AAC and Autism

1. AAC and Autism An Introduction to LAMP: Language Acquisition through Motor Planning Margaret Perkins M.A. CCC-SLP, ATP Communication without Limitations

2. What LAMP and AAC is NOT • Augmentative • Alternative • Communication • Device used along side other approaches • ABA, PECS, Floor time, etc. Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

3. “…I think that it is not okay to get it wrong for even one person; when we talk about communication, we are talking about peoples’ lives, no less than that…..If we get it wrong, if we miss the boat – people drown.” Pat Mirenda from ‘A Back Door Approach to Autism and AAC’ September 2008 Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

4. Desired Outcomes • (1) that the children will become more proficient communicators, utilizing a variety of communication modes which may include AAC, speech production, or a combination of the two; • (2) that language comprehension and expression will develop so that the children can communicate beyond the one word level; and • (3) that the children will develop an increased understanding of the power of communication. Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

5. LAMP approach Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

6. Communication Goal • Same as for all AAC users • S: Spontaneous • N: Novel • U: Utterance • G: Generation i.e. expressive, generative communication Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

7. Sensory Processing and ASD • Sensory processing disorders in those individuals with autism are well documented in the basic science and literature and in first-person accounts of those living with autism. These children and adolescents respond differently to sensory experiences than do their peers without disabilities. Tomchek & Dunn, AJOT Vol. 61, Number 2 p. 190 Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

8. AAC & Autism:Sensory Processing • Sensory processing refers to our ability to take in information through our senses (touch, movement, smell, taste, vision, and hearing), organize and interpret that information, and make a meaningful response. -Foundation for Knowledge in Development • In contrast, sensory processing dysfunction is a disorder in which sensory input is not integrated or organized appropriately in the brain and may produce varying degrees of problems in development, information processing, and behavior. -Cindy Hatch-Rasmussen, M.A., OTR/Lwww.autism.org/si Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

9. Typical Sensory Difficulties • Difficulty modulating sensory information may be involved with: • Auditory Processing • Also Auditory filtering & auditory hyper & hyposensitivity • Visual Responding • Avoidance of eye contact & inefficient use of eye gaze • Atypical use of peripheral vision • Tactile hypersensitivity • Possibly interconnected with inflexible behaviors & repetitive verbalizations Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

10. Considerations for AAC & Autism • Most likely have Sensory Processing Impairment • Focus on coordinating three sensory systems for language acquisition • Motor movement (proprioceptive system) • Auditory (hearing) • Visual • Should also be aware of • Tactile and vestibular Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

11. ASD Learning Characteristics • Likely have gifted Visual memory (rote) • Excellent visual spatial pattern recognition • Strength in rule-based learning • Gestalt learner (chunked learning) • ‘the whole is greater than the sum of its parts” • Frequently hyperlexic Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

12. LAMP approach Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

13. Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

14. LAMP: Consistent & Unique Motor Patterns • Each Word has it’s own unique Motor Pattern • Focus on Pattern, not icon • Language connections made through: • Initiating a unique motor pattern and hearing a word • Experiencing other’s reaction to the word • repetition of the Motor Pattern & experience with words Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

15. How to Model Vocabulary to Achieve Motor Automaticity • The goal is that the child will press the correct icon or icon sequence spontaneously and independently. However, to get to that end, you may have to help the child through the movement initially. You want to back off the amount of cuing that you are giving as soon as possible so that the child does not become cue dependent. Remember, it is a lot easier to remember how to get somewhere if you were the driver last time rather than the passenger. Levels of motor assistance: • Hand over hand • Point to icon • Point to general area of icon • Point to device • Wait for child to activate Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

16. Fitts and Posner (1967) proposed a three stage model of motor learning. The first stage is the cognitive stage in which the learner has to attend to the process of learning a motor action. This stage is marked by highly variable performance. The learner may or may not know what they are doing wrong or how to correct their performance and will need guidance to assist them. In the associative stage, he works on refining his skill and is able to detect and correct their errors. The autonomous stage is the result of a lot of practice. At this stage, the learner does not have to concentrate on the movement and can attend to other aspects of the activity. Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

17. Motor Planning and AAC Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

18. Automaticity: The Great Equalizer • Natural Language • Cognitive activity: Formulation of thoughts • Motor activity: Speech & Gesture (automatic) • AAC Language • Cognitive activity: Formulation of thoughts • Motor activity: Device activation (automatic???) Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

19. "In the practiced automatic movements of daily life attention is directed to the sense impression and not to the movement.  So, in piano playing, the beginner may attend to his fingers but the practiced player attends only to the notes or to the melody.  In speaking, writing and reading aloud, and in games and manual work, attention is always directed to the goal, never to the movement.  In fact, as soon as attention is directed to the movement, this becomes less automatic and less dependable." • Cattell, J.M. 1893 Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

20. Fundamentals of Motor Planning in AAC • Stop Looking • Meaning of each location must be unique and consistent • Focus more on patterns, less on picture interpretation • Location label (icon/picture/word) becomes ‘placeholder’ • Stop Thinking • Predictable next movement • Teach patterns Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

21. Motor Planning and AAC • “Using Motor Planning for language acquisition requires more than simply keeping icons in stable locations. It requires an understanding of where the system is headed years down the line, and teaching the motor patterns accordingly. The motor patterns must not change, rather they build upon themselves as vocabulary increases and language skills develop.” Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

22. Physiology Matters • Law of Neural Habit (1890s) • Repetition of a neuromotor pathway eventually requires less energy & enhances performance • Pathways are physiological, chemical processes • The same physiology that makes a movement strong also makes it hard to change Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

23. Consistent and Unique Motor Patterns • LAMP was developed with two “levels” of motor planning. Level 1 requires a single movement before the word is spoken by the device. • Level 2 requires two movements before a word is spoken. • Unity® vocabularies were used because they support consistent motor patterns that builds in a systematic fashion. Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

24. LAMP approach Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

25. Auditory Processing and ASD • “Autistic children typically have problems processing auditory information. One auditory processing problem occurs when a person hears speech sounds but does not perceive the meaning of the sounds. Sometimes the lack of speech comprehension is interpreted by others as an unwillingness to comply. However, the person may not be able to retrieve the meaning of the sound at that particular time.” Stephen M. Edelson, Ph.D, “Auditory Processing Problems in Autism” Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

26. Auditory Filtering • “Sensory Processing in Children With and Without Autism” • Compared 281 children 3-6 y.o. with ASD to age-matched peers who were typically developing. • Items • Is distracted or has trouble functioning if there is a lot noise around • 58% ASD compared to 2.9% • Appears to not hear what you say • 73% ASD compared to 4.3% • Can’t work with background noise • 12.5% ASD compared to 2.9% • Has difficulty paying attention • 79% ASD compared to 1.8% Tomchek & Dunn, AJOT Vol. 61, Number 2 p. 190 Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

27. Auditory Signals • Keep language models short, simple, natural • Focus on words ‘spoken’ by child with AAC device • And their natural consequences • Little to NO verbal prompts initially • Limit auditory input that child needs to process • Avoid ‘cluttering’ interaction with verbal prompting • May not be understood • Could encourage verbal prompt dependency and ‘key pushers’ Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

28. Auditory Signals • “Input from the vestibular, proprioceptive, and auditory systems is critical for the development of speech and language (1989, Windeck & Laurel) • Children need to experience words, not just repeat them • In LAMP each unique motor pattern = specific auditory signal • a specific word • Needs to be immediate (both signal and response) • Engagement and attention likely short-lived for student with ASD Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

29. Language Connections • The AAC device is a tool that allows the child to “babble” and learn about language. For example, after saying “more” to get bubbles, the child might think that pressing the key for “more” means “bubbles.” A beginning talker might make the same conclusion. However, in another instance what the auditory signal means when the child says “more” and gets more juice, the meaning of “more” is revised by the child. • As the child learns with the AAC device, he/she is learning consistent motor patterns that result in an auditory signal. Depending on the natural consequence triggered by the auditory signal, the child may modify his/her perception of what the auditory signal means. Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

30. LAMP Language Consideration: Single Words • “Communication is based on the use of the individual words of our language. True communication is spontaneous and novel. Therefore, communication systems cannot be based significantly on pre-stored sentences. Communication requires access to a vocabulary of individual words suitable to our needs that are multiple and subject to change. These words must be selected to form the sentences that we wish to say.” ASHA’s AAC Glossary Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

31. Language Development Questions • Is there research establishing a process for normal language acquisition? • Is normal language acquisition a simple or complex process? • Have you seen research that establishes how children with developmental disabilities acquire language? • In the absence of this research, on what do you base your intervention for helping children with disabilities acquire language? Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

32. From ASHA Leader “To integrate AAC systems with the curriculum, we must consider several issues. First, language develops and expands in an orderly fashion. Our devices and systems must allow for this development from the beginning. Typically, children acquire spoken language by progressing from one-word utterances to two-word utterances to simple sentences and so on. Language form, function, and use proceed in a fairly predictable pattern. AAC intervention should begin early, and clinicians should provide support for the way we know language typically develops rather than use devices that generate complete sentences at the onset.” Julie Schers and Pamela Hart, Wichita State University The ASHA Leader Vol. 7 No. 16 Sept. 10, 2002 Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

33. Words vs. Phrases for Autism • Individuals with ASD tend to be ‘Gestalt Learners’ • Tendency to take in chunks of info • Phrase “I want spin toy” is learned as 1 entity • Even the simple phrase “I want” • Phrases = participation, don’t build language skills • Individual words are the building blocks of language • We can have participators AND communicators • Two words can be something new • Two phrases can only be two phrases Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

34. LAMP approach Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

35. Natural Consequences • No Mistakes: Respond to all communication • Respond Naturally & with Animation • Ex. Loud crunching when pretending to ‘eat’ • Use Natural responses to build language Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

36. Natural, Visual Consequences • Emphasize words with a natural visual reaction • “Interestingly, those individuals who do not have auditory processing problems are often ‘auditory learners.’ These children do very well using the ABA approach, whereas those who are visual learners do not do as well…given this, one might suspect that many visual learners have auditory processing problems and that visual learners will do well with a visual communication/instruction approach.” Stephen M. Edelson, Ph.D, “Auditory Processing Problems in Autism” Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

37. Core Words & Natural Consequences • ‘go’ has a natural consequence that child can see • How would you respond to ‘Wednesday’ in a meaningful way? • ‘more’would have a similar visual consequence • “What color is this?” facilitates response ‘red’ • Conveniently, core words are the most powerful • Can be used in virtually any activity Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

38. Core Defined • Words that are common to peers of a similar age. They are common words used across all communication environments…which include structure words (e.g. want, more) that provide a framework for functional language use. (Banajee et.al., 2003) Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

39. Evidence Based Practice Despite evidence that nouns are not among core vocabulary used by preschoolers…clinicians typically select nouns representing foods and objects as first symbols when designing AAC systems. (Banajee, et. al., 2003) Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

40. a about after again all almost already also an and another ant any are aren't around as at away baby back bad bad ball bathroom be bean because before being bet better big bird birds 333 Most Frequently Occurring Preschool Words: The Marvin SamplingCompared with Banajee Sampling: all words present • doesn't • dog • doing • don't • done • door • down • drink • duck • eat • eating • else • even • everybody • everything • face • fall • find • finger • fire • first • five • fixed • fly • foot • for • from • found • get • gets • getting • girl • girls • give • go • goes • going • gonna • good • great • green • guys • had • hair • hand • hands • has • have • haven't • he • he's • her • head • hear • hello • help • here • here's • hi • high • hill • him • his • hold • home • horse • hot • house • how • huh • hum • I • I'll • I'm • if • in • inside • is • isn't • it • it's • juice • jump • jumped • jumping • just • kind • know • last • leaves • let • let's • lift • like • little • long • look • looking • lot • lunch • made • make • man • many • may • maybe • me • mean • messy • middle • mine • mom • mommy • more • most • move • much • must • my • myself • Name • name • named • need • never • new • next • nice • no • not • of • off • oh • other • ok • old • on • one • only • open • or • our • ours • out • over • paint • people • pet • name • pick • piece • play • please • push • put • ready • really • red • remember • ride • right • room • run • said • same • saw • say • see • she • she's • show • shut • side • sit • so • still • some • somebody • someone • something • sometimes • somewhere • stop • stuff • swing • tape • tell • than • that • that's • the • their • them • then • there • there's • there's • these • they • they'll • they're • thing • things • this • those • three • threw • through • time • to • today • together • too • top • toys • trees • try • trying • turn • turtles • two • um • up • us • use • used • very • wait • want • wanted • was • wasn't • watch • water • way • we • we'll • we're • well • went • were • what • what's • when • where • where's • which • while • who • who • whole • why • with • won't • would • ya • yes • yet • you • you'll • you're • your • yours • bite • black • blue • both • box • boy • bugs • but • buy • by • bye • call • came • can • can't • candy • car • catch • cause • chair • come • comes • cookie • corn • could • couldn't • cup • cut • day • did • didn't • different • do • does • doctor Christine A. Marvin, David R. Beukelman, Denise Bilyeu AAC, Vol. 10, Dec., 1994 Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

41. Toddler Vocabulary Arranged by Frequency Words Percentage I 9.5 No 8.5 Yes/yea 7.6 my 5.8 the 5.2 want 5.0 is 4.9 it 4.9 that 4.9 a 4.6 go 4.4 mine 3.8 you 3.2 what 3.1 on 2.8 in 2.7 here 2.7 more 2.6 out 2.4 off 2.3 some 2.3 help 2.1 all done/finished 1.0 96.3% 26 core words shown at left comprise 96.3 percent of the total words used by toddlers in this study Banajee et al. Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

42. LAMP Language Consideration: Core Words • Essential for expressive communication • Children with ASD tend not to spontaneously generalize concepts • Core words can be used in multiple contexts with varied meanings • Essential for ASD student to make language connections • Used to build flexibility with language meaning Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

43. Core Vocabulary has few Picture Producers • Fewer than 5 percent of all words used by toddlers are picture producers (Banajee, Dicarlo & Stricklin, AAC, 2003) • Concrete graphics can only be made for picture producers • More than 90 percent of core vocabulary words are not picture producers (Hill, Dissertation, Establishment of Performance Indices, 2001) Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

44. LAMP approach Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

45. Readiness to Learn • In preparation for learning child may need: • Calming: • rocking, brushing, massage, push/pull, oral motor (chewing, sucking), quiet sounds • Alerting: • swinging, rolling, dancing, oral motor (sour, crunchy). Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

46. Shared Focus • “Sensory modulation impairments represent a mismatch between the external contextual demands of the child’s environment and his or her internal characteristics (e.g. attention, emotion, sensory processing) and can impair the ability of the child with autism to sustain engagement with people or in activities.” Tomchek & Dunn, AJOT Vol. 61, Number 2 p. 190 Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

47. Shared Focus • Vary activities to find motivator • Use that motivator for language learning • Follow your student’s lead, give up control • Can be flexible and still meet goals • Keep student challenged by building on activity • Attend to their every move • Treat everything as intentional and purposeful • Be prepared to move Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

48. Shared Focus • Capture attention by doing surprising and novel things • Avoid predictability • Don’t be afraid to be Goofy • Goal is to engage student • Then teach language Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

49. Shared Focus • Use isolated interests as opportunity to teach language PASSION Not OBSESSION • Compliance vs. Communication • Stop asking “What” start asking “Which” • Stop Testing Start Teaching Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company

50. Taking advantage of Expected Behaviors • Mis-hits offer a profound learning opportunity • if met with natural consequences • Device exploration is OKAY • Will depend upon reinforcement Adapted from ‘LAMP: Language Acquisition through Motor Planning’ authored by John Halloran, MS, CCC-SLP and Mia Emerson, MS, CCC-SLP Prentke Romich Company