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how l...
In the past, alternative and augmentative
communication was perhaps seen as a rather exclusive
field - but this is changing.
A small number of service users will always need
specialist input using high tech equipment and it is
important that we have therapists who keep up with the
breathtaking pace of improvements in the capacity and
flexibility of technology. At the same time, however, we
have greater awareness of the fundamental importance
of all therapists developing an inclusive and enabling
communication environment for everyone.
Whether high tech, low tech or a combination of
methods, our three contributors demonstrate why the
implementation of AAC needs strategic thinking,
practical skills and a strong focus on the needs of users.
How I
augment
AAC
Read ths
you
coud make more use o AA
nd ads are not used by cents
have dcuty accessng specast
support
Practical points: AAC
1. Respond to long-term and
changing needs
2. Focus on building opportunities for
conversation
3. Take time to reflect
4. Understand why AAC is used - and
why it is not
5. Network to share skills and secure
funding
6. Work from the clients level but
leave room for growth
7. Be as consistent as possible
8. Check that meaning is shared
9. Provide an appropriate range of tools
10. Involve users, families and carers
at every stage.
To find out more about AAC, check out CASC Road Shows. They...
Provide an overview and an update of specialised communication aid technology for use by people
with complex communication needs.
Are sponsored by the UK Trade Association of Communication Aid Suppliers (a sub-group of
Communication Matters)
Include mini-master classes on latest products presented by their manufacturers and suppliers
Have a full day programme including time for browsing, hands-on and discussion, and workshop sessions
They are intended for...
People new to the field of AAC and voice output technology
Professionals specialising in this field who want to keep up-to-date
Everyone with an interest in communication technology
Anyone who works with children or adults with complex communication needs
Presenting companies can include...
Cambridge Adaptive Communication, Don Johnston, Liberator, Prentke Romich International, QED 2000,
Sensory Software International, Sunrise Medical / Dynavox, Crick software and Widgit.
And...
They are FREE.
A list of CASC Road Show dates is at www.communicationmatters.org.uk.
Janet Scott is a speech and language therapist
at SCTCI, Westmarc, Southern General Hospital,
1345 Govan Road, Glasgow G51 4TF,
tel. (0141) 201 2619, e-mail
sctci@sgh.scot.nhs.uk.
Please note:
Janet Scott does not endorse any particular
graphic (or other) symbol system or approach,
and the views expressed are her own.
Sally Millar is a speech and language therapist
at the Communication Aids for Language and
Learning (CALL) Centre, University of
Edinburgh, Holyrood Road, Edinburgh EH8
8AQ, e-mail sally.millar@ed.ac.uk.
Cheryl Davies is a specialist speech and
language therapist at Denewood Centre,
Denewood Crescent, Bilborough, Nottingham
NG4 2FT,
tel. 0115 915 9619,
e-mail cheryl.davies@nottshc.nhs.uk.
simple line drawing. Unless the photograph is
carefully set up with good lighting on a non-dis-
tracting background selected to provide a good
contrast to the target item, the end product may
well pose an interesting figure-ground quandary -
the opposite of what was intended. For others,
three-dimensional, tangible symbols (or objects of
reference) may be more appropriate - perhaps as a
stepping stone to more abstract levels of represen-
tation (Rowland & Schweigert, 1989; 2000).
How genuinely guessable / transparent is
the symbol?
Graphic symbols can be graded along a spectrum
of iconicity (the visual relationship between the
symbol and its referent). At one end are transparent
symbols; at the other, the relationship between the
graphic symbol and the referent is opaque or
arbitrary. Translucent symbols fall somewhere in
the middle - the meaning may not be immediately
apparent but becomes obvious once it is explained.
Most symbols are accompanied by text (the gloss).
For people who can read, this tends to disguise
how opaque even a fairly pictorial symbol actually
is. Test out your friends with a selection of symbols
with the gloss removed. How many can they
understand? How far from the accepted meaning
are they? Even the most pictorial symbol systems
involve a degree of lateral thinking, of metaphor,
of life experience and simply of remembering what
the particular symbol means.
Meaning?
Culture has a huge impact on peoples understand-
ing of what they see and hear. The further away
our clients life experiences are from our own, the
less we should assume that we share a common
meaning. Perception of symbol meanings varies as
a function of culture / ethnicity (Huer, 2000).
However, cultural differences can be very subtle
indeed. Phillips (2001) identified distinct differ-
ences in the understanding of the phrase play
with your child. Life experience is so important in
shaping our understanding. Early in my career I
realised a client thought there were five types of
people: girls and boys, women and men - and
wheelchairs. Given the language he heard around
him every day and his extremely limited life experi-
ence, this was an obvious link to have made: Line
the wheelchairs up at the door, The wheelchairs
go in the bus first, and even Wheelchairs have
their dinner first - they take longer to eat.
3. Flexibility:
Vocabulary?
Shades of meaning can be hard to convey, and mor-
phological and syntactical markers may be lacking
in a graphic communication system. Where the
emphasis is on a functional means of communica-
tion, full grammatical sentences can seem a luxury.
However the use of graphic symbols to represent
higher level linguistic concepts may influence how
language is acquired, understood and produced
(Sutton et al, 2002). One of my clients demonstrated
how l...
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 (
Figure 1 Comparison of picture producing versus non-picture producing symbols across four different symbol systems
Blissymbol Makaton PCS Rebus
house
tree
happy
under
this
MacDonald (1998) suggests you consider three
main aspects of a graphic symbol system:
1. Construction:
Ease of reproduction?
Computers, scanners, photocopiers have made it
much easier to create good, high quality images
time after time.
Visual abilities?
We need to be aware of our clients visual skills -
their field of vision, their acuity, whether they are
sensitive to contrasting levels of brightness between
different surfaces, their colour vision and so on
(Aitken & Buultjens, 1992). A significant percentage
of people with cerebral palsy have a cognitive visual
impairment; they may also have problems with visual
acuity and motor dysfunction affecting their ability
to coordinate their eye movements. Some of the
more pictorial symbol sets have detail, which may be
distracting for some. We might need to think about
whether colour or black and white symbols would
be easier. It might be helpful to accentuate or high-
light the salient part of the symbol with glitter, a
bright colour or a different texture. We might need
to think about the background for the symbol dis-
play (to make the figure ground contrast more
effective), or the spacing of the symbols, and even
whether to laminate the displays (and if so, whether
to use matt laminate rather than the standard,
cheaper shiny variety).
2. Level of symbolic representation:
Are graphic symbols appropriate?
For some people photographs and other more con-
crete referents will be easier to understand than
even the most pictographic symbol. However for
others they can be more visually confusing than a
Of the confusing number of
graphic symbol systems, how
do you choose which one to
use? The best? The one you
know? Whats been used in the
past? Or, like me, the easy
option (one with a computer
package which creates high quality materials)?
Before computers, I recall hours at the photocopier
then cutting and sticking, and the laborious tracing
or drawing of symbols. I remember scouring mag-
azines and catalogues for pictorial material to
make up communication charts. That still goes
on, but usually it is to supplement a more stan-
dardised symbol set - then it was the symbol set!
Perhaps, though, we actually thought more about
how and why we used graphic symbols? Maybe it
is time to re-evaluate our choices?
Sadly, there is no perfect graphic symbol system;
each has its strengths and weaknesses, each its fer-
vent proponents. Choice of one over another should
be based on the needs and abilities of the client. UK
mainstream graphic symbol systems include
Blissymbols, Makaton, Picture Communication
Symbols and Rebus. Symbol systems associated with
particular high-tech communication aids include
DynaSyms (also known as PicSyms in their low-tech
life), mainly used in the DynaVox family of communi-
cation aids, and Minsymbols (or multi-meaning icons)
used in the Minspeak family of communication aids.
Finally, a number of other graphic symbol systems
have been developed to meet a local need or a spe-
cific client group such as the Bonnington Symbol
System designed to help communication, informa-
tion and access, and a set from Speakability to help
people in the early days of aphasia.
Every symbol system has to be taught to its users,
some are more pictorial than others, some symbols
are fairly easy to guess the meaning of, others are
not. Abstract language is always difficult to convey in
a pictorial way (compare the more concrete mental
image generated by the spoken word house or tree
with the feeling / association of happy and with the
idea / concept of under or this - see figure 1).
Get out there and use it!
There are many things to
think about when choosing
a graphic symbol system.
Janet Scott takes us through
the decision-making process.
Blissymbols are reproduced
from Bliss for Windows -
Export Program, Pub.
Handicom, The Netherlands,
1996.
Makaton symbols are
reproduced from The
Makaton Core Vocabulary
Data Base Pub. Makaton
Vocabulary Development
Project, Camberley, Surrey,
1996.
Rebus Symbols are
reproduced from Symbols for
Windows 2000, Pub. Widgit
Software Ltd., 124 Cambridge
Science Park, Milton Road,
Cambridge, 2003.
PCS are reproduced from
Picture Communication
Symbols, 1981-2002,
Mayer-Johnson Co., PO Box
1579, Solana Beach, CA 92075,
USA.
a cookery session), dinner place mats (for
lunchtime chat), hard backed folding boards, cred-
it card sized symbol wallets, keyring / chain on a
belt clip, stuck inside a plastic lunchbox with carry
handle, on an apron or vest (Goossens & Crain,
1992) or mounted on an eye gaze (ETRAN) frame.
In its most complete form, a communication book
is a full-scale formal communication system, consist-
ing of a large bank of symbols and words, providing
the user with access to a comprehensive vocabulary
covering any and every situation. To produce an
efficient communication book, consider:
1. Design
First consider the basics - size, shape, weight,
style. A4 ring binders are often too unwieldy and
- importantly - uncool. A5 size display folders or
FiloFax style (from office supply catalogues, sta-
tioners and photo shops) are better, with pages in
plastic pockets or laminated.
For people using the Picture Exchange
Communication System (PECS), the communica-
tion book is organised very specifically using
Velcro strips on each page, with each individual
symbol Velcro-backed, so that it can be easily
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003
how l...
A communication book is a
simple, low-tech aid to commu-
nication either on its own or as
part of a range of augmenta-
tive communication methods.
Communication books are on a
continuum.
At one end of the continuum are resources
whose primary purpose is to provide listeners and
potential communication partners with back-
ground and day-to-day information about the
person (which might or might not be accessible to
the client). These include Personal
Communication Passports (Millar, 2003) and home
school / centre diaries.
In the middle ground are resources such as a sym-
bol diary, which provide some element of back-
ground information, and also a shared context for
conversation using text, photos, pictures and sym-
bols. Other examples are:
a scrapbook or Clue Book in which the writer
attaches objects of significance, such as a birthday
candle, shop receipt or cinema ticket, plus a
prompt to launch an appropriate conversation
path (Guess where we went on Saturday).
a more structured Conversation Book which
scripts exact questions for the communication
partner (Ask me where I went at the weekend;
Ask me where I like to go best) alongside the
symbols which will provide the answers.
a photograph album to stimulate conversation.
Captions or accompanying stories can be written
in symbols if that helps. (The easy-to-use new
Talking Photo Album (Liberator, 32) is a cheap
and cheerful way to turn photo albums into
communication aids.)
Towards the other end of the continuum are
resources used more independently for day-to-day
interactive communication. Displays can be of a
limited amount of vocabulary linked to one specific
setting or topic, or a full-scale vocabulary bank.
Symbols can be displayed in all sorts of ways,
including: laminated topic sheets (such as for use in
the importance of not neglecting these grammatical
features when he spontaneously generated this
novel message: Grandpa sore leg get (then he
selected the past participle key) got bandage. I
was so excited to hear this as he had only been pro-
vided with a symbol based electronic communica-
tion aid three months previously, when he was 3;11.
Abbot (2000) provides a useful overview of the
main reasons for using graphic symbols, such as
for accessing information, to support inclusion, to
aid comprehension, to develop literacy skills. It
can be helpful to ask yourself:
Why do I want to use the symbols?
What am I hoping to achieve?
Why am I introducing symbols in the first place?
In addition, you should consider:
What other graphic symbols systems are in use?
Look not just at the clients current school or
resource centre, but also at what is used in the
local environment and wider community.
What support is available?
Symbols become more functional if they are not
the preserve of the therapy cupboard! Look for
computer packages for writing, symbol games,
books with symbol support, using symbols in
email, symbolised websites.
Symbols are becoming more mainstream in our
increasingly visual, pictographic world. Graphic
symbols are on crisp packets, our computer
screens, clothes labels, by the side of roads, at air-
ports. Symbols can make a real difference for the
people we work with (see Walker & Keating
2000a and b; Trapnell & Chapman, 2002).
However, remember that the graphic symbol set
used is the language encoding system for its user -
how they think, how they work out what the world
means. Dont change or introduce a new system with-
out a lot of thought. Try to be consistent across all the
different things the person uses - computer program
for writing, the symbol set in their high-tech aid and
in their low-tech display. Apart from that, dont worry
too much about which symbol system to use. Just
choose one, and get out there and use it!
References
Abbott, C. (ed) (2000) Symbols Now. Widgit
Software Ltd.
Aitken, S. & Buultjens. M. (1992) Vision for Doing:
Assessing Functional Vision of Learners who are
Multiply Disabled. Moray House Publications,
Sensory Series No. 2.
Huer, M.B. (2000) Examining Perceptions of
Graphic Symbols Across Cultures: Preliminary Study
of the Impact of Culture/Ethnicity. Augmentative
and Alternative Communication 16 (3): 180-185.
MacDonald, A. (1998) Symbol Systems, in Wilson,
A. (ed.): Augmentative Communication in
Practice: an Introduction - revised edition. CALL
Centre, University of Edinburgh.
Phillips, J. (2001) The Culture of Community: Do par-
ents and speech and language therapists mean the
same thing when they talk about play? Paper pre-
sented at the XXV IALP World Congress, Montreal.
Rowland, C. & Schweigert, P. (1989) Tangible
Symbols: Symbolic Communication for Individuals
with Multisensory Impairments. Augmentative
and Alternative Communication 16 (2): 61-78.
Rowland, C. & Schweigert, P. (2000) Tangible
Symbols, Tangible Outcomes. Augmentative and
Alternative Communication 5 (4): 226-234.
Sutton, A., Soto, G. & Blockberger, S. (2002)
Grammatical Issues in Graphic Symbol
Communication. Augmentative and Alternative
Communication 18 (3): 192-204.
Trapnell, N. & Chapman, J. (2002) Reading with
Symbols at Frederick Holmes School.
Communication Matters 16 (1): 29-31.
Walker, L. & Keating, F. (2000a) Being Arrested.
Grampian Primary Care NHS Trust (for more infor-
mation contact Lynn Walker, Speech and Language
Therapy Department, Woodlands Hospital,
Craigton Road, Cults, Aberdeen AB15 9PR).
Walker, L. & Keating, F. (2000b) Being a Witness.
Grampian Primary Care NHS Trust (see 2002a).
Resources
Blissymbols (Blissymbolics UK c/o the ACE Centre,
92 Windmill Road, Headington, Oxford OX3 7DR)
Makaton (The Makaton Vocabulary Development
Project, 31 Firwood Drive, Camberley, Surrey GU15 3QD)
Picture Communication Symbols (Mayer-Johnson
Co., Box 1579, Solana Beach, CA92075-1579, USA)
Rebus (Widgit Software Ltd., 124 Cambridge
Science Park, Milton Road, Cambridge CB4 0ZS)
DynaSyms (Sunrise Medical Ltd., AAC Department,
Sunrise Business Park, High Street, Wollaston,
West Midlands DY8 4PS)
Minspeak (Prentke Romich International,
Minerva House, Minerva Business Park,
Lynchwood, Peterborough, Cambs PE2 6FT)
Bonnington Symbol System (Bonnington Resource
Centre, 200 Bonnington Road, Edinburgh EH6 5NL)
Speakability, 1 Royal Street, London SE1 7LL.
Communication - by the book
Sally Millar explains how
different communication
books match different
clients abilities and
situations.
Look, stop, come, like, help
I (me, mine), you/yours, Mum, Dad,
More, not
(I need the) toilet: I feel bad;
Ive finished; more please; I like it; I dont like it; I
want; I need
Whats happening?; When?
Youve got that a bit wrong, Im going to start
again; its something like; opposite; sounds like
(Yes & No unless they can be indicated clearly in
some other, unaided, way.)
I like to mount this frequently used vocabulary
on the inside covers of the book, around the out-
side of the symbol pages that are cut smaller than
the total area of the binder. Another strategy is to
have the core vocabulary on a separate page
attached to the inside cover of the front of the
book that unfolds out to the left hand side, to be
permanently visible and accessible whilst the user
turns to different vocabulary pages of the book to
the right. With smaller books, the actions and sen-
tence starters might be down the left hand side of
each page, with descriptors across the top of the
page, each colour-coded.
3. Symbol books and language development
To develop a users linguistic ability, the book
needs to reflect the users actual level of language
and cognition ability, plus room for growth.
Latham (2003) has developed a prototype com-
munication book design based on her earlier work
at the Redway School (Latham & Miles, 1997) in
which vocabulary is not only divided up into core
and fringe vocabulary but also into developmental
stages 1-5 (matching the bands outlined in the
book). A Stage 1 left-hand core page has a few key
words and phrases, while a Stage 5 core page has
fold-outs with a full set of core chat words,
questions, pronouns, and starters.
It is important, however, not to overlook low
tech, simple options. One of my most successful
AAC solutions consisted of a piece of white paper
with the letters of the alphabet on it (in QWERTY
rather than alphabetic layout, to link with com-
puter use) cut to size and inserted into a clear
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003