Support

Prompting

Any new learning can be quite overwhelming for the user. Any user can benefit from prompting, regardless of age, communication skills, or cognitive ability.  Prompts can be used to assist the user in successfully learning to perform a task - it is a method of guiding the user to give the correct response. If you don’t prompt, the user will continue an incorrect behaviour, and the motivation to learn will decrease.

What is a prompt? 

A prompt is a cue or instruction that is given before or during a user's action or response. There are different types of prompts that you can use to motivate the user to learn and succeed.

When to start prompting?

It is very important to do sufficient modelling over several weeks, without expecting any sort of response from the user, before you start prompting them for a response. This gives the user sufficient time to observe how the word is modelled before being expected to mimic the same.

What are the different types of prompts?

There are different types of prompts. For example:

Verbal prompts, such as saying “Tap the picture of popcorn!”

Gestural prompts, such as pointing to an appropriate icon on Avaz to remind them to use it.

Physical prompting
Physical prompting involves taking the user’s hand and making them point to the appropriate icon. However, recent research doesn't support physical prompting as it is quite difficult to fade it away. Besides, it makes the user believe that they have no say in the communication and need to go by what the partner is making them do. Physical prompting includes hand-under-hand (which is better recommended compared to hand-over-hand, as it can be more easily faded. Physical prompting is less helpful and using them is not really advocated and it is extremely culturally sensitive (and it does not support safe practices that are important to protect vulnerability) 

Watch Carole Zangari's video about  Prompting and modelling for AAC below (6 min viewing time).  
Read more about Carole Zangari here - Prompting for AAC.  
Prompting Hierarchy - Least-to-most prompting

Though prompts are very useful in teaching a new concept and working on the use of it, it is also important to use them cautiously. Users become dependent on prompts easily and  would seek an adult's or partner’s help before they make any type of response. Research suggests the hierarchy of least-to-most prompting as it provides the user sufficient time to respond to a natural stimulus occurring in the environment. Prompting hierarchy refers to the order and different levels of support that can be used to help the user get the appropriate responses. Remember, as you decide the type of prompts you also need to think of ways to fade prompts over time. Regardless of how often we provide prompts or what type of prompts we provide, providing a model of the possible words suitable in the conversation is considered the most useful strategy we can use.

Let us look at various prompts ranging from least intrusive to most intrusive with encouraging  the user to use the word ‘GO’ to make the car go.

Prompting hierarchy 

E.g. to prompt the word DRINK

Prompting hierarchy
Prompt Intrusiveness	Prompt level	Prompt type	Description	Example
LEAST	0	Independent	No guidance - user responds independently	No prompting required
	1	Visual	WAIT 5-15 seconds for a response. IF they don't respond: Use your body language to indicate that a response is expected. Have an anticipatory look to indicate that you are expecting a response. Wait for 10-15 seconds	Look at the user with raised eyebrows or a shrug of your shoulders and and then roll your eyes towards Avaz . Nodding.
	2a	Verbal - indirect	If they don't respond: Give an indirect verbal hint that indicates to the user that something is expected. Wait for 10-15 seconds.	"Maybe you have something to say?" OR "What do you tap next"
	2b	Verbal - direct	If they don't respond: Direct the child more specifically. Say what has to be done without telling the word to be tapped Wait for 10-15 seconds.	"Tap DRINK"
	3	Gestural	If they don't respond: Point your finger above the icon and gesture a tapping action if required Wait for 10-15 seconds	Point the DRINK button with your finger and gesture the tapping action over it.
	4	Modelling	If they don't respond: Demonstrate how to tap the word while you tap it yourself while speaking the word aloud in the sentence. Wait 10-15 seconds.	Tap the DRINK button as you say "I think you want to DRINK water", while stressing on the word DRINK.
	6a	Physical - Partial	If they don't responsd: Tap or give a nudge at the elbow or fore arm to prompt the child to a response. Wait for 10-15 seconds.	Tap the forearm or at the elbow, nudging them to tap the word.
MOST	6b	Physical - Full	If they don't respond: Try the hand-under-hand method to guide the child's hand to the correct response - partner's hand to be under the user's hand. The hand-over-hand is not preferred as it is hard to fade. Wait for 10-15 seconds.	Hand-under-hand prompt - partner's hand under the user's hand to guide them to DRINK

Important * 

1. Although the hierarchy includes physical prompting as the last option, it is recommended to avoid physical prompting as mentioned above. 
2. It's perfectly ok to continue to model as much as possible and move on. It can take many sessions of modelling before an AAC learner will use a modelled word or utterance. 
3. It is really important to note that the last step is NOT TO FORCE a response from the user. Forcing communication can lead to reluctance or refusal later, because communication becomes a demand or a test.
   
4. Avoid "testing" the child by saying "Show me the apple". This puts pressure on the child to perform. Instead, use visual, indirect prompting and gesturing, which are far more effective to elicit a response, since the child doesn't feel "tested" or judged. 

Example of using Prompting hierarchy

Watch this Video showing the use of the Prompting hierarchy

Note

1. Read more about Importance of PAUSING between prompts for the user's response
2. Avoid directing or instructing the user to do things. As Kate Ahern suggests "If you are telling a student where to navigate or what to say on his or her system you are being a director (and bossy).  Instead of being directive be conversational and use visual, gestural and indirect verbal prompts to guide if you must and then model (if need be) how to get to a relevant page."

If the user responds (using any mode of communication), acknowledge and respond immediately - How to respond when the user attempts to communicate? 

If the user does not respond, move through the next prompt in the hierarchy and WAIT for the response after allowing the indicated wait time. 

What is Prompt dependence?

This occurs when a user needs (depends on) prompts in order to respond. In many cases a user is accidentally taught to wait for a certain prompt before responding.

Some reasons for prompt dependency are:

• Over-use of  prompts                        

• Helping too much or helping too soon 

• Failure to fade prompts

• Repeated use of prompt hierarchy across all the environments and partners thus hindering independent selection of icons 

Prompt fading

If the user doesn’t respond, give the next prompt in the hierarchy and WAIT for the response.  If you don’t use enough wait time, you may be providing more prompts than needed. Remember, rushing through prompts essentially takes away opportunities for the user to respond. Inappropriate prompting can result in prompt dependence, passive engagement, and of course poor use of communication tools. Hence it is very important to start fading prompts gradually but consistently so that the user doesn’t become dependent on the prompts. Start with the one that is most appropriate for the user, but regardless of the prompt used, work towards making your user independent of the prompt. Fade each type of prompt until the user is able to respond independently, without any prompts.

Courtesy: This section is compiled in collaboration with Octave Speech and Hearing, Bangalore.

References: 

Watch video Prompt hierarchy and AAC (13 min video) - by Megan Stewart, MS-CCC SLP

AAC Prompting Hierarchy from Rachel Langley