adults have what they need to support the learner’s communication.
- Consistent conversations with families are critical. Families can share observational data about how the AAC system is working in different environments. It’s also a great opportunity to problem solve communication needs at home and in the community.
Six weeks is often the right amount to trial a new AAC system—to say if it is working or not—and gives enough time for collecting data, for the learner to become familiar with it, build motor plans and reinforce memory. Six weeks also allows some wiggle room for those days when the learner is feeling sick or tired.
Our kids with CVI have so much to say. A carefully designed AAC system matched to the child’s unique needs will help them thrive.
Keep the learning going right here at CVINow.org! Read about how two learners with CVI use AAC.