OT Belongs in AAC
Occupational therapists (OTs) should be involved in the fitting, trialing, and training of Augmentative and Alternative Communication (AAC) devices. What? You heard that right. But let’s take a step back first… A lot goes into the process of obtaining an AAC device for an individual, including deciding what type of AAC device is most appropriate and functional, practicing its use with the individual and making adjustments as needed, and training the individual and any important friends and family on how to incorporate its use into everyday activities. With that process comes many barriers, including the complexity of devices, social acceptance of using a device for communication and readiness to learn by the individual, and inconsistent follow-up procedures and prescription review processes, making the entirety quite long and somewhat daunting (Lindsay, 2010). With great importance laying in the final decision of this process, it only makes sense to pair speech language pathologists (SLPs) with OTs to ensure the most fitting, functional, and motivating AAC device is found (and adapted if necessary) at the end of this journey.
In reality, OTs are and should already be integrating AAC use into their everyday practice. According to the 2004 amendments to the Assistive Technology Act of 1998, assistive technology devices are “any item, piece of equipment or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities.” This includes products as simple as a pencil grip to a commercially bought AAC device. Assistive technology services are “any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device” (Public Law 108-364.118). Because assistive technology falls under the OT scope of practice, OTs can and should be advocating for their role in AAC device services. These devices and more are being utilized and implemented into daily occupations by those receiving occupational therapy services to improve their occupational engagement and performance (can you say the word “occupation” three time fast?). From an OT’s perspective, the goal of using an AAC device is to increase independence and participation in meaningful occupations, including those tied to work or school, leisure, and social participation.
In order to integrate the use of an AAC device into daily occupations, the individual first needs the skills to use the device in a non-restricted environment, or while not engaging in other activities. A few of the skills that may be needed to functionally use an AAC device include visual scanning and processing skills (for letter recognition, word recognition, and accurate processing of visual input), physical motor strength and planning skills (for balance to sit upright to use device, positioning the head to access eye-gaze, and targeted reach for direct select options), and social rules of communication (for initiating conversations, sequencing responses, and attending to conversations). Many individuals who are looking to use an AAC device as a means of communication are also diagnosed with co-morbidities, which may include physical disabilities affecting upper extremity active range of motion (or how much you can independently and accurately move your arms and hands), vision and visual processing difficulties, and/or sensory processing issues, making fitting for a communication device that much more challenging. When OTs are involved in the AAC process, they can use their knowledge and skills to help target some of these difficulties to utilizing an AAC device. Below is a very short list of skills OTs can target to ensure individuals are most prepared to integrate their AAC device into everyday occupations:
Physical: seating (adapting seating options as needed to establish sound base of support and solid balance so the individual can focus on other skills), positioning (modifying and supporting the position of the individual’s eyes, head, arms, and hands and all access methods and equipment to provide the most successful opportunities for easy use and function), and strength (building strength and range of motion in the upper extremities to allow functional control and targeted reach to all access methods).
Sensory: sensory processing (many individuals experience sensory processing difficulties which may interfere with long appointment times to set up, trial, and modify AAC devices as well as the positioning and access method of the device; OTs are specially educated on utilizing sensory strategies to ease the individual during the session as well as identify potential sensory issues with the entire AAC set up), and visual processing (developing necessary skills such as maintaining visual attention to device, divided visual attention between the device and the concurrent occupation, visual targeting used for eye-gaze devices, visual motor skills to visually identify where and how to interact with the device with motor planning skills to reach your finger (or other access method) to the desired button or area, and visual processing skills to comprehend what the individual is looking at).
Incorporating into functional activities: modifications (using activity analysis, knowledge of the person, their environment, and the device, and creative thinking to modify the individual, the device, or the activity being completed to improve performance skills), caregiver education (educating family, friends, and others on the use and integration of the device to allow for better buy-in, increased support to utilize the device, and more functional use during activities), and practice in real situations with assistance from OTs to learn how to balance engaging with the AAC device and in meaningful occupations.
Alt text/ID: A teenaged male student is seated at a table completing a visual and fine motor task with crayons. The student is wearing noise-cancelling headphones and has his SGD in reach.
As a recent graduate, I am very grateful to be in the minority of occupational therapists who have experience collaborating with SLPs on AAC device implementation. Not only did it give me a great outlook on the importance of collaboration in health care settings, but it showed me the importance of OTs being more involved in communication (a key to improving occupational engagement!). Following is a very brief outline of how I was involved in the AAC process in my past experience. I share my experiences not to state that this is the one and best way for OTs to be involved with AAC, but rather to show others how OTs can be involved and begin conversations about the best way for OTs to be involved. Once an individual was referred for an AAC evaluation, both an SLP and an OT would be scheduled to complete a 1-2 session evaluation, which included chart reviewing the individual, discussing their desired outcomes and goals for the device use, and evaluating their physical, visual, verbal, social, cognitive, and attention skills as well as readiness to learn. Once all data had been collected, the SLP and the OT collaborated to decide what they believed to be the most fitting device (and language program) for the individual. From there, trialing sessions are scheduled with the individual, SLP, OT, and a representative from the chosen AAC device company if able to begin testing the fit of the device for the individual. These sessions are spent trying out the device and any access methods, modifying the individual, device, or environment for best use, and beginning to practice its use in a restrictive environment. This is a great time for any questions from the individual or their family to be answered as the session included a representative to answer any questions regarding the physical device, an SLP with specific knowledge in the language program chosen for the device, and an OT with specific knowledge in the positioning, use, and implementation of the device into everyday routines. Once a device was identified and fit for the individual, they entered the training phase, which included a series of OT/SLP sessions for the individual to begin practicing how to use the device and incorporating it into functional activities. This is also a great time to see long-term effects of the device use and any modifications needed to be made.
As you can tell from this brief outline of the process, choosing an AAC device and incorporating it into everyday use takes a team effort; and the American Occupational Therapy Association agrees, stating that “assistive technology is best provided through a collaborative and interdisciplinary approach” (AOTA, 2016). Occupational therapists need to be more involved in the AAC device acquisition process to ensure a more holistic approach. The way an individual communicates is so individualized to the person that it takes a team approach to really ensure appropriate fitting, buy in, and use of an AAC device. OTs are specialized in this holistic approach through our PEO model of practice. The PEO model, which is an essential theory to the practice of occupational therapy, points out the unique relationship between the Person, their Environment, and Occupations, or meaningful daily activities. OTs are educated and skilled to consistently evaluate, analyse, and modify the relationship between these three entities. By incorporating an OT into the AAC process, they can use their expertise to evaluate and influence the relationship between an individual, their environment, and their AAC device to improve occupational engagement, role competence, and overall quality of life.
American Occupational Therapy Association (2016). Assistive technology and occupational performance. American Journal of Occupational Therapy, 70, 7012410030p1-7012410030p9. http://dx.doi.org/10.5014/ajot.2016706S02
Assistive Technology Act of 2004, Pub. L. 108-364.118 Stat. 1707.
Lindsay, Sally (2010). Perceptions of Health Care Workers Prescribing Augmentative and Alternative Communication Devices to Children. Disability and Rehabilitation: Assistive Technology, 5(3), 209–222, doi:10.3109/17483101003718195.
United States (2012). Assistive Technology Act of 1998.
Kylee Hooper is one of the most passionate OTs with an interest in AAC I have ever had the pleasure to work with. She came to Bridgeway Academy with a wealth of experience and ideas about how to work towards functional and long-term communication with life and vocational skills as the settings and goals. I’m proud to call her my colleague.