JCPSLP Vol 17 No 3 2015

demands relating to their children’s disabilities, as well as feelings relating to grief and loss (Marshell & Goldbart, 2008). These pressures may influence their capacity to engage with their child’s AAC intervention. Marshall and Goldbart (2008, p. 95) explained that: parents vary in how much and at what point(s) they prioritize communication over other issues, how involved and how ‘expert’ they want to be. They experience the insufficiency of time which makes it difficult to achieve all that they would like to and they may feel frustrated and guilty about their children’s difficulties and what they are able to offer them . Professionals must acknowledge these factors and tailor their expectations and approaches to align with individual families’ priorities and needs (Marshall & Goldbart, 2008). Communicative functions All too often caregivers and teams become focused on the communication of basic wants and needs such as mealtimes and toileting. While these types of messages are highly important, it is critical for children with CCN to be introduced to a wide range of communicative functions (Cress & Marvin, 2003; Light & McNaughton, 2014; Van Tatenhove, 1987), for example, commenting, arguing, requesting, protesting, greeting, asking questions, initiating, and many more. Intervention focusing on core vocabulary development not only provides the user with communicative power, but also ensures the modelling and use of a range of communicative functions. Prerequisites for AAC use An important myth to dispel is the presumption that a set of prerequisites must be met before AAC intervention can commence. For example, it was previously thought that children needed to demonstrate understanding through a hierarchy of symbol representation methods from real objects to photos before moving onto line drawings. However, Romski and Sevcik (2005) argued that no such hierarchy exists. Their assertion was backed up by research with typically developing children across three developmental stages (6, 9 and 12 months) which found no significant differences between or across participant responses to photos versus PCS symbols for choice making (Da Fonte & Taber-Doughty, 2010). Another misconception is that the child must demonstrate a certain level of cognitive skill before AAC is introduced. This assumption is dangerous as we do not approach language acquisition with typically developing children in this manner. Rather, we understand that we must speak to them for at least 12 months before they are likely to speak their first word back to us. Furthermore, we speak to them using many more words than they can say to us at any given time, while concurrently reducing the complexity of our language, enabling us to operate within their zone of proximal development (what the child is able to achieve and learn with the support of an adult; Vygotsky, 1978). This process of feeding language in before expecting output highlights the two key components of language acquisition and use, which are, receptive (what one understands) and expressive (what one is able to communicate). For all people learning language at any stage of life, language must be absorbed receptively before it will be expressed. For users of AAC, this process can be replicated through the use of their AAC system by their communication partners (Goossens, 1989; Porter, 2012).

It is also understood and accepted that typically developing children experiment and play with language in order to refine their language use (Cress & Marvin, 2003). Therefore, children with CCN must have access to comprehensive AAC systems in order to have the same opportunities for language play and exploration (Burkhart, 2008; Porter, 2012). Without AAC systems in place, children with CCN have limited capacity to demonstrate their ability and understanding (Romski & Sevcik, 2005). A person’s ability to communicate is strongly linked to cognitive development and also to their ability to demonstrate knowledge (Romski & Sevcik, 2005), making it essential for children with CCN to have access to AAC systems early on so they can experience these language learning opportunities. It is necessary to point out that while prerequisite skills do not exist before AAC systems can be implemented, foundation interaction skills do need to be addressed during EI. These skills support all communication interactions, including the use of AAC. They include the development of cause and effect, joint attention, intentional behaviours, shared enjoyment, and receptive language skills (Blackstone, 1999). Experts interviewed on this topic reported placing particular emphasis on making interactions engaging for children, using a range of AAC tools concurrently, and focusing their interventions on the use of core vocabulary (Blackstone, 1999). For some children, concurrent operational skill development also needs to take place in order to enable functional and independent long-term use of AAC systems. For example, those with motor impairments may need exposure to switch skill development in order to compensate for their physical disabilities. A review of studies focusing on technology use with infants and young children between 1980 and 2004 revealed 12 studies that demonstrated strong evidence for teaching switch activation successfully to children under 1 year of age with a variety of diagnoses and cognitive abilities (Campbell, Milbourne, Dugan, & Wilcox, 2006). Guidelines for AAC intervention The following section provides suggestions for where to start with AAC intervention for children under 5 of age. 1. Follow language progression models of typically developing children by targeting appropriate language levels within intervention. As discussed above, the language development of typically developing children is supported by a significant amount of receptive language input, accompanied by adult support within the child’s zone of proximal development. Opportunities to use, explore and play with language are reinforced by communication partners attributing meaning to children’s communication attempts. For children requiring AAC, it is essential that these same foundations and opportunities are provided, and that we use models of typical language progression to guide intervention (Burkhart, 2008; Cress & Marvin, 2003; Light & Drager, 2007; Porter, 2012; Van Tatenhove, 1987). 2. Focus on highly motivating interactions to teach the power of communication. Implementing AAC in the context of highly motivating interactions is critical (Blackstone, 1999; Burkhart, 2008;

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JCPSLP Volume 17, Number 3 2015

Journal of Clinical Practice in Speech-Language Pathology