Cultural Considerations for Alternative & Augmentative Communication

Multicultural Considerations for Alternative & Augmentative Communication

Augmentative and Alternative Communication (AAC) includes various technology and communication modalities used to supplement or replace verbal communication and can provide alternative means of communication for those with limited communication skills. AAC may benefit diverse clinical populations, including those with Apraxia, Aphasia, Cerebral Palsy, laryngectomy, tracheostomy, spinal cord injury,  Autism Spectrum Disorder, and more. AAC includes high-tech electronic systems, such as applications used with a computer or tablet, and low-technology systems, such as picture cards or pen and paper. 

The Participation Model of AAC

The Participation Model of AAC assessment and intervention, as presented in Beukelman & Mirenda (2005), is based on the World Health Organization-International Classification of Functioning, Disability, and Health (WHO-ICF). The WHO-ICF model assesses an individual's disability not only in terms of bodily function and structure but also in terms of specific activity limitations and broad participation in life. The WHO-ICF model also considers the individual's personal and environmental factors that affect activities and participation. To guide decision-making in AAC intervention, The Participation Model considers the participation patterns of typically developing same-aged peers, the particular communication needs of the individual, and the barriers to functional life participation. This model can be adapted to incorporate multicultural considerations.

Participation Patterns of Same-Aged Peers Without Disabilities

Assessing the expectations for similarly communicating peers and typically communicating peers allows the clinician to determine the steps required for functional AAC communication.  Assessment across different cultural contexts in which the individual communicates is required.

• Considering the client’s communicative contexts and environments and identifying cultural patterns may require repeated observation and interaction with the AAC user and family. 

• Differences in interpersonal modes of address (e.g., child to adult) may influence vocabulary content and organization needed in the child’s AAC system.

• Attention to the level of communicative independence demonstrated by a bilingual peer in various activities and settings can establish the steps required for successful communication for the AAC user.

Participation Barriers

Participation barriers may be physical, attitudinal, social, or cultural and may relate to the individual or their environment. Identification and consideration of participation barriers are crucial for providing effective AAC intervention.

Opportunity Barriers

Opportunity barriers are socially-imposed; for example, segregation policies in school districts are an opportunity barrier. These barriers include policy and practice barriers, barriers related to facilitator skills, barriers resulting from the attitudes of communication partners.

Policy and Practice Barriers

Policy barriers are legislative or regulatory, whereas practice barriers are procedures and conventions. Some procedures are so long-standing that they are often believed to be legislated. 

• Family participation in AAC device decision-making and implementation may be active or passive and varies considerably in form and function.

• Schools may separate bilingual students for instruction.

• Schools may place non-verbal students in self-contained classrooms where typical peer interaction is unavailable.

Facilitator Skill and Knowledge Barriers

A lack of information regarding AAC options and technology or a lack of skill implementing strategies and techniques may contribute to participation barriers. When working with multicultural AAC users, a lack of cultural competence may also affect treatment efficacy. 

• Awareness and training of service delivery professionals affect the priority placed on the AAC device.

• The cultural perspective of the facilitator may affect the clinical process.

• The AAC user's level of acculturation to the majority culture influences vocabulary choice and organization.

• The facilitator should be competent in the language and cultural considerations of the client or collaborate effectively with a bilingual and bicultural interpreter or cultural broker.

Attitudinal Barriers

Attitudes across circles of communication include the attitudes of members of the AAC team, parents, relatives, peers, community members and leaders, and the general public, which may contribute to participation barriers. 

• Perspectives regarding the value and use of an AAC device vary within and between cultures. AAC device use may not be compatible with family values and belief systems.

Access Barriers

Access barriers are imposed by the individual capabilities and resources of the user (e.g., a vision impairment) or the system (e.g., limited memory capacity).

Cultural Barriers (includes financial, technical preferences, and decision-making)

• Financial resources and training affect AAC device use.

• Whether high-tech information is needed or preferred varies within and across families.

• In heteronormative Euro-American culture, the mother may prefer social information while the father may prefer operational information.

• Some families may prefer to independently access information and referral databases regarding assistive device planning, acquisition, and implementation. Other families may prefer that a professional review the information with them.

• The format of information provided varies across cultures; for some Asian families, the presentation of videos showing others using AAC is more valued than professional information-sharing in verbal or written form. 

Language Barriers (includes symbols, language choice, and vocabulary)

• Symbol perceptions may vary according to culture; symbols should be selected in collaboration with clients and family. 

• Results from a survey on symbol perception (2000) of 147 participants from a variety of cultures found that Picture Communication Symbols (PCS) were considered more translucent (have the strongest relationship to their referent word) than Blissymbols and DynaSyms for European Americans, Mexicans, African Americans and Chinese Americans (Mandarin speakers).

When assessing culturally and linguistically appropriate AAC intervention, a clinician should consider the following:

• English language competence of the AAC user and frequent communication partners

• Limitations of an English-only AAC system

• Limitations of AAC manuals written in English

• Availability of lexical items and metaphoric phrases particular to specific cultures 

• Whether writing and literacy is prevalent or valued in the culture of the AAC user

Current Communication Assessment and Intervention

Assessment of an individual's current communication use allows the clinician to determine strengths, challenges, interactive patterns, and participation barriers. Assessment and intervention should be culturally sensitive and inclusive.

Beukelman & Mirenda suggest a three-phase assessment approach to determine appropriate candidates for high or low technology devices.  In phase one, current levels of communication, as well as physical, cognitive, and sensory strengths and weaknesses, are assessed in all environments. In phase two, the future needs of the AAC user are evaluated. In phase three, skill maintenance is assessed and the need for further treatment is determined.  Attention to client mobility, range of motion, client needs, expectations and frequency of use are important in determining the correct type of device for each AAC user.

Special Considerations in AAC

Many AAC devices use symbols to represent words. These symbols can be classified as iconic or non-iconic. Iconic symbols resemble the object they represent. Non-iconic symbols are abstract and do not resemble the objects they represent. Symbol selection for use with multicultural populations requires a careful review of the cultural values inherent in each representation.

AAC use may carry stigma in various cultures, which is contributing factor in device abandonment.  Sources of stigma may include device aesthetics, gender and age appropriateness, social acceptability, sublimation and professional deference, teacher acceptance of disability, and universal design principles.

Resources for Coding and Reimbursement

ASHA has provided modules for Speech-Language Pathologists and Audiologists to encourage appropriate documentation, coding and, reimbursement for services rendered, which may be helpful when using AAC with a client. 

Examples of Multilingual Devices

In a 2006 American Speech Language and Hearing Association (ASHA) presentation, speakers Alaina Levant and Nicki Veede stated that the following devices to have multilingual output:

1. Unicorn

2. Text to Speech

3. Synthesis Chip

4. Proloquo to go

5. Layout Kitchen

6. LAMP Words for Life - Spanish/English

7. UNIDAD

Oregon Agencies that offer high-technology AAC loaner devices and limited interpreting services

Oregon Technology Access Program (OTAP) provides information, training, and referral services for children and adults with disabilities up to age 21.  OTAP provides short-term loaner equipment and multilingual software, as well as training in equipment and software use for parents.

Telecommunication Devices Access Program (TDAP) provides information and loaner equipment to adults who have speech, hearing, cognitive, and communication differences and deficits. Equipment is available with multilingual software. An application and certification of communication impairment from a physician, nurse practitioner, audiologist, speech-language pathologist, or rehabilitation instructor for the blind is required.     

Examples of Software (for use with mobile devices) available in multiple languages:

• Proloquo to go: Spanish version is currently in development.  Cost: $ 189.00

• My Talk: Limited vocabulary sets in English and Spanish.  Cost: Free

Cultural views on the interaction of AAC and verbal language development

When selecting appropriate AAC technology and facilitating the development of linguistic, social, and strategic skills, a clinician should consider the following questions related to the client's culture. 

• Is technology acceptable? If so, is high technology or low technology preferred? 

• Is voice output acceptable?

• Is eye contact expected?

• Are interruptions acceptable?

• Is silence or waiting for someone to finish acceptable?

Potential for environmental adaptations

Adaptations may include altering a physical space or structure. For example, adjusting furniture height or adapting the communication modality to the cultural setting may be appropriate.

• In cultures other than Euro-American, public use of AAC devices may be negatively perceived; it may be best to seek a low-tech/no-tech solution for certain settings. 

Potential to use AAC systems/devices

Constraints Profile

Identification of cultural constraints allows the AAC team to provide culturally sensitive intervention. A client's constraints profile includes individual, family, and social preferences that impact AAC use (e.g., the level of independence fostered, demands on families by their home community, or cultural perceptions of disability).

• The family may want their child to have communication independence or may welcome the child’s dependence on them to interpret needs.

• The individual may feel that the benefit of independent communication is outweighed by the stigma of using a device that signals disability.

• The social context of device use affects how families view changes in routine, quality of life, and social visibility.

Facilitator Skills Profile 

In this context,  a “facilitator” is in some way responsible for the operation of the AAC device and teaching the individual to use it. The facilitator may be a professional such as an SLP, teacher, or a family or community member. 

• Bicultural competence is the cultural understanding of both the home culture of the client and that of the majority culture. This is crucial to program and provide culturally sensitive messages for the different environments in which the client participates.

• Operational competence includes the competent operation of the AAC device, from the basics of charging the battery and powering the machine on and off, to navigating screens, adding content, and operating supplemental systems such as cameras and microphones. Social skills, linguistic skills, and competence in instructing and modeling AAC communication are required.