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AAC Industry Summary | AAC Technology Market Size and Users | AAC Technologies Currently Available
| Input Technologies | Display Systems | Processing | Output |
Clinical Decision Making: Matching the Device to the Individual | Funding Sources for AAC | References

AAC Industry Summary

This document is a brief summary of the augmentative and alternative communication market in the United States. It is intended to provide the reader with a basic understanding of the current and potential future market size, the communication enhancement technologies currently available, and reimbursement sources.

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AAC Technology Market Size and Users

Demographic research in several countries reveals that between 8 to 12 persons per 1000 have such severe communication disorders that they cannot meet their daily communication needs using only natural speech and handwriting. The 2 to 2.5 million Americans that comprise this group represent a variety of ages, disabilities and conditions.[1] Of that number, 237,000 are unable to have their speech understood and 2,284,000 have a functional limitation in speech.[2] It is estimated that communication disorders (including speech, language, and hearing disorders) affect one of every 10 people in the United States.[3] The number of AAC users in the United States is expected to significantly increase by the year 2020, putting the number of users at over 3 million.[4]

AAC devices generally are recognized as an appropriate solution for, and have become standard practice in, providing a mode of communication for individuals with a variety of impairments. Some prevalent types of conditions associated with AAC are dysarthria, apraxia, and aphasia. These speech and language disorders can occur independently of each other, or they may coexist in some individuals. Other conditions that may underlie the need for AAC are included in figure 2. Due to the scope of possible combinations of conditions, only a sample of the disorders is noted.

Figure 2. Causes of Communication Disorders

Source: Bloomberg, K. & Johnson, H. (1990). A statewide demographic survey of people with severe communication disabilities

The dysarthrias are a group of motor speech disorders resulting from disturbed muscular control of the speech mechanism due to damage of the peripheral or central nervous system; oral communication problems due to weakness, lack of coordination, or paralysis of the speech musculature.[5] Different types of dysarthria can be caused by a variety of diverse conditions. Some common causes of dysarthria include Cerebral Palsy, Amyotrophic Lateral Sclerosis, Multiple Sclerosis, Parkinson's disease, Brain-stem Stroke, and Traumatic Brain Injury.

Apraxia is a neurogenic speech disorder resulting from impairment of the capacity to program sensorimotor commands for the positioning and movement of muscles for the volitional production of speech. The two types of apraxia that affect speech are Developmental Apraxia of Speech (DAS) which occurs in children, while Acquired Apraxia of Speech (AOS) is found in adults. The most common cause of apraxia is stroke, although it may also occur through other types of neurological damage, such as with a brain tumor or traumatic brain injury.

Aphasia is an impairment of an individual's ability to understand and formulate language, typically involving the left, language-dominant, cerebral hemisphere. With aphasia, language and often communication are permanently altered. Different types or patterns of aphasia correspond to the location of the brain injury in the individual case. By far the most common cause of aphasia is stroke, although aphasia may also result from brain tumors, head injuries, or other insults to the areas of the brain that mediate language processing.

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AAC Technologies Currently Available

AAC includes conventional and non-conventional methods of conveying information and ideas that may take on linguistic or non-linguistic forms. Sign language and finger spelling are examples of unaided, non-conventional forms of communication. Aided techniques include electronic or non-electronic devices that supplement or replace speech-such as symbol systems, communication boards with words, phrases, and pictures, or computer based voice-output communication systems.

To address the varied needs of individuals with severe communication disabilities, AAC devices are divided into several categories. Important considerations when categorizing AAC devices are the type of input (access) and processing features (methods of message generation) they exhibit, as well as the software packages they are able to utilize, and output technology.

Input Technologies consist of two main types of selection techniques, direct and indirect selection.

In direct selection, the user directly selects the desired item from the selection set using the control interface. All of the elements in the selection set are available for selection at any time. Direct selection techniques are the most straightforward and cognitively simple approaches to use in a human/technology interface. Direct selection itself can be divided into categories, for example, direct selection with physical contact, and direct selection with electronic accessory. The downfall of direct selection is that it requires fine motor control. For this reason, indirect selection methods have been developed.[6]

Indirect selection is different from direct selection in that intermediate steps are required to select an item from the selection set. The most common methods of indirect selection are message encoding and scanning.

Message Encoding is a technique in which the user gives multiple signals in order to specify the correct item from the users selection vocabulary. Some devices offer the use of numeric, letter, or iconic codes as a way to store and retrieve messages, and as a rate enhancement technique. Encoding methods are generally implemented in three ways: memory-based, chart-based, and display-based.

Scanning allows items in the selection set to be presented to the user one at a time for the user to select from by activating the control interface at the proper time.[7] Row-column scanning is the most common method of group-item scanning, though other forms of multi-dimensional scanning are available. In addition there are alternate techniques such as linear and circular scanning, and auditory scanning.

Display systems are also an important component in AAC devices.

A dynamic display depicts language in an electronic format. As a result, the information displayed changes in response to user input. That is, when the user selects a location on the display, the device is able to speak a message immediately or changes what appears on the screen. Dynamic displays are essentially computer screens, and therefore typically offer a range of rate enhancement features and message storage options. Devices having dynamic displays can be grouped based on six basic categories. These are taxonomic/thematic, symbolic, alphanumeric, categorical, semantic/syntactic, and frequency.

A static display provides language symbols in a tangible format. An example of a static display is a computer keyboard, which has a fixed layout of letters, numbers, punctuation marks and operational command keys. Most digitized speech AAC devices have static displays, which typically are constructed by an SLP. It should be noted that AAC devices with static displays place cognitive, motor, perceptual and learning requirements on persons using devices to communicate.

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Levels are a main component of storing and retrieving language. Level capability means that each cell shown on the display can produce more than one message. Multiple levels permit the storage of more symbols, letters, words, and/or other messages than can fit within the physical dimensions of an AAC device display. By offering a level alternative, AAC device users have access to more of the language they require to meet their communication needs.

Rate enhancement techniques include letter word prediction, message prediction, semantic compaction, and speech output enhancement.

Branching is a technique of language presentation that allows users to navigate through multiple levels until they find what they want to say. The goals are to get to the message while limiting the number of times a person must hit a switch. Some key aspects involved in branching are the number of branches, the kind of cueing used, and the visual presentation of information.

Three commonly used language representation methods exist in AAC. Spelling is useful for extended vocabulary in that any word can be spelled, provided that the user has the skill and literacy required to do so. Single meaning pictures are a form of direct representation of language, based on the concept that discrete pictures can represent each word. Semantic compaction (multi-meaning icons) provides a means for coding language where combinations of multi-meaning symbols yield specific messages.

Several types of language packages are available for AAC devices. Some manufacturers of AAC technology offer AAC software that is sold separately or in conjunction with a multipurpose hardware platform. An example of AAC software is speech synthesis technologies, which transform ordinary text into speech.

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AAC devices with digitized speech output essentially produce natural speech. Digitized speech output is speech of an individual- the user, or someone other than the AAC device user, such as a spouse, SLP, or other person selected by the user- that has been recorded, stored, and reproduced. AAC devices with digitized speech output are recognized in the professional literature as "closed" systems because they reproduce only those words or messages that have been pre-stored for their user. Although AAC devices with digitized speech output require messages to be pre-stored, the amount of language (words, phrases, sentences or messages) that can be stored in the device, and thus be available to the user, varies greatly, as does the memory capacity of the device.

AAC devices producing synthesized speech output are also available. Speech synthesis is a technology that transfers text input into device-generated speech using algorithms representing linguistic rules. Of these devices, some require message formulation by spelling, and device access by physical contact direct selection techniques. Individuals who have the cognitive and linguistic ability to formulate messages independently require AAC devices with synthesized speech output.

Other AAC devices with synthesized speech output permit multiple methods of message formulation and multiple methods of device access. This allows users to take advantage of text, words, and/or pictographic symbols to formulate some messages or parts of messages and to spell others.

Low-end AAC devices include a range of manual technologies. Communication and picture boards or binders are the simplest systems. The user merely points to words or pictures on a page to express what he or she wants to say. Some drawbacks to this method of communicating are the limited space available for messages and the necessity for the user to first get the attention of the interlocutor.[8]

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Clinical Decision Making: Matching the Device to the Individual

When an AAC device is going to be purchased by a new user, a comprehensive assessment is conducted by a speech language pathologist (SLP), with input as needed from other allied health professionals. The assessment involves six steps:
1. Determining current functional communication levels
2. Predicting future levels of communication effectiveness
3. Identifying functional communication goals and treatment approaches
4. Selecting AAC treatment approaches
5. Selecting an AAC device and accessories
6. Procuring training and follow up

The outcome of the assessment process is a narrative report that includes an AAC treatment plan identifying the functional communication goals the individual is expected to achieve with the AAC device. The SLP then sends the narrative report to the individual's treating physician, who then prescribes AAC treatment and completes the certificate of medical necessity.

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Funding Sources for AAC

Medicare is the nation's largest health services funding program. Many people who need AAC devices, whether the need arises from a congenital impairment, such as cerebral palsy, or an acquired impairment, such as ALS or a stroke, can obtain funding for their AAC devices from Medicare.

This federal health insurance program covers three classes of recipients: Persons age 65 or older, persons receiving Social Security Disability Insurance (SSDI) payments (including many adults with developmental disabilities who receive SSDI on the earnings record of a parent), and persons with end stage renal disease.

Commencing January 1, 2001, Medicare began to cover and provide reimbursement for some AAC devices. Speech Generating Devices (SGD) that are "functionally dedicated" were covered as of this date, however limitations were still imposed. Laptop computers, desktop computers, PDA's (personal digital assistants) or other devices that perform other non-medical functions are not considered dedicated SGD's, and therefore are not covered. On March 26, 2001 Medicare dropped the computer exclusion for AAC devices. Now reimbursement is available for those devices classified as functionally dedicated, including the previously omitted computer and personal assistant based devices.[9]

AAC devices will be covered under Part B as an item of durable medical equipment or as a prosthetic device:

Durable Medical Equipment (DME): Medicare's regulations define DME as equipment that (1) can withstand repeated use; (2) is primarily and customarily used to serve a medical purpose; (3) generally is not useful to an individual in the absence of illness or injury; and (4) is appropriate for use in the home. Dedicated AAC devices meet this definition and ALJ (Administrative Law Judge) hearing decisions have cited the DME category as available for funding AAC devices.

Prosthetic Devices: These are devices "that replace all or part of an internal body organ." Medicare policy expands on this statutory definition to include devices that "replace all or part of the function of a permanently inoperative or malfunctioning external body member or internal body organ." AAC devices can replace the function of the impaired speech center of the brain; of impaired nerve pathways between the brain and speech production organs and structures; and of impairments directly to the speech production organs and structures. ALJ hearing decisions have cited this category as available for funding AAC devices as well. The initial Medicare claim for an AAC device will consist of 2 documents, an AAC evaluation and funding justification, as well as a prescription and certificate of medical necessity. These documents will provide the information necessary to establish the recommended and prescribed AAC device meets the key Medicare criteria for funding approval.

Medicaid funding for AAC devices has been established in at least 45 of the 50 states. It may cover any service fees (health care provider visits), hardware and software requirements, and sometimes an allowance for other equipment. Eligibility is based on financial need and medical necessity (as determined by health care provider). Individual states are permitted to offer the following types of optional services, provided they are specified in that state's approved Medicaid plan:

· Clinical services.
· Treatment for speech, hearing, and language disorders.
· Prosthetic devices.
· Other diagnostic, screening, and rehabilitative services.

Any other type of medical or remedial care recognized under state law and approved by the Secretary of Health and Human Services.

Rehabilitation Services Administration (Vocational Rehabilitation) This is a state-federal program authorized by the Rehabilitation Act of 1973, which provides services for individuals with disabilities in order to assist them in obtaining employment. However, one must meet eligibility requirements to participate in a VR program. U.S.

Veterans Administration Some assistive devices, such as AAC devices, may be reimbursable.[9] Veterans must contact a VA medical facility near their home for specific coverage information.

Private Insurance coverage of augmentative communication devices varies among companies and individual policies. It is important to follow the processes accurately, and to document the need for the service, as required.

Services and equipment are purchased by health benefit plans only if demonstrated to be medically necessary. A speech device may be "medically necessary" if needed to communicate with other people in a manner consistent with his or her potential. Arguments for the equipment should discuss how the impact of the individual's disability will be reduced if the device is provided. This is generally independent of the setting in which it will be used.[10]

Civic & Service Organizations[9] Many community service organizations receive charitable donations to purchase augmentative communication devices for low-income individuals who have speech and/or language disorders. Some of these include (in some locations):

· National Easter Seal Society
· March of Dimes
· Telephone Pioneers of America
· Lions International
· Kiwanis Clubs
· Rotary Clubs
· Sertoma Clubs
· Optimist Clubs
· Knights of Columbus

Local Agencies & Programs[9] Local agencies sometimes receive donations or private funds to assist individuals with various needs. These may include:

United Way agencies (services through local speech and hearing centers)
Speech and hearing centers
Community centers
Religious organizations/institutions
Organizations dedicated to helping people with a specific disability such as ALS Association and the Muscular Dystrophy Association[11]

ADA Compliance Reimbursement The ADA requires, "No person shall be discriminated against on the basis of disability in the full and equal enjoyment of the goods, facilities, privileges, advantages, and accommodations of any place or public accommodation." The 1990 amendment to the Americans with Disabilities Act permits eligible small businesses to receive a tax credit for certain costs of compliance with the ADA. Small business' whose gross receipts do not exceed $1,000,000 or whose workforce does not consist of more than 30 full-time workers may claim a credit of up to 50% of eligible access expenditures that are between $250 and $10,250.[12]

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References

1. National Institutes of Health. (2000). Communicative Competence of Users of Augmentative and Alternative Communication (AAC) Systems. [online]. Available: http://grants.nih.gov/grants/guide/pa-files/PA-96-032.html. (October 11, 2000)
2. UCPA. (1999). "How People Who Use Electronic Augmentative and Alternative Communication Devices Utilize Telephony." [online]. Available: http://tap.gallaudet.edu/UCPA/default.htm. (May 1, 2001)
3. NICHY. (2000). Info About Speech & Language Disorders. [online]. Available: http://www.kidsource.com/NICHCY/speech.html. (November 10, 2000)
4. Huer, Mary Blake. (1998). Augmentative and alternative communication: Changing demographic patterns. "Projected Growth of AAC Users by 2020"
5. M. N. Hegde. "Pocket Guide to Treatment in Speech-Language Pathology." 2nd Edition. 2001. Wright State University College of Engineering and Computer Science. (1999). Selection Systems. [online]. Available: http://www.cs.wright.edu/bie/rehabengr/AAC/selectmethod.htm. (January 24, 2001)
6. Wright State University College of Engineering and Computer Science. (1999). Selection Systems. [online]. Available: http://www.cs.wright.edu/bie/rehabengr/AAC/selectmethod.htm. (January 24, 2001)
7. Minnesota Assistive Technology Loan Network. (2000). What is Augmentative Communication. [online]. Available: http://www.admin.state.mn.us/assistivetechnology/loan/aacinfo.htm. (February 1, 2001)
8. Golinker, Lew. "Medicare drops computer exclusion for AAC devices." Email to the RESNA list serve. March 29, 2001.
9. Gallaudet University. (1999). National Information Center on Deafness: Hearing Aids and Other Assistive Devices: Where to Get Assistance [online]. Available: http://www.gallaudet.edu/~nicd/548.html. (April 25, 2000)
10. Empowerment Zone. (200). Private Health Benefit Plans. [online]. Available: http://www.empowermentzone.com/atinsure.txt. (December 14, 2000)
11. Zygo. (2000). Funding Programs. [online]. Available: http://www.zygo-usa.com/medical.htm. (December 14, 2000)
12. The U.S. Equal Employment Opportunity Commission. (1990). Americans with Disabilities Act. [online]. Available: gopher://trace.wisc.edu/00/ftp/PUB/TEXT/ADA_INFO/HANDBOOK/H_FAQ.TXT. (April 25, 2000)

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