A WORKING MODEL OF AAC INTERVENTION IN THE COMMUNITY

Any system that attempts to compensate (either temporarily or permanently) for the impairment and disability patterns of individuals with severe expressive communication disorders is Augmentative and Alternative Communication (AAC). It is imperative that AAC utilizes individual residual communication disabilities to the full extent (ASHA 1991). AAC systems can be used by anyone irrespective of age, socioeconomic status and social backgrounds. However, the system itself may have to be culture specific, individual specific and probably language specific.

Until recently in Pakistan, in the management of speech language and communication disorders with children with disability, undue emphasis was given on oral speech language in spite of awareness that verbal language may not develop in some individuals.

There has been a shift from traditional methods of speech language therapy for children with disability. The outlook has changed from an individual centered therapy to a more holistic approach involving the family and community.

In the sphere of individuals with disabilities, a particularly vulnerable and neglected group is those with communication impairments due to their inability to articulate their needs, feelings and rights. Amongst this group there is a significant number of individuals with limited or minimal speech abilities. One of the reasons for this is the fact that the individuals with speech and communication disabilities in India are not exposed to Augmentative and Alternative Communication (AAC) strategies as it is still a new field of expertise in Pakistan. Furthermore, programs to address the communication needs of these individuals with disability are limited, scanty and exist only in certain pockets of major urban towns like Karachi, Lahore, Islamabad & Peshawar.

In this scenario the dilemma facing AAC service delivery in community-based rehabilitation is multifactorial. Ideally, individuals should at least receive services at a clinic which provides the clinical expertise needed to effectively evaluate communication needs, prescribe an appropriate system, and provide necessary training and support to the user and his or her communication partners. The medical model in which professionals take responsibility for intervention decisions is still prevalent. However there are relatively few specialists who can provide these services, especially in rural communities. Distance, lack of funding, inadequate transportation, and the frequency of required training sessions make it difficult or even impossible for clients to come to the clinic for these services or for an institution or clinician to provide services in rural areas. Also where service has been initiated, sustainability, ongoing follow up and support have been difficult in spite of good intentions of some non-governmental organizations.

In view of the fact that individuals with little or no speech have a right to communicate, have the same communication needs as others and are capable it is imperative that measures to boost Services in Augmentative and Alternative Communication be undertaken. Learning to use Augmentative Alternative Communication (AAC) devices requires extensive training and support from a speech therapist and communication partners. AAC devices are often abandoned by users due to mismatches between skills, expectations, and device capabilities.

In light of the service availability in Pakistan, any initiative towards AAC service provision should adopt a trans-disciplinary approach. This implies the crossing of traditional disciplinary boundaries, where professionals can work together, share their expertise and exchange certain roles and responsibilities to develop new ideas and strategies for service provision. Professionals delivering AAC intervention need to be play the role of trainer, prescriber/negotiator and collaborator.

Multiskilling is one effective way of cross training professional or support workers. It would mean creating knowledge base, and developing skills for imparting training. It would also consider the role transition in the light of socio-cultural factors. Consequently it will mean multiskilling of primary care workers, volunteers, parents or family members of the speech and language impaired individuals who are often the only and constant source of support and assistance.

Consideration of these aspects while developing a working model of AAC intervention in the community would mean the use of an asset based rather than a need based approach. This approach would ensure long term sustainable models of imparting intervention by gradually building on the strengths of the community and building capacities at the individual, family and community level. Self-reliance and ability to develop sustainable support systems will be the hallmark of this model of training caregivers.

Communication is the essence of human existence. Every individual has the urge and potential to communicate. It is a well-known fact that 93% of human communication is through non-verbal means and speech accounts for only 7% (Borg, 2010) though the importance given is the contrary. This also implies that an individual with little or no speech can have a good quality of life if provided with nonverbal or augmentative and alternative means of communication.

In the case of individual with communication impairment, AAC is in fact a key to access learning, foster independence and establish healthy and sustained interactions with his environment. Therefore it is the responsibility of professionals to provide for AAC to realize the ultimate goal of rehabilitation, which is to maximize an individual‘s potential within the realms of his physiological limit.

In reality the course of AAC has been extremely slow and fragmented in Pakistan. Also, little is known or has been published about communication intervention and AAC in Pakistan. Education research in Pakistan has not been given sufficient importance.

Firstly awareness has been extremely limited both at the professional level and client level. Competency in AAC has been wanting, as there is no comprehensive training in AAC in personnel preparation programs. The Department of Special Education, University of Karachi is offering PGDip (leading to Master) in Speech-Language Pathology since 2002. The current syllabus has consistently included AAC course in third semester (see Table-1) but the depth of knowledge and skills acquired by students have been inconsistent. Individuals with greater interest seem to acquire better skills whereas for the rest it has been limited to an awareness and sensitization level. Therefore the implementation of AAC has been sporadic. Interviews with students frequently site the main difficulty being in knowing the process of implementation in AAC. Often the students are able to identify the need for AAC in children with communication difficulties but wary about introducing it and unsure of the strategies and process to be followed to ensure successful AAC intervention. Successful intervention of AAC has also been dampened by persistent myths about AAC and lack of conviction among families of potential AAC users.

Table 1: Course Outline of AACS 

Third Semester AUGMENTATIVE & ALTERNATIVE COMMUNICATION SYSTEMS 2+1 Credit Hours 2 Theory (60 Marks)) 1 Practical (40 Marks)   Unit 1: Overview of Augmentative Communication Systems 1.1         Terminology 1.2         Components: aids, symbols, techniques, and strategies 1.3         Access Methods 1.4         Message Storage and Retrieval Methods 1.5         Acceleration Techniques 1.6         Prediction Strategies   Unit 2: Classification of AAC 2.1 Aided/Unaided 2.2 Low technology / high technology 2.3 System components 2.4 Symbol sets-standardized and non-standardized 2.5 Selection of modes pertinent to various communication disorders 2.6 Merits, Demerits of various systems 2.7 Relevant research   Unit 3: The Assessment Process 3.1 Components of an Assessment 3.2 Considerations for Selection 3.3 Training and Follow Up 3.4 Positioning, Message needs, Modality of communication, initial vocabulary selection,             Reading, writing skills and future needs.   Unit 4: Features of AAC Devices 4.1 The AAC System 4.2 Electronic Communication Device Features 4.3 Electronic Communication Device Examples 4.4 Matching Systems to People   Unit 5: AAC Strategies for Children with Developmental Disabilities (message selection-              vocabulary, symbols, rate enhancement, small talk, storytelling etc).   5.1 The Decision to Implement AAC 5.2 Developmental Apraxia of Speech 5.3 Autism and Pervasive Developmental Disorders 5.4 Intellectual Disability Disorder

AAC requires active participation of communicative partners with lot of opportunities made available in the environment .As the main objective of AAC is establishing communication in children with limited communication skills, it is important that effort initiated should suit the individual needs and be applicable in the natural environments of the individual. This requires considerable skill in engineering environments, creating opportunities in the various communicative contexts for the child and facilitating use of AAC in realistic contexts. However this is the major thread lacking among professionals as hands on and practical training in AAC is either extremely limited or virtually non-existent.

Secondly training in AAC implementation has been limited to a few urban areas in Pakistan. Efforts of individual professionals or institutions has been isolated and a generalized thrust required for its development has been lacking due to persistence of myths about AAC, inadequate manpower resources, financial constraints, lack of indigenous culturally sensitive and appropriate materials and sustainability of initiatives undertaken and sometimes even reservations on the part of professionals to share knowledge. Implementation of AAC has not seen great successes because a medical model rather than a social model of implementation has been followed.

As a consequence, the current status of AAC in Pakistan is way behind the trends seen in developed countries. Keeping in mind the technological barriers that Pakistan is breaking across the world, it is time for reckoning as far as AAC is concerned. One of the solutions to make headway in service delivery of AAC is to adopt a trans-disciplinary approach and make training available to the members of the community who are relevant in the life of an individual with developmental disabilities. The Department of Special Education, University of Karachi has started conducting caregiver-training programs to generate manpower working in the field of rehabilitation. However there are no training programs for training members of the community and specifically caregivers in AAC.

Pakistan being a vast country, involvement of caregivers in rehabilitation is one assured way of service delivery in urban and rural areas as the supply of professionals is likely to be less than the demands. Caregivers are adults who opt for working in organizations and are often enthusiastic in acquiring skills and knowledge to contribute better. It is these attributes that make them suitable candidates for multiskilling and training in AAC. Multiskilling of caregivers is going to help hold the ideals of rehabilitation from crumbling into idealistic oblivion.

Given the present scenario of resources, the need of the hour is to develop and provide the much-needed impetus for development of efficient AAC service delivery systems. This would entail developing a generic AAC training program that will facilitate a trans-disciplinary action, reduce duplication and fragmentation of services and bring about uniformity, consistency and enforce practice guidelines based on sound scientific principles. Research undertaken in this perspective would set the trend for rehabilitation to be truly community based.