Augmentative & Alternative Communication Next Steps (Assessment and Implementation) Kathleen Post, MS-CCC/SLP K. Post AAC Linked Series for Infinitec

Welcome! Plan for the day

IL State Standards Social Emotional Learning Listening and Speaking Goal 2 - Use social-awareness and interpersonal skills to establish and maintain positive relationships. Goal 3 - Demonstrate decision-making skills and responsible behaviors in personal, school, and community contexts. Listening and Speaking Goal 4: Listen and speak effectively in a variety of situations. Plus more (reading, writing, etc.)! http://www.isbe.net/ils/ 3

Begin with the end in mind. -Stephen Covey

What do we know? AAC - Augmentative & Alternative Communication Who Goals Martinsen & vonTetzchner, 1996 Paula defined three groups based on Martinsen & vonTetzchner, 1986 Alternate Language Group- little or no speech, difficulty in understanding language Autism, severe cognitive impairment, auditory agnosia Goal- to assist the understanding of langue, develop interaction skills and increase opportunities for expressive language. Expressive Language Group- severe speech motor dysfunction Cerebral Palsy, Severe Dysarthria, as age, gap increases between what can say and what understand Goal- To provide means to express interests, needs, and comments and to provide opportunity to actively participate in the curriculum and to develop literacy skills. Supportive Language Group- moderate motor speech dysfunction, problems with speech and language Speech is poor, but typically do become intelligible speakers, Downs Syndrome, Apraxia, Severe oral-motor impairments, severe articulation disorders Goal- provide a bridge for the development of speech and language and a means to enhance participation and communicative competence. However, all children's need for augmentative communication is not the same. Martinsen & von Tetzchner (1996) identified three groups of children who require augmentative/ alternative communication. They called these the: alternative language group, expressive language group, and supportive language group. Each of these groups is very different and requires AAC for different reasons. The Alternate Language Group is made up of children who use little or no speech to communicate and have a difficult time understanding spoken language. Children with Autism and severe cognitive impairment fall into this group, as do children with auditory agnosia (Problems recognizing sounds as meaningful linguistic elements.). Children in this group often use gesture as their primary means of understanding language. The primary goals of AAC with this group are to provide input to assist the student in the understanding of language, to develop interaction skills for that student and to increase the opportunities for expressive communication. The Expressive Language Group includes students who have severe motor involvement, thus severe speech motor dysfunction. As they mature these children experience a widening gap between what they understand and what they are able to express using speech. Children with athetoid cerebral palsy and severe dysarthria of speech are examples . The main goal for AAC intervention with this group is to provide a means to express their interests, needs, and comments, provide opportunities to actively participate in the curriculum and focus on the development of literacy skills. The Supportive Language Group includes students with moderate motor speech dysfunction. These children often have problems with both speech and language. Speech is poorly articulated during the birth through preschool years, although many of these children will become intelligible speakers. This group may include children with: Down syndrome, apraxia of speech, severe oral-motor impairments, severe articulation disorders and developmental delay. The primary goal of AAC intervention for this group is to provide a bridge for the development of speech and language and a means to enhance participation and increase communicative competence.

Alternative Language Group Who little to no speech & difficulty in understanding language (Autism, severe cognitive impairments, etc.) Goal assist in understanding language, develop interaction skills, increase opportunities for expressive language Stand if you have kids in this group! Count numbers! Video of Danny

Expressive Language Group Who severe speech motor dysfunction (CP, Dysarthria), widening gap between expressive and receptive language Goal provide means to express needs, interests, comment, actively participate, develop literacy skills, etc. Stand if you have kids in this group! Count numbers! Video of Kylie B

Supportive Language Group Who moderate motor speech dysfunction, problems with speech and language, speech is poor, but may develop more intelligibility (Downs, Apraxia, etc.) Goal provide a bridge for development of speech and language and a means to enhance participation and communicative competency Stand if you have kids in this group! Count numbers! Video of Kelly and Jack Aided Language Stimulation can also be used when a student needs receptive vocabulary increased. Students in the Alternative Language Group especially benefit from an environment where communication partners use alternative language forms on a regular basis. So it is important to use Aided Language Stimulation, to provide picture schedules and to accompany spoken language with graphic symbols when communicating with a child in this group. When a student uses an augmentative communication board or device (or even their own voice) to respond to communication, but rarely or never initiates communication, increase communication opportunities through Environmental Communication Teaching.-Environmental Communication Teaching (ECT) uses incidental teaching episodes that are short, positive and geared towards functional communication, not language training. There are three major components to ECT training: (1) Use of structural analysis and modifications, (2) use of cues, prompts, and descriptive feedback, and (3) use of AAC techniques and approaches (McCloskey & Fonner, 1999). Structural analysis and modifications specifically focus on knowledge of the different contexts for interaction, how the contexts are socially regulated, and how communicative functions are utilized within those contexts. Within the ECT training, cues, prompts, and feedback strategies are used to facilitate the initiation of communication interaction. These strategies are also utilized to encourage the use of age- and activity-appropriate communication. The prompt hierarchy listed below is employed when target students do not exhibit the level or amount of communication expected.

Assessment & Evaluation How do we help? Assessment & Evaluation University of Oregon Teaching Effectiveness Program defines assessment as: Assessment is the process of gathering and discussing information from multiple and diverse sources in order to develop a deep understanding of what students know, understand, and can do with their knowledge as a result of their educational experiences; the process culminates when assessment results are used to improve subsequent learning. Found on

Assessment and Evaluation Evaluation can be defined as: to draw conclusions from, judge, compare and contrast, interpret, decide. In AAC, assessment and evaluation are used interchangeably, but perhaps they should be used together!

Augmentative Communication Assessment Goal of AAC- Assist individuals with communication disorders to become communicatively competent to meet current needs and to prepare them for future needs. Beukelman & Mirenda, 1998

Augmentative Communication Assessment Purpose of AAC Assessment: Determine which methods and tools will improve the exchange of information between the individual and others- communication! Knowledge of individual Assessment of the skills and needs of the individual in multiple areas affecting access to and understanding of communication (vision, motor, hearing, language, etc.) Knowledge of AAC (not just devices, but also techniques and strategies) Integrated with Evidence Based Practice Includes research Clinician’s expertise Consumer’s values and preferences Beukelman & Mirenda, 1998 Heling & Rush, 2009

Results of the AAC Assessment To provide a plan for communication supports that includes: Details of recommended non speech and/or speech generating systems Recommendations for any changes to the environment to support communication (including training partners) Recommendations for intervention to address or improve operational, linguistic, strategic and social competence

Team Approach Who should participate? Why?

Types of AAC Assessments Candidacy models Who needs AAC? Replaced by Communication Needs models Based candidacy on needs, not on impairments Participation model Assess and base AAC on functional participation requirements of peers Feature-Based Assessment for Speech-Generating Devices (SGD) Beukelman & Miranda, 1998

Plan to Assess and Evaluate Identify and define areas of concern Gather information related to concerns Gather relevant information for various skill areas related to the use of Speech Generating Device (SGD) Analyze information Create a Feature List Generate and prioritize potential solutions Compare intervention options Develop trial action plan Conduct trials and collect data on effectiveness Formulate recommendations Document Politano, 2009

State the Need or Goal Make sure that everyone is on the same page! What do you hope to achieve by the end of this assessment and evaluation process?

Gather the Information Survey family and team members or service providers regarding: Current problems Current communication behaviors or skills Activity preferences Any history of usage of communication supports If there is conflict over whether the student needs AAC refer to an intelligibility test! Create your own or use The Quick Screener powerpoint Need Case History Form

Gather the Information What can I use? Any case history form obtained or developed or customized for this purpose WATI forms http://www.wati.org/?pageLoad=content/supports/free/index.php Easter Seals DuPage forms http://dfvr.easterseals.com/site/PageServer?pagename=ILDU_AssistiveTech Infinitec Student Summary forms (handout)

Gather the Information Sensory/Perceptual Goal is to determine size, type, placement of symbols & identify language input & output options Vision (Any standard assessment information and/or informal notations by team members) Visual Acuity Visual Field Oculomotor Functioning Light Sensitivity Color Perception Ask for ideas of how to assess this skill (what other tools can be used, such as Powerpoint, BoardMaker Plus, Device software)

Gather the Information What can I use? Formal or Informal testing materials may be: TASP (Test of Aided-Communication Symbol Performance by Joan Bruno) Created boards/electronic displays with differing symbol sizes and placements (eye gaze and direct selection) Pogo Boards (https://www.pogoboards.com/Login.aspx) Speech Generating Device Page sets/tasks DynaVox, Prentke Romich Company, Tobii, etc.

Test of Aided-Communication Symbol Performance (TASP) Written by Joan Bruno, available from Mayer-Johnson, www.mayer-johnson.com A tool for the assessment of Mayer- Johnson symbol-based communication skills Includes subtests on symbol size and number, grammatical encoding, categorization and syntactic performance Results may help determine AAC intervention strategies and goals Provides starting point for designing communication boards or selecting a page for an AAC device Show pages scanned in

Gather the Information Sensory/Perceptual (cont’d) Hearing (Standard Assessment) If aided, where is sound best heard from? Other sensory systems (tactile, olfactory, vestibular, gustatory) * * If these are the targets for more in-depth investigation, use of Every Move Counts, Clicks and Chats is recommended as the assessment tool. Information from that tool can then be brought to the Feature Match outline for further determination. Bring out Every Move Counts book. Discuss kids with significant challenges for whom connecting with the environment is a major goal and there disabilities a major road block. Discuss the need to develop communication keys: Be able to separate themselves from the environment, Understand that these is something they can do to exchange information with someone, understand that there are things about which to communicate, and understand that there are people with whom to communicate. Sternberg, L. 1980, Communication Programming Inventory. In Educating severely and profoundly handicapped studnets, 325-333. Rockville, MD: Aspen Every Move Counts is a unique blend of communication strategies with sensory integration techniques to better meet the needs of individuals with disabilities. Studies by experts in SI have reported an increase in spontaneous language after vestibular stimulation. (Magrun, W.M., K. Ottenbacher, S. McCue, and R. Keefe. 1981, Effects of vestibular stimulation on speontaneous use of langauge in developmentally delayed children. The American Journal of Occupational Therapy 35(2):101-4.) Process for Every Move Counts: Identification Process (find activities to which the individual responds (hopefully in a positive manner) Definition Process (a specific response is selected and contingencies are introduced--the occurance of a pleasurable event becomes dependent on the individual giving a more clearly defined response) Co-occurance! Elicitation and Refinement Process (provide frequent opportunities for the individual to experience co-occurances between their response and the event). Generalization and Expansion Process Allows for individuals limitations rather than penalize for them, it does not require a specific response, but gives you a framework for interpreting the responses given.

Gather the Information Motor Skills Goal is to identify optimal seating, positioning, and motor technique for using AAC system Work with other members of the interdisciplinary team, as necessary Identify appropriate positioning Identify selection method and technique (direct, scanning, encoding) Where on the body (hands, head/voice, feet, arms/elbow, legs/knees, eye gaze) Positioning has a direct impact on motor control, which is necessary for use of all AT Determine direct selection via what? And then Range Target Size Experience with Control Enhancers If Scanning: determine visual, auditory or both? What type of switch access, describe, timing, method of highlighting, memory load of messages or cuing.

Definitions Direct Selection- Scanning- Directly touching the item or target desired Scanning- Moving a highlight to a specific target Linear, circular, row column, column row, group row column, etc. Single switch automatic scanning, two switch step scanning, inverse scanning, etc.

Switch Data Talk about How do you know it, How can you show it book from WATI site

Gather the Information Motor Skills cont’d What action will be used How with the movement be used (direct select, head pointing, eye gaze, joystick, Morse code, scanning) Considerations Type, range, accuracy, consistency, strength, speed, etc. Activation site: the minimum size of the targets, possible number of targets, spacing of targets, etc., will be determined by accuracy Sensitivity: the amount of pressure or force needed to activate the target.

Gather the Information

Gather the Information Questions to ask yourselves: Can the method of access be used repeatedly without undue fatigue, discomfort or embarrassment? What does the student like/tolerate? Can this method be used across all environments or will there need to be other options for other situations/positions?

Gather the Information What can I use? Formal or Informal testing materials may be: TASP (Test of Aided-Communication Symbol Performance by Joan Bruno) Created boards/electronic displays with differing symbol sizes and placements (eye gaze and direct selection, scanning) Pogo Boards (https://www.pogoboards.com/Login.aspx) Speech Generating Device Page sets/tasks DynaVox, Prentke Romich Company, Tobii, etc.

Gather the Information Cognition Goal is to identify AAC techniques & strategies & select types of symbols Modification of existing assessment instruments may be necessary along with the expertise to interpret results Gain information on how the student perceives world and how they may use communication within their understanding.

Gather the Information Cognition cont’d Assess ability to categorize Assess ability to use memory skills/motor patterns What can I use? Communication Matrix (www.communicationmatrix.org), Every Move Counts-Clicks & Chats, Communication and Symbolic Behavior Scales by Wetherby and Prizant, TASP, other formal or informal tests and inventories.

Gather the Information Language skills Goal is to identify language skills for communication and comprehension. Modification of existing assessment instruments may be necessary along with the expertise to interpret results Vocabulary Grammar Discourse/Pragmatics Literacy (assess understanding if possible and survey needs) Assess reading, spelling, and writing skills if present. Can the student use letter cues, recognize words when offered, understand alphabetical arrangements, etc.

Gather the Information What can I use? Use word lists, use interview and observation inventories. Use formal tests (TACL, CELF, SPELT) Video an interaction opportunity, take a language sample! What topics initiated, continued, terminated? What types of words used, how frequently, etc. Use formal or informal assessments regarding literacy levels, sight words, etc.

Gather the Information Symbol Selection Goal is to identify types of language representation Modification of existing assessment instruments may be necessary along with the expertise to interpret results Determine how an individual can communication with symbols & possible symbol types Objects, Texture cues or symbols, Cut Out Photographs, Pictures, and Symbols, Photographs, Line Drawings (Color), Line Drawings (Black & White), Realistic (Color), Realistic (Black & White), Visual Scenes, Alphabet/Spelling Talk about use of photos with BM symbols on them and then fading, etc. Pogo boards with different symbols, etc.

Gather the Information What can I use? TASP; Speech Generating Device Protocols; Metaphor Protocol by Gail VanTatenhove (http://www.vantatenhove.com/showfree.php?id=182) Informally created comparisons

Gather the Information Use of Communication Partners & Environments Note support or prompting help given by communication partners Note needs for different environments What can I use? Informal observation/documentation, video clips, interview, Social Networks by Sarah Blackstone.

Social Networks

Analyze the Information Determine a list of features needed based on performances, behaviors, needs gathered. Input Features and Selection Methods Access Method Direct Selection- Range/size, touch sensitivity or responsiveness, position, zoom Scanning- Number of choices, prompting (auditory/visual), zoom, highlighting, etc.

Analyze the Information Input Features and Selection Methods (cont’d) Display Design Size of targets, number of targets, arrangement, contrast, etc. Think about direct selection-- motor memory is important! Maybe do motor memory test?

Analyze the Information Output Needs Speech output Type- digitized, synthesized, combination Display output Words/letters for partner/user reference Activation marker Environmental controls Interface to computers, printers, phone systems

Analyze the Information Message Characteristics Whole sentences Phrases Words Letters Pictures Ability to combine any of the above? Rate Enhancement Strategies Visual scenes, topical dictionaries, Unity, word prediction, abbreviation-expansion

Analyze the Information Physical Characteristics Size Weight Battery Life Durability Mounting Transferability Ease of setup Visibility Backup systems

Determine Options How do I do that? Generate a list of systems that meet many or most of the needs list How do I do that? AAC TechConnect (trial) Manufacturer Websites Handouts from other sources Own Experience Talk about asking manufacturers representatives Show some examples of charts

So many options!

Resources for Systems Comparison AACtechConnect www.aactechconnect.com My Dynamic Therapy www.mydynamictherapy.com/tools_for_professionals.htm Closing the Gap www.closingthegap.com SETBC http://www.setbc.org/lcindexer/default.aspx ABLEDATA http://www.abledata.com Assistive Technology Exhibits (ATIA, CTG,CSUN etc) Speech Generating Device manufacturers Enabling Devices http://enablingdevices.com Gus Communications Inc. http://www.gusinc.com/Communicators/ Dynavox Technologies http://www.dynavoxtech.com/products/devices.aspx AMDI http://www.amdi.net/comparisonMain.php Ablenet http://ablenetinc.calls.net/Home/Products/CommunicationProducts

Trials Where can I go? Obtain the top 3 systems for trial State Assistive Technology Program- Lending Program,www.iltech.org Infinitec Coalition Speech Generating Device Companies Professional Loan Local Representative Device Rental School Districts and Special Ed Cooperatives Infinitec Website ilTech website

Trials Set up systems for student Vocabulary, access method, voice, positioning Train staff that will be involved with student for trial Try systems with student and note performance, behaviors Length of trial may depend on student and equipment availability Determine what is important to observe during the trial Ease of access Use of the system functionally (where and with whom and with what other supports) Document performance

Trials Compare performances and data and discuss with team members Determine next plan of action Further trials Procural of system and supports Develop communication intervention plan Determine responsibilities for ongoing training, troubleshooting, and updating

Where do I go to write the report/submit for purchase? Report Templates and Funding Information AAC-RERC http://aac-rerc.psu.edu/ Assistive Technology Law Center, Inc. www.aacfundinghelp.com Funding Sources AAC Report Coach Funding Assistance from Speech Generating Companies Other processes within district or use of established forms from WATI or GPAT (www.gpat.org/)

Activity Break into small groups One person volunteers to present a student they work with (no real names please) Work through the Assessment process with the group and determine: What type of communicator? What team members need to be involved? Roles-responsibilities What do you know as it relates to the Assessment process? What information still needs to be collected, how? Next steps.. Be prepared to share key points with group.

Contact Information Kathleen Post, MS-CCC/SLP Manager, Assistive Technology Department, Easter Seals DuPage & Fox Valley Region 830 S. Addison, Villa Park, IL 60181 Kpost@eastersealsdfvr.org Infinite member website: www.myinfinitec.org Wiki site for AAC Linked Series: at http://aacworkshop.pbworks.com/