Pediatric Assistive Technology, AAC Devices, Keyboard Aids

What is pediatric assistive technology?

Assistive technology is a term that covers assistive, adaptive and rehabilitative devices for pediatrics with disabilities. It also includes the process used in selecting, locating and using them. By enabling pediatrics to perform tasks they were unable to accomplish before, or had great difficulty doing so, it encourages self-reliance and enhanced independence.

Augmentative and alternative communication (AAC) is a term that includes the communication methods used to add to or replace speech or writing for those with impairments in producing or comprehending the spoken or written language. An AAC aid is any “device, either electronic or non-electronic, that is used to transmit or receive messages.” AAC can be a temporary aid, or a permanent addition to someone’s communication. AAC systems have two categories: unaided communication using no equipment and includes signing and body language, while the aided approach uses external tools. Aided communication methods range from paper and pencil, to communication books or boards, to devices that produce voice and/or written output.

Who benefits from pediatric assistive technology?

To enable pediatrics with disabilities to use modern touch screen mobile computers such as the iPad, iPhone, and iPod touch, assistive technology devices have been created, bringing touch screen technology to those who were previously unable to use it. Those making use of AAC include individuals with a variety of congenital conditions, such as autism, cerebral palsy or intellectual disability. Acquired conditions for AAC users include amyotrophic lateral sclerosis, traumatic brain injury and aphasia. AAC users typically utilize a variety of aided and unaided communication strategies.

Individuals with cerebral palsy may require AAC support for communication. When accessing an AAC device, gross and fine motor challenges are often of particular concern. Appropriate seating and positioning need to be maintained to ensure optimal stability and movement, and extensive motor training and practice may be required to develop proper AAC access and use.

Pediatrics with intellectual impairments face challenges in developing communication skills. These include problems with the transfer of learned skills into daily activities. AAC intervention for this group stresses partner training along with opportunities for integrated, natural communication. Use of AAC techniques with children with this impairment can enhance communications skills, choice-making, and increase participation in activities. AAC approaches can be used as part of teaching functional communication skills to non-speaking children for the purpose of exerting independence, taking control or informing preferences.

Children with autism tend to have strong visual processing skills, which make them good candidates for an AAC approach. AAC intervention in this group is directed towards the social and linguistic abilities of the child. It includes providing the child with a solid means of communication, and facilitating the development of interactional skills. AAC systems for autistic children generally begin with communication boards, and/or object or picture exchanges.

A child with developmental verbal dyspraxia, also known as childhood apraxia of speech, often experiences large amounts of frustration. Therefore, AAC can be a strategy to support communication alongside traditional speech therapy to improve speech production. Gestures or manual signs are frequently introduced to these children, and can include the use of fingerspelling alongside speech. Aided AAC systems typically include speech generating devices and communication boards. A multimodal approach may be used with several AAC approaches introduced, so the child can take advantage of the most effective method for their particular situation.

Severe motor speech disorders can be the result of a traumatic brain injury. AAC intervention may involve identifying communication signals, simplifying reliable yes/no responses, and the ability to answer questions and express basic needs. Difficulties with memory and learning new skills may influence AAC choices.

Children with aphasia often communicate using a combination of gestures, speech and aided communication. The proportion of each may change as they recover. They may use AAC interventions such as communication and memory books, written words, photography, drawing, speech generating devices and keyboards, depending on their cognitive and language skills.

Those with amyotrophic lateral sclerosis (ALS) may use a procedure known as voice banking. This procedure digitally records words and phrases while they are still able to do so. Later, they can add the recording to a communication device. AAC systems that are used typically change over time, depending on the severity of their speech impairment, communication needs and physical status. The use of augmentative communication strategies generally begin when the speaking rate drops to 100 words per minute. In the beginning, AAC may consist of using an alphabet board to cue them to the first letter of the word being spoken. Later, AAC often becomes the main communicative method. Writing-based systems are preferred to graphic symbols, since cognition and vision are typically unaffected in ALS. A head mouse or eye tracking access device may be used initially, in the spinal form of ALS. Handwriting and typing on keyboard-style devices tend to be the first forms of AAC, in the bulbar form of ALS. Access methods may change as the disease progresses.

Individuals with multiple sclerosis (MS) vary widely in their abilities, therefore, the methods of access to AAC technology are adapted accordingly. Visual impairments are common in MS, so it may be necessary to use large-print text, auditory scanning systems or synthetic speech feedback that play back words and letters as they are typed.

What types of assistive technology devices are available?

Low-tech communication aids are those that do not need batteries, electricity or electronics. These are often very simple communication boards or books. To communicate a message, the user selects letters, words, phrases, symbols and/or pictures. They may indicate the appropriate message with a body part, eye-gaze direction, light pointer, or a head/mouth stick, depending on physical abilities and limitations. Or, they may indicate yes or no while a listener scans through possible options.

High-tech AAC aids permit the storage and retrieval of electronic messages. They are known as speech generating devices, or voice output communication aids. A device’s speech output may be digitized and/or synthesized. Digitized systems play recorded words or phrases and are generally more understandable. Synthesized speech uses text-to-speech software that can be harder to understand, but permits the user to spell words and speak messages. High-tech devices vary in the amount of information they can store, as well as their weight, size and portability.

The types of selection methods available for those with communication impairments have dramatically increased due to recent technological advances. In “Direct Selection”, the selection is made by pointing to the desired symbol using a finger or an alternative pointer, such as a head stick, eye gaze, or head- or eye-controlled mouse. In “Indirect Selection”, items displayed for selection are scanned. The scanning may be visual, using indicators such as highlighting, lights, and contrasting borders or it may be auditory using spoken prompts. There are three main selection control techniques in scanning. In “automatic scanning”, the scan proceeds at a pre-determined speed until the user selects an item. In “inverse scanning”, the switch is held down to advance the scan, and released to choose the item. In “step scanning”, the AAC user has one switch to move the indicator through the items, and another to select the item.

The way pictures, words, phrases, and sentences are displayed on the communication system refers to vocabulary organization. Communication books and devices are often presented in a grid format. The vocabulary items displayed within them may be organized by spoken word order, frequency of usage, category, or specific activities. Visual scene displays are similar to activity displays in that they contain vocabulary that is associated with specific activities or routines. Research suggests that visual scene displays are easier than grid displays for young children to learn and use.

AAC is typically slower than speech, with users generally producing 8-10 words per minute. Rate enhancement strategies can increase the user’s rate to around 12-15 words per minute, and there are two main options for increasing the rate of communication: encoding and prediction. Encoding is a technique allowing the user to produce an entire word, sentence or phrase by using only one or two activations of their AAC system. Prediction is a strategy that enables the device to attempt to predict the letter, word or phrase being written by the user. Word prediction software may determine the words predicted based on their frequency in language, past choices of the user, association with other words or grammatical suitability.

How do I choose the right device for my child?

An evaluation of an individual’s abilities, limitations and communications needs is necessary to select appropriate AAC techniques. AAC evaluations are often conducted by specialized teams which may include a speech-language pathologist, occupational therapist, rehabilitation engineer, physiotherapist, social worker and a physician. Users, family members and teachers are also key members of the decision making team. A user’s motor abilities, communication skills and needs, cognition and vision are assessed in order to determine the most appropriate match to a communication system. It is important that the AAC systems selected also reflect the priorities of the individual and their family.

Rehabmart carries a large assortment of high quality assistive technology products from well-respected vendors that include Sammons Preston, Ablenet, Enabling Devices, Adaptivation and the Attainment Company.

Hulet Smith, OT
Rehabmart Co-Founder & CEO

lb