Augmentative and Alternative Communication (AAC) Programs and Devices
Communication is an essential part of life. We rely on communication to express our wants and needs, form friendships, exchange ideas, and engage in our communities. For the many people with disabilities who have difficulties with spoken communication, augmentative and alternative communication (AAC) devices and programs can bring language alive and make communication possible.
So, what is AAC, and what kinds of AAC devices are out there? How do you know if your child could benefit from one? What kinds of support and funding are available? We sat down with speech-language pathologist (SLP) and AAC specialist Ali Steers, and Undivided’s Head of Health Plan Advocacy Services, Leslie Lobel, to learn more.
What is AAC?
“AAC looks like so many things,” Steers says, “so it can be really hard for someone to wrap their brain around what exactly AAC is.” Functionally speaking, AAC can be anything from an iPad app to a computer with text-to-speech software to a dedicated, portable device or low-tech systems like communication boards, PECS, and signing. “We can all kind of think of ourselves as AAC users,” Steers says. “All of us are sending text messages. All of us are writing emails. All of us are using emojis.”
Steers adds that it’s important to recognize that all children already communicate in some way, whether it’s verbal, with their eyes, or vocalizations, and that AAC devices are used to augment or add to a child’s communication.
For more on what AAC is from Ali Steers, watch this clip:
How do I know if my child needs AAC?
A child could benefit from an AAC device if they:
have difficulties speaking verbally,
are speaking verbally unreliably, or
are unable to speak verbally.
“If your child is not developing intelligible speech with their mouth on par with their typically developing peers, then, in theory, you should be talking with a speech therapist, and that speech therapist should be giving you good advice about whether or not your child has the ability to develop intelligible speech without augmenting their communication,” Steers explains.
Note that it's never too early or too late to start with AAC, according to Steers:
How will I know what kind of AAC my child needs?
Steers suggests that parents think about AAC in the same way they think about German or French — it really is “a language that we use all day to communicate.” So, it’s crucial that the right device and system are chosen for your child’s unique needs.
An essential first step is speaking with a professional who is knowledgeable about AAC programs and devices, and who will take many variables into account when helping you determine what system is going to work best for your child.
An evaluator will look at the following:
Access: Can the child use this device?
- For example, a child who does not have the fine motor control to use an iPad shouldn’t be given one for communication. In that case, other options should be considered.
Environment: Who is the child going to be communicating with?
Language organization: How is the child going to be communicating? What words do they need access to, and how should these words be organized?
Steers tells us that a language system should be set up for durability and longevity because the system will need to grow with the child.
The way the system is set up is essential to whether your child will be able to communicate effectively with their device. Are high-frequency words easily accessible? Are there enough words available to them?
- Steers suggests trying the device out for yourself. Can you talk to your child using the system? If not, the layout may need to be redesigned, because if you are not able to communicate with the device, they will likely struggle as well.
- Portability: How will the device move around with the child?
- For example, a child can use a cross-body strap to carry the device, or it can be mounted on their wheelchair. Whether a mount or strap will work well depends on the needs of the child and the device itself.
AAC programs and devices
Steers suggests testing a program or device before committing to it whenever possible to ensure it will work for your child. Working with a knowledgeable SLP will help you start narrowing down the best AAC system (such as apps or speech-generating devices), as there are many options currently available on the market, including:
Direct Selection programs and devices, where the child will directly point to, press, gaze at an image or word they wish to select, or give (as with PECS).
- Note that while these can be helpful when a child is young, they tend not to be sustainable over time as a child grows.
Letter and alphabet boards
iPads with language system apps installed, such as:
Tactile or auditory devices for children who are visually impaired, such as Enabling Device’s Tactile Symbol Communicator
Standard USB joystick or mouse
- A joystick or mouse can be used to control the pointer on some AAC devices such as those in the PCR Accent series.
Head pointing devices, such as NuPoint’s Head Tracking for Accent 1400
Head pointing is a great option for users who need a hands-free device.
NuPoint’s device works by placing a reflective dot on the user’s face, which is tracked by the device and used to control the pointer on screen.
Pointer sticks that are worn on the user’s head are also available.
Eye-gaze devices, such as:
The I-Series by Tobii Dynavox
Eye-gaze devices are most beneficial for children who don’t have the fine motor control to use direct-select or switch control systems.
Eye gaze has recently become available on iPads but can be less reliable than when used with a dedicated device. The success of the software will often depend on the quality of the iPad’s camera.
Steers tells us that “for individuals who would not be good candidates for using their eyes or their hands, they’ll be controlling a screen with, ideally, two switches. Maybe they’re on both sides of their face, and they’re using one switch to scan and the other switch to pick.”
They can be auditory or visual, depending on the needs of your child.
Who pays for AAC?
As Steers points out, communication is a medical necessity. “Everyone needs to be able to communicate, to speak to their doctors and their health team,” she says. “We need to be able to build relationships with those in our environment. Communication is absolutely a medically necessary function, in the same way that a wheelchair is.”
Steers goes on to say that some dedicated devices can cost between $10,000 and $20,000, and that she never recommends families attempt to pay for them out of pocket. So, where can you find funding?
There are several funding sources you may have access to, including:
You will need to provide a letter of medical necessity from your child’s doctor that explains why the specific device is appropriate for your child’s diagnosis as well as a signed prescription. You will also need to provide an evaluation report from your child’s SLP or speech therapist that highlights the reason this specific device is essential for your child’s health and safety.
Undivided’s Head of Health Plan Advocacy Services, Leslie Lobel, explains, “Your health plan will want a speech evaluation recommending the specific device as well as why it is needed so that the doctor can reference that, and so the durable medical equipment (DME) provider has that information as well.”
The majority of insurance companies require that the prescription from your child’s doctor is dated no more than six months after the date of the most recent face-to-face office visit — this is particularly true of Medi-Cal and Medicaid plans.
Speech-generating devices are considered durable medical equipment under most insurance policies and are typically covered. However, Steers warns that every policy is different, and some may have exclusion policies and will not cover specific devices, including SGDs. (Low-tech systems such as PECS are typically not covered.)
Lobel suggests requesting a list of in-network DME providers from your insurance company “to gain a sense of their plan’s coverage for an AAC device in terms of their deductible and what share of the cost they have after deductible.”
“Sometimes plans have a separate deductible for DME from the medical deductible, and sometimes it is the same,” Lobel adds. “Sometimes plans have an annual maximum dollar amount that they will pay per year for DME.”
DME providers can walk parents through additional steps needed for authorization, including a demo of the device and additional assessments.
Lobel explains, “The DME company will submit to the health plan for pre-approval of the device once all the documentation is in order. If the health plan denies the first authorization request, an appeal may be needed.”
Because AAC devices are expensive, you will need to get prior authorization from Medi-Cal before applying for the device, which means Medi-Cal has to agree to pay for the item before they will provide it.
As with private insurance, you will need to provide a letter of necessity from your child’s doctor or therapist (or both) that details when your child was seen, which device is recommended, and why the device is medically necessary. It’s also important to know that Medi-Cal will only pay for the lowest-cost device that will meet a child’s needs.
If your child uses multiple insurance plans, Medi-Cal will be the payor of last resort, which means you will need to receive a denial from your private insurance before applying through Medi-Cal.
Lobel suggests that families whose children have Medi-Cal coverage should talk to their DME provider about using Medi-Cal as secondary coverage after private insurance.
Undivided’s Public Benefits Specialist, Lisa Concoff Kronbeck, adds that while Medi-Cal may fund the portion of the cost that insurance doesn’t cover, they may ask parents for additional documentation before they agree to that funding (including documentation of what insurance paid). For example, they might ask for additional letters of medical necessity, documentation of what other devices have been tried and haven’t worked, and more.
Your child’s school
AAC devices and programs can be funded through the IEP process if they are deemed necessary for a child to access a free, appropriate public education (FAPE). Thanks to the recent California Assembly Bill No. 605, schools and local educational agencies are now required to provide eligible students with continuous access to their AAC devices at school, in their homes, and in the community, which means that students can bring those devices home with them after school hours and during all school holidays, including summer break. (Here is a sample letter you can write to your school's special education specialist to request an evaluation for AAC.)
Like Medi-Cal, Regional Center is a payor of last resort, so you will need to attempt to go through other sources first.
Regional Center may also fund services from Orange County’s Assistive Technology Exchange Center (ATEC), which can provide the following:
- AAC devices, both high- and low-tech (including a loan program);
- parent training and support; and
speech language services with SLPs who can visit a child’s home and school to provide support and training for a child’s device.
For children who are unable to speak verbally or have difficulties doing so, AAC devices can be obtained through the California DOR’s Voice Options Program.
Who should receive training to use an AAC program or device?
For your child to get the most from their AAC program or device, everyone who interacts with them will need to receive proper training, including family members, teachers, and peers.
In most cases, an SLP will provide initial training on using the system for a child’s family members, teachers, aides, peers, and any other person they interact with on a regular basis. Parents can also request that group time with their child’s classmates be written into their IEP, so the SLP can help other students learn to use the device alongside their child.
Once a person is thoroughly trained and proficient, they can then train others. Steers tells us she has had great success with parents teaching other family members and teachers instructing a child’s peers and friends.
Where can parents find resources and support for AAC?
Learning to work with AAC programs and devices will take time and practice and can be an overwhelming experience. If you feel like you need more support, you can:
Speak with an SLP who is knowledgeable about AAC.
- Steers tells us that not all SLPs are fully trained in AAC, and parents should ask detailed questions.
Once you’ve determined your device and program, you can visit the company’s website. Many of them offer articles, webinars, or training to help you learn more.
Other companies and organizations offer similar funding support, including:
For support with training, programming, and learning a new device, check out:
Reach out to your Regional Center for support and training.
Remember that it's a journey and a process that requires patience, practice, and perseverance. Watch this clip of parent Lelah Coppedge, whose son Jack works with Steers:
Did we answer your questions about AAC? What other concerns do you have? Let us know in the comments!