Dismantling the Access Method Hierarchy

Hannah Foley -

It is crucial to look beyond labels and diagnoses to ensure optimal outcomes in healthcare related services. A diagnosis or perceived abilities should never be the sole determinant when selecting an AAC access method.  

One of the most common misconceptions in AAC assessment and decision-making is assuming that a certain access method will be the best fit for an individual based solely on their diagnosis or perceived fine motor skills, or that an access method hierarchy exists.  

  • This can lead to overlooking the unique needs, preferences, and abilities of the individual with complex communication needs.  

While diagnoses may provide helpful context for understanding an individual’s needs and abilities, they do not determine the most appropriate AAC access method.  

  • For example, someone with cerebral palsy might be assumed to need to use switch scanning due to impaired fine motor control, but their gross motor control, cognitive abilities, and visual attention may support the use of eye gaze or head tracking.  
  • Similarly, a person with autism may be assumed to need a light-tech communication board, but they could thrive with an electronic speech-generating device.  

Everyone's functional abilities must be assessed, not just through the lens of their specific diagnosis.  

  • People with the same diagnosis can have vastly different needs and abilities, so it is essential to look at how an individual interacts with their environment, their preferences, and their unique motor and cognitive capabilities before selecting an AAC tool (Beukelman & Light, 2020).  

Perceived fine motor skills cannot be used to determine which access method will be most efficient for an individual (Binger & Light, 2006). Just because a person might have limited or impaired fine motor abilities does not necessarily mean they cannot use certain access methods or that they need certain AAC device accessories.  

  • For example, someone with fine motor impairments may not be able to make precise activations on a small touch screen, but they may have enough control to use a larger touch screen with customized settings. 
  • Similarly, someone with significant fine motor impairments may use direct selection via touch and not need a keyguard.  

It is important to note that fine motor abilities are not static - they can change over time, especially with intervention (Iacono & Cameron, 2009).  

  • An individual who initially appears to have significantly impaired fine motor skills may be able to gain more control and dexterity with practice, or their control over their body may decrease over time due to the nature of a progressive condition. 

Assuming someone can or cannot use a certain access method due to a perceived level of motor control can inadvertently limit their potential.  

Comprehensive and dynamic AAC assessment is essential to the identification of appropriate access methods for individuals with complex communication needs (Dada & Ball, 2015). This should involve understanding the individual’s skills—motor, linguistic, cognitive, and communicative—not just focusing on perceived limitations based on their diagnosis.  

  • Collaborating with the individual with complex communication needs, their families, and a transdisciplinary AAC team ensures that the AAC access method chosen leverages effective, efficient, and seamless communication.  

Dismantling the access method hierarchy is critical to realizing the skills and potential of individuals with complex communication needs. It is essential to move away from the idea that any single access method is best for a certain diagnosis or based solely on perceived skills.  

Identifying the most effective and efficient access method empowers those with complex communication needs to communicate, engage, and achieve their full potential. Through ongoing flexibility, collaboration, and comprehensive and dynamic AAC assessments, the access method hierarchy is dismantled and every individual with complex communication needs is provided sustainable access to AAC, regardless of their diagnosis or perceived abilities.  

References 

Beukelman, D. R., & Light, J. C. (2020). Augmentative & Alternative Communication: Supporting Children and Adults with Complex Communication Needs (5th ed.). Paul H. Brookes Publishing Co. 

Binger, C., & Light, J. C. (2006). The effect of enhanced milieu teaching on the communication of preschool children who use augmentative and alternative communication. Journal of Speech, Language, and Hearing Research, 49(2), 537-548. https://doi.org/10.1044/1092-4388(2006/040)

Dada, S., & Ball, L. (2015). AAC access methods for children with complex communication needs: A review of the literature. International Journal of Disability, Development and Education, 62(3), 237-251. https://doi.org/10.1080/1034912X.2015.1060833 

Iacono, T., & Cameron, L. (2009). Ethical considerations in the provision of AAC systems to children with disabilities. Augmentative and Alternative Communication, 25(4), 271-285. https://doi.org/10.3109/07434610903309927