Aac assessment Introduction

Recent years have seen an increase in the number of individual children with complex communication needs who require high tech augmentative and alternative communication strategies (AAC). Extrapolation of existing data on identified need suggests a prevalence of 0.05% of children and young people needing high technology AAC, representing an estimated 6,200 children and young people in England. Reference: The Communication Council September 2010.

Web Reference:

http://www.thecommunicationcouncil.org/council/communication-council-papers/meeting-on-16-september-2010/

Assessment materials have traditionally been comprised of a mixture of methods, predominately being subjective in nature, such as observational charts and checklists that are based upon knowledge and experience of the assessor. Such assessments play a vital role in highlighting a young person’s abilities and difficulties with regards to communication and AAC use. However, in the ever increasing climate of evidence based practice* and use of SMART* targets, more formal assessments materials have been developed that are specifically aimed at children and young people who use AAC as their prime mode of communication. Demands for performance measures link simultaneously with the demands for reduced costs and such challenges have resulted in ensuring comprehensive and effective management plans which are based upon functional assessment data.

The following pamphlet contains a description of some of the most popular assessments available and an example of their use with a child or young adult, alongside an example of a treatment plan based upon their assessment results.


Evidence Based Practice – This refers to preferential use of health interventions for which systematic empirical research has provided evidence of statistically significant effectiveness as treatments for specific problems.

SMART targets – SMART is a mnemonic and although there is no clear consensus about precisely what the five keywords mean, typically accepted values are: specific, measurable, attainable, relevant and time bound.

Augmentative and Alternative Communication Profile – A Continuum of Learning

ACAP: Augmentative Communication Assessment Profile

Communication Matrix – Online Version (2004)

Social Networks: A Communication Inventory for Individuals with Complex Communication Needs and their Communication Partners

Frenchay Screening Tool for AAC

This assessment is aimed at children who require AAC systems (by this the author typically means use of a high tech communication aid) and some adults with complex communication needs (not acquired communication disorders).

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  It was developed as a comprehensive assessment tool aimed to determine the course of development of communicative competence using AAC.
  
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  It uses Janice Light’s (1989) definition of communicative competence to determine the skills needed to achieve clinical outcomes in areas that support development of communicative competence using AAC. See definition page.
  
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  It is intended for use by a multidisciplinary team, including family members who have knowledge about the person’s physical, cognitive and social skills relating to AAC.
  
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  It measures subjective, functional skills and is aimed at assessment of current and desired communicative competence alongside defining skills required to increase competencies and to measure and document progress towards individualised outcomes.
  

The AAC profile defines five ability related levels, called Skill Set Levels (1-5). These levels represent a continuum of communicative abilities and range from early functioning to independent use and AAC mastery. In the manual there is a detailed breakdown of each Skill Set Level with examples of communication behaviours at each level and a guide of percentage of accuracy. The skill of the person who uses AAC is assessed alongside communication partner skills.

The assessment uses a scoring system of rating the frequency that the person demonstrates the skills. This is 3=frequently, 2=sometimes and 1=seldom.

The assessment is administered by selecting a Skill Set Level (it is recommended to start at Level 1 when unfamiliar with the assessment or where the assessor is confident that the person would score a 3 of the majority of skills at previous Levels). Administer all items within the Level and score. If the majority of the items are scored at 3, continue through each Skill Set Level until the majority of assessment items are rated as 2 or 1. The highest Skill Set Level where the majority score is 3 becomes the current Communicative Competence Level.

The assessment records current Communicative Competence Level for all four areas of learning.

The desired Communicative Competence Level for an Area of Learning may be where the person scores 2 on the majority of items within a Skill Set Level. However, the author recommends that this is up to the AAC team to ultimately decide and may be based upon observations and knowledge of the person who uses AAC.

Performance is then plotted on the Performance Profile summary graph. This represents an individual’s communication abilities using an AAC system and indicates areas of strength and areas that may require increased intervention and can direct treatment plan development. Re-evaluation data can also be added to produce illustrations of change over time.

Practical Case Example

Abigail was four years old when first assessed on the AAC Profile – A Continuum of Learning. She has no diagnosis but has a motor speech disorder, and could only produce vocalisations and a few sounds. She was very communicative and used a mixture of signing, a low tech communication book and a Dynavox Vmax communication aid. She had had Abigail had been using her communication aid for 6 months and was working at navigating her way around the pages and using a mixture of single words and some 2 word level structures on the device. The assessment was carried out in order to determine her levels of competence within the four areas of learning and to help plan future input for Abigail.

The assessment was carried out by her speech and language therapist with input from her mum, teacher, specialised teacher and speech and language therapy assistant.

Abigail’s skills were plotted on each level, beginning at Skill Set Level 1 for each area of learning. The results were plotted on the Performance Profile Summary and indicated that her strengths lay lied within the operational and linguistic areas of learning. The assessment highlighted the need to increase her social and strategic areas of learning and to provide increased training to her communication partners. It also helped to formulate an effective treatment plan.

The assessment was repeated 12 months later. Abigail was now then 5, and communicating with a mixture of speech, (3 -4 words together, unclear without context or familiar partner) and her Dynavox VMax. Speech and Language therapy had targeted increasing her social use of communication and development of strategies to help repair misunderstandings, alongside development of language structure and use.

The repeat assessment indicated that Abigail had progressed in the linguistic area of learning and the social area of learning, having increased these skills by one skill set level. She had not made any progress within the operational or strategic levels of learning.

Abigail’s initial treatment plan had highlighted working on all 4 areas of learning and her treatment plan had one goal within each area. As her operational and linguistic learning was progressing but her social and strategic areas remained static it was decided to target these two areas of learning. Class based observations soon highlighted some difficulties. Abigail’s teaching assistant in school had become very familiar with Abigail’s ways of communicating and mostly understood her speech. This meant that Abigail was using speech alone in the everyday classroom situation and was looking at her teaching assistant in order for her to interpret her speech. In effect, she was using the assistant as her communication aid and all her previous AAC strategies were diminishing when in the classroom. In a 1:1 situation with the Speech and Language Therapist she was able to demonstrate good operational and linguistic skills on her Dynavox and could put simple sentences together and was beginning to be able to include some grammatical markers.

The first part of the treatment plan was to develop the role of her communication partners in school and this was carried out by a short “hands on” training session for her teacher and teaching assistant. This highlighted how critical it is to be a good role model in developing children’s use of AAC and short recordings of interaction were used as a focus and discussion point.

Modelling techniques and practical demonstrations were required to show how to create and use opportunities within the everyday situation. In focussed therapy the emphasis was on independent communication and use of some pre-stored phrases which could cue a listener into a topic if Abigail did not know a word. These included phrases such as “the word isn’t here” “it begins with...” “It’s a bit like...” “It’s a person/place/thing”. To develop her social competence the focus was on developing increased opportunities to communicate new information to a peer. For now, there is no emphasis on further developing Abigail’s linguistic or operational skills until she has reached a level of social and strategic competence that mean she is less reliant upon others to interpret her meaning.

This assessment was developed to identify which communication system would be of most benefit to a non verbal child with a diagnosis of Autistic Spectrum Disorder.

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  It was initially an informal assessment tool and was then developed for practitioners who required some objective guidance to assist them in identifying a primary method of communication for an individual child.
  
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  It aims to provide a basis to set objectives in order to develop a child’s communication skills.
  
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  It is an assessment for signing and low tech communication methods only.
  
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  The assessment has been used for children aged 3 – 11 but it is advised that it is appropriate for any age group
  
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  There is a pre-requisite to using the assessment that the child must have at least fleeting attention skills, intentional communication, can differentiate between people and objects and is motivated by one or more item or activity.
  

The Assessment Profile consists of 27 closed questions (yes/no questions) which relate either directly or indirectly to communication. They are organised into 9 categories. Each question has a criterion and a clarification. The criterion is the question and the clarification is an example or statement that matches the question.

The assessment is administered by answering “yes/no” to the 27 questions and then counting up white boxes containing an affirmative response, and then the grey tinted boxes. If the majority of responses are recorded in white boxes, (and within these boxes 5 are highlighted) check if all 5 of these highlighted boxes have been ticked. The manual then advises the assessor to proceed to the interpretation. Likewise, if the majority of the boxes ticked are grey, proceed to interpretation. If the responses fall fairly equally between both white and grey boxes, use the transparent overlay which is provided with the assessment by placing it over the completed form. Ensure all the yellow coloured boxes are ticked. If they are, proceed to interpretation.

The test interpretation gives an indication based on the completed assessment as to the type of AAC that may best benefit the child. The following three examples are provided:

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  Signing - If the 5 bold boxes are ticked, some form of signed communication may be most beneficial.
  
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  Picture Exchange - If predominantly grey boxes are ticked, a picture trading communication system such as the Picture Exchange Communication System (PECS) is indicated. See definition page.
  
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  Picture Pointing - If the yellow boxes are ticked (with use of the transparent overlay) this would suggest that a picture pointing communication system may be most successful.
  

Practical Case Example

Paul was 15 when assessed on the ACAP. He has a diagnosis of autistic spectrum disorder (ASD) and severe learning disabilities. He is predominantly non verbal, only using an occasional word when extremely frustrated. He has used the Picture Exchange Communication System (PECS) for several years now to initiate communication with a partner and make a choice between activities or items. His teacher requested a review of his communication as she was finding that PECS use was becoming very established within certain routines but almost impossible to generalise to a wider range of communicative functions or wider range of choice making. It was decided to assess Paul informally via observation in different environments and to support decision making by carrying out the ACAP assessment.

All four of the pre-requisite questions were passed and a profile of his skills within the nine category areas was developed. These areas were, attention, visual, physical proximity, communication, behaviour, cognitive development and receptive language. The questions were straight forward and it was quick and easy for a familiar communication partner to give an accurate answer. The assessment profile indicated that Paul had predominately grey boxes ticked but he did not have the 5 highlighted boxes ticked. According to the interpretation this indicated that a picture trading system (such as PECS) was indicated.

The assessment was useful as a descriptive assessment and clarified what was already known but did not provide any further information over and above what was known at this point, and did not give any indication of input that may be beneficial (although this was never indicated that it would).

The assessment was therefore repeated on a much younger child with a diagnosis of ASD in order to determine if the assessment was better suited to considering use of augmentative communication in a child who had not commenced any form of AAC as yet.

Charlie is 3 years old and has a diagnosis of ASD. At present, all communication is on his terms only and he can become very frustrated, hitting and biting children or adults who try to initiate interactions with him. He has not yet been introduced to any form of AAC as he needs to develop improved emotional regulation strategies. The ACAP assessment was completed to see if introduction of AAC should be considered to eliminate some of the frustrations he shows. All four of the pre-requisite questions were passed and a profile of his skills within the nine category areas was developed. Charlie had a very different profile to Paul and an equal spread of white and grey boxes. The interpretation indicated that he would not yet be ready for introducing signing, picture pointing, or PECS for communicative purposes. This backed up the knowledge that the team around the child already knew.

The assessment appears better suited if looking at introducing AAC for a child where the team feel the child is ready, rather than a child who may not be ready (e.g. Charlie) or who is already using a system (e.g. Paul). It would also serve as a useful assessment tool for an individual who is developing skills in working with children in ASD and wishing to expand their knowledge as to why AAC may be successful.

This assessment is an easy to use online assessment designed for individuals of all ages who function at the earliest stages of communication. It was first published in 1990 and reviewed in 1996 and 2004. It aims to document the expressive communication skills of children with severe and multiple disabilities including sensory, motor and cognitive impairments.

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  The Matrix accommodates any type of communicative behaviour, including augmentative and alternative forms of communication (AAC) and pre-symbolic communication (such as gestures, facial expressions, eye gaze and body movements).
  
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  The Communication Matrix is NOT suitable for individuals who already use some form of language meaningfully and fluently.
  
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  The Communication Matrix involves three major aspects of communication. These are, the behaviours that someone uses to communicate (such as pointing), the messages that someone expresses (such as “I want that”) and the level of communication (such as use of symbols)
  
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  There are 7 levels of communicative behaviour, from pre-intentional communication through to use of simple combinations of words or symbols.
  
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  The Matrix is organized into four major reasons to communicate that appear across the bottom of the Profile and these are:
  
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    to REFUSE things that we don't want;
    
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    to OBTAIN things that we do want;
    
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    to engage in SOCIAL interaction;
    
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    to provide or seek INFORMATION.
    

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  Under each of these four major reasons are more specific messages that people communicate: these correspond to the questions that must be answered as the Matrix is completed.
  
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  The information that you provide is used to generate a one page Profile and a Communication Skills List.
  

The Profile provides a one-page visual summary of the information that has been

entered about an individual’s communication skills.
Communication Skills List

The Communication Skills List lists each message (such as "Obtains More of

Something"), and how it was communicated alongside if the skill has emerged or is mastered.
Using this Assessment

Register online for free by providing an e-mail address and password. Demographic information will be collated but no personal details stored. Three questions are asked which determines which section of the assessment will need to be completed. These three questions will then direct the assessor to the appropriate section (Section A, B or C). Between 3 and 24 questions will be asked about specific messages that the individual communicates. For each behaviour the assessor has to select whether the child has mastered the skill or if the skill is emerging. Once all the appropriate questions are answered, a profile of the child’s skills is produced and can be viewed in different formats. Progression can be documented and intervention can be planned based upon gaps in the child’s profile, or increasing particular skills which have been highlighted as requiring development. Levels of communication can be targeted and specific messages and communication behaviours can be developed.

Two very different children have been assessed on the Communication Matrix to compare and contrast the assessment for use with children with very differing needs.

Molly is 2. She has a metabolic condition and as a result of this has profound and multiple learning difficulties. She also has a severe visual impairment and is registered blind. The Communication Matrix assessment was completed, involving answering a set of questions about Molly’s skills. A profile was generated indicating that she has mastered level 1 (pre-intentional behaviour) for all of the major reasons of communication (refusal, obtaining and social). She is developing skills at an intentional level (level 2). Within the subsections of this level she has mastered refusal (intentional protesting) but has not yet used any communicative behaviours to obtain something. Within the social section, her skills at this level are emerging (attracting attention by vocalising).

For Molly this was an extremely useful profile to share and to indicate next steps in development of her communication skills. Feedback from her parents and key worker in her inclusive nursery included: “the profile reflected an accurate picture of what Molly could do and gave us some good ideas of what to do next”.

Harry is 3. He has a diagnosis of cerebral palsy and cannot walk or talk. Harvey attends a mainstream nursery school and is very communicative. He can understand what is said to him and uses different strategies to communicate his needs. He can make a few signs (they tend to be one handed), can point at photographs and some symbols and is practicing using different light tech devices for joining in with activities with the rest of the class. The Communication Matrix was completed jointly with Harry’s mum, teacher and speech and language therapist. His profile was generated indicating that he had surpassed levels 1 and 2 and had mastered most of the skills within level 3 (unconventional communication). At levels 4, 5 and 6 (conventional communication, concrete symbols and abstract symbols) he scored a combination of mastered, emerging and not used within the different subsections.

Harry’s profile indicated gaps that he had within the levels and also that he was using the skills he does have to communicate a range of functions across three of the four major reasons cited (refuse, obtain, and social). This visual representation of his communication skills made it easy to plan intervention strategies that could target gaps and allows parents and staff to think around the wider the issues of communication including; not only having a way in which to communicate, but also to have something to communicate about.

The Communication Matrix is an assessment tool that can be easily repeated and can show progress over time. It is best used for pupils at early stages of communication, including those at early stages of AAC. It would not be the most suitable assessment tool for a child who was competent within the field of AAC and successfully communicated to a range of people using low and/or high tech strategies.

The communication matrix assessment was used to develop a treatment plan for Molly. The matrix is set out in such a way that makes it really transparent to see the next steps that child should be learning according to a developmental model. For Molly, this meant developing her intentional communication skills which were just beginning to emerge. She was able to use communicative behaviours to refuse something (e.g. turning head away or arching back). The plan was to now develop her ability to request. Motivating items were selected, for Molly these were a space blanket, a noisy bell toy and a fan blowing towards her face. These items were presented individually in a calm environment with minimal language used, then taken away accompanied by the word “gone”. Any movement or sound used by Molly was interpreted by the adult as a request for more and the item was re-presented with the accompanying word “more”. Over time, she began to turn her head towards where the stimulus had been indicating an awareness of the stimuli and the team took this response as a request for wanting it again. Molly is not yet reaching unless prompted physically and this is the current emphasis on intervention, when she moves her head in the direction of the stimulus an adult is physically prompting her to reach towards the item. This will need to be carried out many times and with many sensory based items for Molly to develop this into a conventional, intentional request for more.

Joan Bruno, Children’s Specialised Hospital (2003)

This assessment was developed in a Children’s hospital in America. The purpose was to provide an objective way of assessing a client’s optimal symbol size, ability to recognise grammatical categories that symbols represent, categorisation skills and ability to form sentences using a picture communication board. Test results then serve as a starting point for creating communication boards or page sets.

The TASP is comprised of different subtests, each focussing on a different skill.

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  Symbol size and number – allows determination of number and size of symbols that a child would be able to select from.
  
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  Grammatical encoding – demonstrates the child’s ability to recognise symbols of different word types such as verbs, adjectives and adverbs.
  
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  Categorisation – demonstrates the child’s ability to assign symbols to the appropriate category
  
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  Syntactic performance – determines the child’s ability to sequence pictures to form messages and simple sentences.
  

The TASP subtests are administered in order (as above), and continued until a ceiling is reached. The ceiling for each subtest is described in the manual. The scoring manuals are provided on disc and the assessment materials, e.g. symbols and category pictures are all provided. The symbol system used is the Picture Communication System (PCS).

The results can be interpreted and used as a direct guide to inform development of communication boards that capitalise on the child’s strength. They can also be used for target setting, which may include developing symbolic skills or working towards communicative effectiveness.

Practical Case Study

Alisha was three years old when she was assessed using the TASP. She has a genetic chromosomal impairment resulting in a severe motor speech disorder, and could only produce vocalisations and a few sounds. She was very communicative and used a mixture of signing (although this was difficult due to poor fine motor skills), and had a communication book with choice of symbols and photographs on each page. She used topic based communication boards to join in with nursery activities such as painting and singing. She was beginning to develop combining two symbols together (e.g. want drink, like bubbles) following lots of modelling by her communication partner and then lots of practice. The TASP was selected to consider Ailsha’s immediate and future potential using symbols and face to face assessment by her speech and language therapist and was carried out over two sessions to complete the profile.

This assessment had be carried out face to face with the child, rather than previous discussed assessments that involved an in depth knowledge of the child.

In the first section which was designed to consider appropriateness of symbol size and number, Alisha scored 100% with selection of 4, 8 and 16 symbols per page. With 32 symbols per page, 20% (1/5) symbols were correctly selected by Alisha.

The second section considered grammatical encoding. She identified

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  75% (6/8) of transparent verbs
  
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  80% (4/5) of people
  
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  13% (1/8) of adjectives
  

The third section assessed categorisation skills. Alisha scored:

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  100% in the transport category
  
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  0% in the food category
  
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  0% in the clothes category
  
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  100% in the animal category
  

The fourth and final section was attempted. This was the subtest for syntactic performance and involved Alisha pointing at two pictures in the correct order. The goal of this was to determine if Alisha could sequence a series of symbols to express a message. She scored 33% (2/6) with the subject-verb two word level task. She did not have any success with the three word level task.

The results summary sheet was completed and this enabled recommendations to be made based upon Alisha’s performance and assessment results rather than “guessing” the next steps. The assessment is not standardised but gives descriptive information and allows progress to be monitored and plotted in a more objective way. Using the assessment for Alisha allowed communication boards to be created which would develop her skills in extending her symbolic communication level.

Example of Treatment Plan

The results of all subsections were used to plan targets that would formulate Alisha’s speech and language therapy treatment plan.

Communication boards were to be created for a variety of topic based activities and should consist of 16 cells for the current time. The size of the symbols should be 1 ½ inches. Section two of the test had informed that Alisha had the potential to use symbols across a range of grammatical classes but this required extension. Aims were put in place to work on receptive knowledge and symbolic knowledge of verbs and prepositions. This was to be via 1:1 teaching by Alisha’s teaching assistant following guidance from the speech and language therapist. Alisha was able to categorise some basic to superordinate categories, and particularly categories that she had experience of, but not grammatical categories. This resulted in implementing targets to increase symbol and categorisation knowledge and semantic activities were suggested. Alisha also demonstrated the beginnings of being able to combine words, so this too was a focus of therapy, following a linguistic approach, (combining subject and verb) and a more functional approach, (combining want and activity).

This treatment plan had a heavy emphasis on developing linguistic skills which tends to be the prime focus of this assessment. Other skills which are essential in development of AAC are not as considered within this assessment framework. Professionals with knowledge of AAC would need to use this assessment to plan the linguistic aims at the level best suited to the child but to also use their knowledge to ensure there was a functional strand to intervention and that the child using the created boards had sufficient reasons and opportunities to communicate. Following a purely linguistic model is likely to result in difficulties with carryover and generalisation into their everyday environments.

This assessment and intervention planning tool is designed to help professionals work with family members and individuals with complex communication needs to determine the most appropriate technologies and communication strategies for individuals to communicate with their communication partners.

It features a DVD which illustrates five individuals with complex communication needs and their “social network” of family, friends, acquaintances, paid professionals and people in the community

Functional goal-setting and person-centred planning are the main features of this assessment. These are what guide the individual and his or her closest communication partners towards the most effective communication strategies and technologies not only to meet their daily communication needs, but also to enhance their participation.

The Social Networks Communication Inventory acknowledges and addresses the multimodal nature of communication and recognises that the social variables such as context and partner affect interaction patterns and modes of communication. This tool, therefore, helps to contextualise information drawn from other AAC assessments.

The goal of Social Networks is to improve the quality of the communication of the individual and also to improve their partners’ communication efforts. (Put another way, the goal is to improve interactions, not individuals.) It considers the current strengths and weaknesses of communicative interactions within an individual's current set of social networks, and uses this information as the basis for planning for future improvement and expansion of networks, topics, technologies and techniques.

With regards to AAC, Social Networks advises that people using high-tech devices tend to use their devices in only one or two circles of communication partners and with a very limited set of individuals. They also always include body-based means (gesture, gaze and vocalisation) among their most used communication modes across communication partners and circles. It is advised that even highly proficient people using AAC consistently use different forms of high and low tech communication device depending on context, topic, purpose and communication partner.

Using the Assessment

As part of the interview process, the client completes a communication diagram consisting of 5 categories (or “circles”) of communicators: life partner and close family, wider family and good friends, acquaintances, paid communication partners, and unfamiliar partners. They are supported to do this by professionals such as Speech and Language Therapists. The client identifies what modality (facial expressions, gestures, vocalisations, speech, use of symbols, alphabet boards, etc. they use and the frequency that they use that modality to communicate with people in each of their 5 circles. The client provides topics currently discussed with individuals in each circle and what topics the client wishes he or she could discuss, if given appropriate support.

Information from the interview schedule is transferred to a summary section. This summary identifies people within each of five circles of communication partners, modes used with people within each circle, those that are effective versus efficient, skill strengths and those needing work, representational strategies and techniques, and strategies that support expression and comprehension. 

Need to carry out assessment to be able to comment on it.

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  Physical access – a framework that describes physical movements that might be used to access an AAC device.
  

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  Visual processing – to ensure information is presented within the person’s visual field.
  
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  Visual acuity (symbols) – to identify the number and size of symbols that is most appropriate. Symbols vary in size from 4 per page up to 128 per page.
  
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  Visual acuity (upper and lower case letters) – to ensure the correct size of print which is to be used.
  
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  Identification of different types of pictures, such as symbols and photographs.
  

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  Categorisation – considers the person’s ability to assign symbols to the appropriate category.
  
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  Visual Scene Displays – to explore whether real life scenes aids the identification of target words or sentences.
  
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  Single word picture matching – to explore single word reading skills
  
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  Reading – with or without symbol support – to explore whether reading is helped or hindered by symbol support.
  
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  Sentence – picture matching – to explore sentence reading skills
  
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  Paragraph reading comprehension – to explore paragraph reading comprehension skills.
  
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  Spelling – to explore the level of spelling ability and the quality of any errors.
  
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  Alpha and numeric encoding – to investigate the ability to make use of letter or number coding as a possible time saving strategy for a keyboard user.
  
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  Iconic encoding – to explore the ability to make use of symbol combinations as a strategy to increase the number of messages on a communication overlay.
  

The Frenchay subtests are descriptive in nature and therefore can be administered according to the individual being assessed. The whole assessment does not have to be administered; the professional carrying out the assessment determines which sections are to be used dependent upon the intended outcome. The whole assessment can be administered and this may take place over more than one session. It would most often be too time consuming to administer the whole assessment in one session.

The results can be interpreted and used as a direct guide to inform development of communication boards and high tech AAC systems that capitalise on the person’s strength and will ensure that AAC options are most likely to be successful as systems can be created that best match the individual’s skills.

Practical Case Study

Emily is a fourteen year old girl who had a traumatic brain injury following an accident. She spent almost a year in hospital and was only able to communicate basic needs via hands movements in response to yes and no questions. She slowly began to regain some speech but it was highly unintelligible due to dysarthria (poor articulation, volume, respiration for speech and voice).Upon discharge from hospital, assessment showed that she was able to speak in single words and had retained much of her language comprehension. Her speech was mostly intelligible when using single words but if she attempted to put any more words together, the clarity of speech was lost and she remained difficult to understand. She also has severe difficulty with her expressive semantic system and significant word finding problems. She was keen to go back to her mainstream high school although required a slow phased approach due to physical difficulties, language difficulties, personality and behaviour changes and extreme fatigue.

The Frenchay Screening tool was used as a part of a whole battery of assessments to determine a baseline for her language skills which were likely to require some form of AAC. Only parts of the assessment were completed as it was physically tiring for Emily and her attention skills spans? were fairly short.

Physical access, identification of different types of pictures, categorisation, reading comprehension and spelling were targeted. It was felt that other sections were covered in the wider battery of assessment material. Considering reading was extremely beneficial and it was found that print was a useful medium to cue Emily into a word that she could not spontaneously recall.

Emily required a period of intensive speech and language therapy support, as part of a multi-disciplinary team consisting of physiotherapy, occupational therapy, clinical psychology, home tutoring and counselling services. Her main priority was learning to walk again and for her friends to know that she wanted to be treated the same as before her accident. Her priority for her communication was to be able to speak the same as before, and it was very difficult to encourage her to break this down into small manageable chunks.