AUGMENTATIVE AND ALTERNATIVE COMMUNICATION (AAC) IN NEURODEVELOPMENTAL DISORDERS: A MINIREVIEW
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Acta Medica Mediterranea, 2018, 34: 1181
AUGMENTATIVE AND ALTERNATIVE COMMUNICATION (AAC) IN NEURODEVELOPMENTAL
DISORDERS: A MINIREVIEW
AGATA MALTESE1*, FRANCESCO CERRONI2*, PALMIRA ROMANO2, DANIELA RUSSO2,3, MARGHERITA SALERNO4, BEATRICE GALLAI5,
ROSA MAROTTA6, SERENA MARIANNA LAVANO6, FRANCESCO LAVANO6, GABRIELE TRIPI7,8
1
Department of Psychological, Pedagogical and Educational Sciences, University of Palermo, Italy - 2Clinic of Child and Adolescent
Neuropsychiatry, Department of Mental Health, Physical and Preventive Medicine, Università degli Studi della Campania “Luigi
Vanvitelli”, Italy - 3Centro di Riabilitazione La Filanda LARS; Sarno, Italy - 4Sciences for Mother and Child Health Promotion,
University of Palermo, Italy - 5Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy - 6Department of
Health Sciences, University “Magna Graecia”, Catanzaro, Italy - 7Department PROSAMI, University of Palermo, Italy - 8Childhood
Psychiatric Service for Neurodevelopmental Disorders, CH Chinon, France
*Equal contribute for Authorship
ABSTRACT
Children with neurodevelopmental disorders such as Autism Spectrum Disorders (ASD), cerebral palsy or severe motor speech
disorders may beneficiate of augmentative and alternative communication (AAC) systems that may improve the developing language
and the communication abilities. The term AAC tend to include each form of communication supplementing or replacing the natural
speech production.
Keywords: augmentative and alternative communication, devices with voice output, Functional Communication training.
DOI: 10.19193/0393-6384_2018_5_181
Received December 30, 2017; Accepted February 20, 2018
Historical background They were the first to use communication
tables with letters, symbols, images. Later, to be
About 60 years ago, the inability to express understood also by people outside the family envi-
themselves with oral language has been considered ronment, he traced gestures in the air as if to write
as a natural symptom of a disease and indicated its words. Until a colleague tired of seeing him gestic-
presence, worsening and severity. There was no ulate in the air, he brought him an alphabetic table,
attempt to reduce the symptom and the goal of a table that gave him a new life(1-5).
improving the quality of life was absolutely not Between the ‘50s and ‘70s the progress of
taken into consideration. When some people, some medical and rehabilitative care led to an increase in
years later, felt this need, the rehabilitative efforts cases of children surviving premature births and of
went in the direction of the restoration of oral lan- adults who survived strokes, traumas and illnesses.
guage with often frustrating results(1-5). For many of them they were posthumous, situations
The first seeds for the future of augmentative of severe motor disability and impossibility to com-
and alternative communication (AAC). were municate through oral language. Few rehabilitators,
thrown in the 50s of the twenty century. Pioneers in going against the current, began to suggest augmen-
this field were people with severe communication tative ways to promote communication and began
deficits and those who assisted them. to spread the results of these experiences.1182 Agata Maltese, Francesco Cerroni et Al
The first documented cases referred to aphasic continued to argue that the use of different ways
subjects or affected by Cerebral Palsy. However, it would have been to the detriment of a possible
must be considered that, despite these exceptions, emergence of oral language. This prejudice is still
the rehabilitators continued to favor an oral present, as already mentioned, not only in many
approach and continued to not recommend sign lan- parents but also in many rehabilitation workers.
guage to the deaf, who even used it in their commu- Since the beginning of the 1980s, cases of people
nities(1-5). began to be published which, through communica-
Between 1960 and 1970 it began to no longer tion programs, succeeded in improving the quality
hide disability. John Kennedy and other famous of their lives.
people began to make known that they had relatives However, these programs were always imple-
with communicative deficits, which led to a first mented after the failure of traditional forms of treat-
initial acceptance of disability and, therefore, of ment of ling. In 1980 and 1982, the first interna-
communication modes other than oral language. tional conferences on “Non-oral communication”
The deaf communities anticipated this process of were held in Toronto. During the 1982 conference
legitimizing an alternative language, demanding the the decision was made to create an organization
right to be educated using sign language. According exclusively dedicated to this clinical field. In 1983
to some, the studies on the learning of graphic sym- professionals from 25 countries in the world found-
bols by chimpanzees would have paved the way to ed the International Society for Augmentative and
the idea of proposing graphic symbols to people Alternative Communication (ISAAC) in New
with serious communication and motor deficits. Lansing (Michigan - USA) and decided to call the
The major prognostic abilities compared to a func- area of interest AAC. Here it was recommended to
tional use of oral language have certainly con- use the term derived from the verb “to Augment”,
tributed to stop true therapeutic hurdles by speech ie increase, in all languages where this was possi-
therapists and to justify different approaches(6-19). ble. The term “Augmentative” had to clarify how
At the University Hospital of Jowa City from the goal of the intervention should be to increase
1964 to 1974 a first program of AAC. aimed at chil- existing communication skills. At that time, the
dren with Infant Cerebral Palsy. In the meantime, Personal Computer became a reality for people with
the idea was also developed that technology could communicative disabilities, and so did the aids with
bypass communicative disability and that adapted output in synthetic voice or in print, because they
typewriters were used for communication. became increasingly smaller and more manageable.
The first technological aid specifically dedi- These technological advances have been fostered
cated to communication was the POSSUM (Patient by the cooperation of people from different coun-
Operated Selection Mechanism) funded by the tries and from different disciplines. In those years,
Polio Research Foundation, which was then used advances in the technology area were those that
until the late 1970s. Many other aids were devel- seemed most to connote the field of AA(20-34).
oped, especially in Northern Europe, but were only In Italy the diffusion and the development of
accessible to those who had acquired the alphabeti- the AAC recorded and continues to lag behind
cal code. Many weighed up to 7 kg. and certainly North America and Northern Europe. Significant
they were not easy to use in everyday life. For milestones in the diffusion of the AAC. The first
many years blissymbolism was the main graphic international meetings of the BCI can be considered
system used in the world. Taking a cue from its in Catania and Milan, respectively in 1983 and
characteristics and its use, other symbolic systems 1988. Later in 1989 the formation of the Italian
have been created for specific needs and categories Group for the Study of Augmentative and
of disability in communication. A functional Alternative Communication (GISCAA) and in 1996
approach to facilitate the communication of non- the creation of the first and , still, the only annual
speakers through non-oral methods was considered training school in CAA in Milan at the Benedetta
legitimate only in the late 1970s. D’Intino Center onlus. The training school is divid-
An American law of 1975 that recognized the ed into several seminars and Italian and foreign
right to education for all children with disabilities, professors collaborate there. Second level initia-
and therefore their right to live in the community, tives are also planned to explore topics and topics
gave even more strength to this current of rehabili- of particular importance in clinical practice in
tative thinking even though many professionals AAC.Augmentative and alternative communication (AAC) in neurodevelopmental disorders: a minireview 1183
The most significant stage for our country was tion with communication tables, devices with voice
the foundation in 2002 of the Chapter ISAAC Italy. output (VOCA) or keyboards. There are assisted
ISAAC Italy gathers interested people in Italy and and unassisted AAC systems. The term system
involved in the AAC, that is the people who use the refers to particular instruments used in specific
Augmentative and Alternative Communication, ways. Non-assisted systems include manual signs,
their family and friends, professionals, technicians gestures and vocalizations. They only require the
and companies that distribute in Italy aids and body and no other system or device external to it.
materials for the AAC. The aims of ISAAC Italy, in The tangible, visual symbols of assisted AAC can
addition to developing the objectives of ISAAC be used alone or in combination with a voice-acti-
International, are to disseminate and promote the vated communication device or with computer aids.
interdisciplinary field of AAC, facilitate access to The assisted systems of AAC allow to transmit
specific knowledge and disseminate a proper CAA messages through AAC instruments >, to > or to >. AAC systems without technol-
evance for the CAA(35-67). ogy are simple tools that do not need batteries or
electrical circuits, such as a tag with a word or a
Tools and devices for AAC communication symbol on top, a small notebook
AAC is part of the field of assistive technolo- containing different communication tables or a spe-
gy. Assistive technology or AT (assistive technolo- cific communication table for an activity.
gy) representing a wide category that includes any An example of a "low-tech" AAC tool are sim-
object and equipment, product or system, even ple devices for voice-based communication
modified or customized, which is used to increase, (VOCA). The high-tech AAC tools are more
maintain or improve the functional abilities of dis- sophisticated VOCA’s, which allow you to play
abled people. The wheelchairs, the handrails, the hundreds of messages and can include portable key-
electric scooters, the ramps, the glasses, the toys boards with which you can generate language and
adapted with switches and the dishes adapted for even predict words. The AAC includes many sys-
eating are all examples of AT. The whole AAC is tems, a set of rules or protocols that are used in the
part of the TA, but not all AT is a type of AAC. The natural environment, such as NAL (a system that
AAC consists of any instrument, device, image, considers the visual code as a real interactive lan-
word, symbol or gesture that compensates for the guage and the verbal language is combined with
difficulties of expressive communication (what key visual symbols, with this system is taught both
“goes out”) and receptive (what “enters”). AAC receptive and expressive language). Many children
tools, aids and strategies serve to "increase, main- react very well as the first type of AAC interven-
tain or improve” a person’s ability to communicate, tion(35-68).
expanding skills he already possesses and providing The Picture Exchange Communication System
an alternative medium where necessary. Thus, the (PECS) is a six-step strategy. First, the person with
AAC covers all types of technological aid that autism spectrum disorders is taught to initiate a
helps a disabled person to communicate. AAC is communication by giving the partner a visual sym-
never used to replace existing functional language, bol to have a very desired object. In exchange,
but to improve it. However, we must remember that image, photo, simple design, the object is then
communication does not always take place in the offered to her. As a second step, the use of images
form of language: communication is an exchange of is expanded to include more people, places and
information, which can be done virtually by any rewards than the person with Autism Spectrum
means. Disorders could wish for. In the third phase, we are
Unassisted AAC includes manual signs, ges- taught to make specific choices among the images;
tures and vocalizations. The use of AAC does not in the fourth, to construct simple sentences with
assisted requires only the body and no other system images, such as >. The answer
or device external to it. Assisted AAC consists of to the question “what do you want?” is dealt with in
objects, three-dimensional concrete symbols, draw- the fifth phase, while in the sixth it is taught to
ings, photographs, words or simple linear symbols. develop the ability to perform, commenting on vari-
The AAC can understand sign language, images, ous objects and activities for social purposes and
words, letters or objects used alone or in combina- not just for a tangible reward.1184 Agata Maltese, Francesco Cerroni et Al
There are other AAC strategies used by people augmentative and alternative communication for indi-
with autism and all of them using a naturalistic viduals with intellectual and developmental disabilities
and complex communication needs: a meta-analysis.
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