Children with little or no speech (augmentative and alternative communication) can now be supported by a wide range of communication aids, but much still depends on funding

Augmentative and Alternative Communication (AAC) is the umbrella term used to describe the full range of communication methods that can be used to supplement or substitute for ‘normal’ speech or writing when these are impaired or absent. The term encompasses everything from gestures and signing, to aids, which can be low-tech (such as picture boards) or high-tech (employing the latest technology). Impaired communication or speech loss can result from a range of conditions, including Down’s syndrome, autistic spectrum disorders (ASD), acquired brain injury, cerebral palsies, hearing impairment and learning disability.

While exact numbers of people who need AAC are not known, research carried out in 2007 by Scope as part of its No Voice, No Choice campaign estimated that 600,000 people in the UK would benefit from it, including 106,000 young people aged between five and 18. However, as the researchers note: ‘Whilst these figures give an indication of the overall level of need; there are no national statistics on what proportion of this population are getting their communication needs met.’

So what solutions are available and what do we know about current provision? Communication aids are usually split into two broad groups: unaided and aided, with the aids sub-divided into low-tech and high-tech. There is an obvious risk in labelling aided AAC systems in this way, in that it could suggest that some are better than others. This is not the case: as with much technology, there is no point in using high-tech solutions if low-tech resources will do the job. Most of us have learnt this lesson the hard way when a high-tech device has let us down in a situation where the low-tech solution would have been more than adequate.

Deciding which form of AAC a child needs requires a full and ongoing assessment, as the child’s needs are likely to be complex and may change over time. Assessment should involve family members as well as teaching and support staff, as the system chosen is likely to be used at home as well as in school. If the child’s needs are complex, it is best if a qualified and experienced professional carries out the assessment.

Where the child’s communication needs are not so severe it may be that an unaided or low-tech system to complement ‘normal’ speech will suffice. Many mainstream schools with units catering for children with speech, language and communication needs support spoken English with either one of the established signing systems (of which more later), or a system of objects, pictures or symbols. For example, a range of objects might be used to indicate what is going to happen next, such as a paintbrush to signify art or a triangle for music. These are sometimes referred to as ‘objects of reference’. Photographs are used instead of real objects in some instances, such as to show the items on a lunchtime menu. Sometimes line drawings or symbols might replace images, as they do in everyday life where it is critical that everyone understands what is being said, as in the warning signs we see on the roads.

British Sign Language (BSL) is probably the best known of the established signing systems. Although BSL is now familiar to most people through its use in signed performances and on television, its widespread adoption and development are relatively recent. The British Deaf Association’s Dictionary of British Sign Language was not published until 1992 and BSL was not recognised as an official British language until 2003. The exact number of people in the UK who use BSL as their first language is not known and common estimates range between 30,000 and 70,000.

BSL is different from other national sign languages because it is a visual-gestural language with its own grammar, syntax and dialects. Other signing systems draw on BSL, but they do not have the status or structure of a language. While BSL is used almost exclusively within some sections of the deaf community, it is these other signing systems that are used to complement spoken English in many schools where children’s speech, language and communication needs are due to causes other than deafness. There are four main signing systems that you are likely to come across.

Signed English, based on BSL, emerged in the 1980s in response to pressure for the use of sign in the education of deaf children. It follows the word order of spoken English and uses additional signs and finger spelling to convey what is being said. Originally developed for use within schools for deaf children, it is now also used with children and adults who have impaired speech and language. Signed English has a sign for every word and is regulated by the Working Party on Signed English.

Makaton was first developed in 1972 in Surrey as a project to teach sign language to deaf adults with learning disabilities and is now especially popular in early years settings, where it is used with children with delayed speech. Today it is an internationally recognised communication system, used in more than 40 countries. Makaton uses signs and symbols to support spoken and written English. Based on BSL, it uses a carefully selected core vocabulary (approximately 450 words/signs) structured into graded stages of increasing complexity. This core vocabulary can be combined to form short phrases and sentences and can be used in combination with other alternative communication tools.

  • Paget Gorman Signed Speech

Paget Gorman Signed Speech was originated by Sir Richard Paget in the 1930s and developed by Grace Paget and Dr Pierre Gorman after Sir Richard’s death in 1955. It consists of a large vocabulary of approximately 4,000 words/signs, extended through the use of affixes to more than 50,000 words. Wherever possible, words are grouped together around a series of Basic Signs. Each word in a group uses the Basic Sign with a gesture that identifies the specific word. Signs are presented in the same sequence as the words in the spoken phrase or sentence. Paget Gorman is primarily used for people with specific speech disorders not related to learning disabilities. A simplified version is used with young children.

Signalong emerged in the 1980s when a group of practitioners wanted a signing system that was more flexible than Makaton. Signalong is a sign-supporting system: it requires you to speak as you sign. Signalong uses unaltered BSL signs wherever possible and is loosely modelled on the structure of the Derbyshire Language Scheme. Phase 1 of Signalong was first published in April 1992. Since then the authors have added to the core vocabulary, now available in four manuals, and published additional resources covering educational and vocational topics. Signalong is now widely used in the UK and Europe.

Many AAC systems use symbols as well as signs. Some are specific to a particular signing system, such as Makaton, while others have been developed independently. At an elementary level, symbols can be used to reinforce speech or signs, or to supplement written text.

A small number of symbol systems besides Makaton are now well established and widely used. These include Widgit Literacy Symbols (previously known as Rebus) and Picture Communication Symbols (PCS: also referred to as Boardmaker Symbols and not to be confused with PECS, the Picture Exchange Communication System). Signalong doesn’t have its own symbol set but is working closely with Widgit to match its signs to WLS. As Signalong explained earlier this year: ‘We have always been clear that our core expertise is in sign-supported communication. While we strongly promote the Total Communication approach [an approach to deaf education that aims to make use of a number of modes of communication, depending on the particular needs and abilities of the child], we have always preferred to work with others who have special skills in other formats rather than introduce unnecessary competition.’

WLS and PCS have much larger vocabularies than other symbol systems and include a range of grammatical elements. This means they are inherently more flexible and symbols can be combined to form sentences and phrases. WLS, for instance, consists of 7,000 images in colour and black-and-white, covering a vocabulary of over 20,000 words.

Symbol systems have long been an important tool for aiding communication but it is computers that have really transformed their use. Bespoke and mainstream software programs have simplified the creation of symbols-based resources and made the translation of text into symbols and vice versa far easier.

Boardmaker from the American company Mayer-Johnson is among the best known software package for creating printed symbol-based resources. The program features more than 4,500 Picture Communication Symbols in colour and black-and-white, sample boards and templates. A new feature of the latest version of Boardmaker is the Symbolate button, which automatically inserts symbols alongside text as the user types. Boardmaker Plus builds on these features by allowing the user to create on-screen activities such as audio, animations and video.

Widgit produces another popular range of symbol-based software, which includes Writing with Symbols 2000, a talking word processor that also automatically inserts symbols as you type. Other features include the generation of grids to make teaching and communication resources, and the on-screen grids to be used as an aid to writing. Widgit’s other products include the Communicate suite, which consists of a desktop publishing program (Communicate: In Print, now available as Communicate: In Print 2), a program for generating early learning activities (Communicate: By Choice) and, most recently, a word and symbol processor for emergent writers (Communicate: SymWriter).

Although a number of symbol-based systems exist, the differences are subtle and there is extensive collaboration between the producers. In 2007 Widgit Software and Mayer-Johnson announced they were teaming up to bring both companies’ products to one another’s home markets.

Widgit says its own system (WLS) is designed to support literacy and written information, while Picture Communication Symbols are designed for face-to-face communication, as in communication aids for people with no speech. In the UK, both systems are also available through Inclusive Technology. Makaton is also now compatible with Communicate in Print, Symwriter (version 1.1.6444) and Writing with Symbols. As well as the established symbol sets, users of both WLS and PCS can import their own drawings and photographs. PCS can also be used in the Clicker software produced by Crick Software, which is popular in both mainstream and special schools.

High-tech aids
Children who have little or no speech might benefit from using a dedicated Voice Output Communication Aid (VOCA) as well as sign and symbol systems. These enable the child to communicate in a setting where signing or the use of symbols is not an option,  extending the child’s independence.

VOCAs range from single-message devices to those capable of storing thousands of messages. Understandably, the more complex the device the higher the price, which is why at this level, above all others, professional assessment is essential. Factors to be considered in choosing a VOCA include the setting in which it will be used, the cognitive ability of the user, how the device will be accessed, appropriate mounting, whether the device will use symbols or text (or both), the type of display (static or dynamic), training, support and, of course, cost.

Scope’s No Voice, No Choice campaign produces a useful Communication Aids Journey Map, which shows the varied — and at times tortuous — routes to acquiring a VOCA. It can be downloaded from Help in choosing an appropriate device can be provided by a number of centres, including the ACE Advisory Trust, the ACE Centre North, CENMAC, AbilityNet and the CALL Centre in Edinburgh. Most centres have a loan bank of equipment, which means children can try out devices before deciding which one to opt for. With the rapid changes in technology it is no surprise that the choice of communication devices has mushroomed in recent years. ACE North’s database of VOCAs includes more than 120 devices although, thankfully, there are relatively few key suppliers. Major names include DynaVox (Mayer Johnson’s sister company), Liberator (part of the Prentke Romich group), AMDi, AbleNet, Attainment Company, Toby Churchill and Techcess.

All VOCAs work by allowing the user to trigger pre-recorded messages, either directly — by touching the relevant text, image or symbol — or indirectly, through scanning and the use of switches. Devices that offer more stored messages than can be reasonably accommodated on the screen do so by storing them in ‘levels’. AMDi’s Smart/128, for example, has a maximum of 128 messages per level and six levels, which means it can store up to 768 messages of 2.25 seconds in length. Optional interchangeable keyguards on a system like this mean that a single user can choose between 4, 8, 16, 32 and 128 ‘buttons’ by grouping locations together. This means the device’s set-up can be changed depending on the user’s ability or the context in which it is being used. On some multi-level VOCAs, it is necessary to change the overlay to access a different level, while on those with ‘dynamic’ pages the level can be changed by pressing a button.

While dedicated aids simply provide speech output non-dedicated or ‘open’ devices combine speech output with other features. These might include wi-fi connectivity giving access to the typical features of a laptop computer, including email and the internet, or environmental control systems (ECS) that allow the user to turn on the lights or draw the curtains.

Funding While technical advances in communication aids have created impressive new opportunities for their users, they have also highlighted a paradox all too familiar to those who work in the field of special educational needs. While everyone will happily subscribe to the view that society should do all it can help individuals realise their potential, there is a cost associated with making each opportunity a reality. Scope’s 2007 Communication Aids Survey found that the average cost of a high-tech aid was £5,800, with 47 per cent of respondents’ aids costing over £5,000. As the survey report noted: ‘The prohibitively high cost of AAC equipment, not including the ongoing costs of insuring, servicing and repairing equipment, means that disabled people on low incomes who cannot get equipment funded by statutory sources are often left without a voice. Significant numbers of people are still told by statutory agencies to ask charities to fund AAC equipment that should be provided

as of right.’

Rectifying this situation is at the heart of the campaigning efforts of Scope and other organisations concerned about provision for those with speech, language and communication needs (SLCN). Between 2002 and 2005-06, the Department for Education and Skills provided £5m a year through the Communication Aids Project (CAP) to help meet some of the demand for communication aids.

During this time, equipment was provided for more than 4,100 children and young people whose needs had not been met locally. Following CAP’s closure, campaigners lobbied for replacement funding.

Understandably, many organisations and individuals raised this issue in the course of the recent Bercow Review. In its final report, the review panel recommended ‘appropriate commissioning, guidance and inspection arrangements should be in place by April 2010 with funding streams identified and mandated across government, including the Department of Health and the Department for Children, Schools and Families’. It also proposed an immediate injection of capital for purchasing, monitoring and measuring the supply of equipment and services, and of revenue funding to avoid the imminent closure of both the ACE Centres. The government’s long-awaited Child Health Strategy, due to be published in the autumn, is expected to contain detailed proposals relating to this.

Meanwhile, Scope launched the second phase of its research project in August, ‘aiming to find out the true scale of the current crisis affecting communication equipment users’.

Its new survey is targeted at professionals and statutory agents, such as speech and language therapists, as well as people involved in the commissioning, assessment, provision and support of AAC services.

Ruth Scott, head of policy at Scope, said: ‘The UK is facing a real communication aid crisis — thousands of disabled people are being denied their right to communicate because they cannot get access to the equipment and support they need. It is essential that professionals and statutory agents are given the opportunity to discuss their experiences of providing AAC services and suggest ways of improving the current situation. This will help us achieve our goal of ensuring that those with communication impairments are able to speak for themselves.’

Scope is calling for any professionals who are concerned with disabled people’s use of AAC, including those working for statutory agencies, to get involved in the research project.

For more details go to