Person-centred Decision Making

Collaboration is an important aspect of communication since it is likely that individuals will need to communicate with many people across their lifetime. Collaboration (working with others to complete a task/shared goal) can often be overlooked when working on AAC-related communication goals. When collaboration is carried out it can lead to positive outcomes across many environments (e.g., home, school, community). Collaboration can include sharing knowledge, expertise, and responsibility and can improve problem-solving. For example, parents and/or families provide information on the AAC user’s home environment, the teachers on the AAC user’s school environment, and the AAC user on their personal preferences. Collaboration is a continuous process.

Research highlights the importance of collaboration when selecting vocabulary to meet the different preferences of AAC users. It also highlights the importance of obtaining feedback from AAC users (if they can participate in the discussions) for their safety and to help accurately describe their experiences.

If everyone (communication partners) is involved in the decision-making process, trust, respect and honest communication can be established and lead to positive outcomes.

When collaborating for vocabulary selection a combination of direct and indirect assessment practices, can be used to gain knowledge, information, and expertise from everyone involved in the decision-making process (see assessment and evaluation tools).

Applied Model of Interprofessional Collaboration (AMIC-A):

Recent research offers a model to ensure collaboration between communication partners (AAC user, teacher, parents/families, professionals). The model is called the applied model of interprofessional collaboration (AMIC-A). AMIC-A can be used when selecting what vocabulary to use within an AAC system that is relevant and beneficial for the AAC user.

The AMIC-A is a process for ongoing assessment and monitoring. It uses a strengths-based strategy to help guide AAC decision-making. It identifies key factors that are influencing an AAC user’s communication and ensures the specific functional needs of an AAC user are met and the right intervention/strategy is given.

AMIC-A advocates for interventions/strategies that address the relationship between people and the environment that shapes and/or maintains communication. AMIC-A ensures evidence-based practice. The AMIC-A works to identify and improve an AAC user’s barriers to participation through first, assessing barriers to opportunities (knowledge and skills of communication partners, policies, cultural attitudes and beliefs). Second, assessing barriers to access (e.g., current communication stage and current skills and abilities).

The four steps of AMIC-A are:

Step 1. Discover and identify strengths and unmet needs 

Strength-Based Assessment—System (Opportunity Barriers): 

Examines the different systems and identify the strengths that could influence AAC system planning.

• D1. Ecological (environmental) system: 

Assess the different systems in the environment, including culture, policies 

(e.g., insurance policy) and procedures.

• D2. Communication context: 

Explore the environment of the individual, where and how they communicate and who they communicate with.

• D3. Communication partner: 

Assess the knowledge, skills, abilities of communication partners.

Strength-Based Assessment—Person (Access Barriers): 

Focus on an individual’s current skills and abilities through assessing an AAC user’s response to previous intervention and their current interventions.

Step 2. Analyse 

Leverage (use) strengths to meet needs: 

Communication partners examine and combine the information and observations found in step one. This will help to clearly identify the strengths and needs to help build strategies and decide on AAC user goals.

The communication partners will decide on the best intervention/strategies that are guided by the best available research and current skills and abilities of the AAC user.

Step 3: Act—Implement instructional practices

Strength-Based Intervention—System (Opportunity Barriers)

• D1. Ecological (environmental) system: 

Uphold an AAC user’s best interests, through advocacy and awareness. To implement the most effective intervention/strategy for the AAC user communication partners can work together to change or adapt to systems (e.g., insurance policy).

• D2. Communication context: 

Changing the environment to increase communication and social interaction for the AAC user. For example, rearranging the classroom furniture for an AAC user to be able to easily access their speech generating device.

• D3. Communication partner: 

Education, and training are provided to meet the needs of communication partners so that knowledge and learning opportunities can be shared through communication partners.

Strength-Based Intervention—Person (Access Barriers)

•  D1. Current communicative repertoire - honouring and shaping current communication forms: Communication partners should recognise and respect the different ways AAC user’s communicate (e.g., gestures). This information can be used to help educate and train communication partners on an AAC user’s ways  of communicating.

• D2. Skill strengths profile - strengths-based AAC modality and instructional practices: 

AAC interventions/strategies should be guided by an AAC user’s current communication stage, communication methods (e.g., speech generating device) and current skills and abilities.

•  D3. Accessibility profile - strength-based access methods and AAC modalities: 

Personalise AAC interventions/strategies that match with the AAC user’s current skills and abilities and address specific conditions of an AAC user (e.g., vision, hearing, physical movement).

Step 4: Evaluate 

Assess impact and address:

 This step involves important aspects that should be continuously included throughout the process, these are:

• Acceptability: 

Whether an intervention/strategy is accepted by communication partners, such as the AAC user and  parents/family. As well as whether the AAC system aligns with the AAC user’s values, preference, environment, social interactions and communication stage.

• Social validity: 

The appropriateness of the intervention/strategy for the AAC user. Feedback is provided from communication partners to inform and guide interventions/strategies.

• Durability: 

Whether an intervention/strategy can continue to be effective and if it has positive outcomes over a short period of time.

• Sustainability: 

How effective and intervention/strategy is at maintaining desired outcomes over long period of time with no additional support.

• Efficacy: 

Whether the effects of the intervention/strategy occur for the AAC user and their specific skills and abilities and functional needs.

• Effectiveness: 

The effect of the intervention/strategy on an AAC user’s behaviour within their environment and social interactions.

• Efficiency: 

Examining the cost, resources and time that can influence AAC interventions/strategies. This involves making changes to align with the AAC user’s current skills and abilities, functional needs and support.

Culture is commonly referred to as a set of shared beliefs, values and attitudes (language, traditional customs, religion) among a group of people. It is important to consider the culture of the AAC user and their parents/family when selecting vocabulary to use within an AAC system. This is because everything is created and influenced by culture. Therefore, culture can affect how vocabulary is selected. These include word choice, type of AAC system, an AAC user’s environment, communication type, functional needs, and assessment and evaluation tools.

Most AAC systems are created for the English language and there is a lack of AAC systems in other languages. Selecting vocabulary to use within AAC systems for bilingual (can speak two languages) and multilingual (can speak more than two languages) AAC users is seen as more complex than monolingual (can only speak one language) AAC users. This is because the number and choice of words for two or more languages must be considered.

Research has shown how Indigenous people and people who speak minority languages and live with disabilities continue to experience disadvantages.

For example, one study has highlighted how the inability to access a bilingual/multilingual AAC system can cause further social isolation and identity confusion and can increase an AAC user’s sense of feeling different.

Research has also shown how Indigenous people, such as Indigenous Americans (United States), Māori (Aotearoa/New Zealand), and Yolŋu (aboriginal Australians from Northeast Arnhem land), have highlighted the impact of collaboration.

Collaboration can help to ensure that the vocabulary selected is tailored and culturally relevant. This can include language, interests, traditional customs, beliefs and values (see collaboration).

Research recommends that long-term relationships with communication partners are built (AAC users, parents/families, teachers).

Functional needs are basic needs that are necessary for an AAC user to be able to do tasks and behave in ways that are essential for their overall quality of life. They help AAC users participate, encourage autonomy and independence, and support further development of communication skills across their environment. Some individuals with autism spectrum disorder and cerebral palsy may only have a small amount of verbal speech, which can make it harder to express functional needs. To enable individuals to meet these needs, studies have discussed various types of vocabulary that can be used within an AAC system (see types of vocabulary and their usage). Vocabulary that is relevant and specific to the individual and their environment and their needs should be used within the AAC system.

Example types of functional needs and related vocabulary:

• Problem solve: I don’t want| Make it better

• Request functional needs: Help| Need| Want| Food

• Comment: Good| Bad| Hard| Easy

• Greet: Hello| Goodbye

• Protest: No| Don’t| Stop

• Label: You| Them| She| Him | Up| Down

• Answer questions: Yes| My name is (AAC user’s name)| I am (AAC user’s age) old

Current skills and abilities refer to an individual’s actual skills and abilities to function. For example, how children play, learn, speak, act and move.

When selecting vocabulary to use within an AAC system, it is important to know the stages of communication development to ensure the AAC user’s current skills and abilities are considered.

It is recommended that vocabulary development follows the same order for all individuals. This is because studies have shown that the vocabulary development of students with intellectual disabilities such as down syndrome, occurs in a similar order to individuals who do not have disabilities.

Within the stages of communication development, it is important to know the different types of vocabulary to use within an AAC system that are appropriate for an AAC user’s current skills and abilities (see types of vocabulary and their usage).

A method to identify current skills and abilities when selecting vocabulary can include the ages and stages questionnaire and direct assessment practices (see assessment and evaluation tools).

Early stage of vocabulary development:

During the early stages of vocabulary development, content words (nouns, verbs, adjectives and adverbs) are recommended to help progress from using single words to joining words together (word combinations), to help develop syntactic communication. Additionally, concept words should represent an individual’s current skills and abilities and be appropriate for the individual (see types of vocabulary and their usage).

During early communication stages children learn how to request and reject things they want or do not want (see individual AAC user's functional needs).

Expressive language (vocabulary to get functional needs met) contain many content words. A large number of content words allow individuals to develop and experiment with different word combinations (see types of vocabulary and their usage).

Many function words start to appear after children have gained the first 50 words and when they are starting to show development in grammar skills (see types of vocabulary and their usage). Word combinations in the early stages of childrens’ vocabulary development have a large number of nouns and action word verbs and fewer adjectives and adverbs (see types of vocabulary and their usage).

Later stage of vocabulary development:

During later stages of development, children start to add more adjectives, adverbs, and function words to their vocabulary. This will help them develop their skills in grammar and sentence structure (see types of vocabulary and their usage).

It is recommended that the vocabulary within an AAC system aligns with age. For example, a study highlighted the importance of providing vocabulary that is suitable for teenagers in social situations/peer interactions.

Examples of popular vocabulary among teenagers and their peers, include the following:

• Guys| Bro| Wait| So| Mate| Man| Stuff| Eh  - Sentence starters/finishers

• Yeah/yep| Nah| Coz| Gonna - Abbreviations

• Pretty - Intensifiers

• Actually| Just - adjectives and adverbs

• Like - Fillers

Note: Vocabulary for individuals will vary depending on the AAC user’s preferences and interests (see individual preferences and interests).

The type of AAC system that is chosen can limit or increase an AAC user’s vocabulary growth and language and communication skills. For example, some AAC systems can only store a limited number of vocabulary. Many AAC user’s face situations where the vocabulary they need to communicate with is not available within their AAC system.

AAC system considerations include the following:

Vocabulary representation:

It is recommended that an AAC system includes vocabulary for an AAC user’s individual functional needs specific to items and activities the person enjoys. As well as vocabulary for a range of social interactions and to be able to communicate with many people. These include vocabulary for requesting certain objects, activities and people in an AAC user’s environment, as well as expressing emotions.

Research has highlighted the importance of selecting vocabulary for an AAC user’s safety to protect themselves and accurately communicate their functional needs and experiences, if they were in an unsafe situation/experience.

Example vocabulary: Bubbles| Juice| Help| Fire| Scared| Angry| Stop|

Another study highlighted the importance of selecting vocabulary to use within an AAC system that are pain related (physically/body and emotionally/mind) to help the AAC user express their pain. The pain related vocabulary would be individualised and can help the AAC user receive faster care, help and treatment.

Example vocabulary: I fell| I’m sad| I’m sorry| Hurt| Pain| I want a hug

Research recommends that a combination of core and fringe words are used within an AAC system for an individual to express their functional needs (see types of vocabulary and their usage).

Selecting vocabulary for functional needs can also be part of an AAC user’s preferences and interests (see individual preferences and interests).

It is recommended that the environment the individual is in is considered when selecting vocabulary within an AAC system. For example, some environments have specific aspects, such as a playground where the equipment is context-specific. There may be some similar vocabulary, but a range of different vocabulary may be needed for the various environments the person engages with. For example, some research has indicated that only a small amount of the same vocabulary is used in two environments (e.g., school and at home). This is because individuals are surrounded by lots of different routines, toys, materials,  and people in different environments.

Fringe words are important for environments specific to the individual. Thus, a combination of core and fringe words may be needed to support language development (see types of vocabulary and their usage).

Case study example:

A ten year old girl called Miriam uses an AAC system (speech-generating, text-based device (see the type of AAC system)) to communicate. The AAC team is working with Miriam, her parents, family, and teachers to select vocabulary that can help Miriam participate across several environments. The three environments that Miriam frequently goes to are the supermarket, home and school.

Supermarket:  Miriam likes to go to the supermarket with her mum to do the weekly shop. They have made a list of common food items that Miriam and her mum buy every week, such as milk, eggs and cheese.

Additional vocabulary for a trip to the supermarket that could be useful to use in her AAC system, include the following:

Supermarket words: Trolley| Checkout| Carpark| Shopping list

Supermarket phrases: Can you get me [item]| Where is the [item]| What isle is [item] on| Can you help me find [item]| I can’t find the [item]| Here is the [item]| I can get the [item]| I can push the trolley.

Home: Miriam lives at home with her mum, dad and little sister. Some vocabulary they use as a family in their household that could be useful to use in her AAC system, include the following:

Home words: Bath| Toilet| Bed| Bedroom| Kitchen| House| Family| Living room| TV| Chest of drawers| Dinner| Breakfast| Garage| Hall| Porch| Roof| TV remote| Give my [item] back| That [item] belongs to me| My [item] is in your closet.

School: When Miriam is at school, vocabulary that could be useful to use in her AAC system when she is around teachers and her peers, include the following:

School words: School bag| Lunchbox| Writing| Reading| Maths| Teacher| School office| Friends| Peers| Classroom| Whiteboard| Book| Pen| Pencil| Paper| Pencil case| Eraser| Playtime| lunchtime| Library