Meeting Communication Needs

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Meeting Communication Needs

• Low tech AAC from single message to complex
  communication
• Wednesday 23rd April 2008
• Victoria Lundie SLT (ACT)
• Ellie Taylor - SLT

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Contacting ACT

• Helpline 0121 472 0754
• Website www.actwmids.nhs.uk
• Email format firstname.secondname_at_sbpct.nhs.uk
• Main phone number 0121 627 8235
• Address ACT, WMRC, 91 Oak Tree Lane, Selly Oak,
  Birmingham. B29 6JA

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Timetable

• 9.00 Registration and Coffee
• 9.30 Introduction
• 9.45 Who and Where
• 10.45 Tea/coffee
• 11.00 Assessing for low-tech AAC
• 12.15 Lunch
• 1.00 Vocabulary selection / organisation
• 2.00 Tea/coffee
• 2.15 Implementation
• 3.00 Ideas, Resources and Questions
• 3.30 Close

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Introducing ACT

• Regional NHS Tertiary Assistive Technology
  Service all ages and conditions
• Mission statement
• To work with patients, clients and their local
  teams to assess and provide them with techniques
  and technologies which optimize potential for
  communication and control
• Staff OT, SLT, Clinical Scientists, Workshop
  team, Administrators about 30 people.
• Other teams in UK are similar but each is unique

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The West Midlands AAC Care Pathway

• Brief history
• About the training packages
• The documentation and how it can be used.
• Sourcing the documentation

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The West Midlands AAC Care Pathway
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The West Midlands AAC Care Pathway
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Learning outcomes

• Following the course participants will

•  
•  Describe the range of people for whom low tech
  AAC is appropriate and the settings in which it
  could be used.
• Make a basic assessment of what sort system might
  be suitable for the person with AAC needs
• Apply the findings of assessment to the
  construction, use and development of a low tech
  paper based AAC system.
• Choose from the range of tools available to aid
  the production of a low-tech system.
• Be aware of factors to consider in order to
  successfully implement low-tech AAC.

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Introductions

• Please introduce yourself and tell us why you are
  on the course

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• A symbol is something which stands for something
  else. It represents an idea.

• Symbols can come in a variety of forms. They can
  be shapes pictures, colours, actions,sounds or
  written words.

• Symbols can be a very powerful way of
  representing ideas and a most effective means of
  communicating.

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Illustration vs Symbol
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Why do we use symbols and signs?
Faster to understand
Clearer means of communication
Hard Hitting!
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Low v High Tech

• Lo, Hi, Light tech
• No tech requires no additional equipment e.g.
  Signing

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Low v High Tech

• Low /light tech this is used to refer to paper
  based materials.

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Low v High Tech

• Medium tech - simple pieces of technology such
  as single messages devices

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Low v High Tech

• High tech - equipment that is electrical and
  requires power and often has voice output.
  Examples would be a computer or an electronic
  communication aid

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Video

• Example of Low tech communication

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Who may use Low tech AAC?
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Who may use low tech AAC?

• Children Expressive language difficulties
• Receptive language difficulties
• Hearing impairment
• Support for learning and writing
• Adult Adults with learning Difficulties
• Adults with acquired communication Impairment
• Adults with progressive conditions
• Dementia and memory books
• Intensive Care use
• People for whom English is a Second language

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Where?

• School
• Home
• Day centre
• Hospital
• Transport
• Shops
• Out and about
• ..

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Explosion of symbol use in Society

• Approaches PECS, TEACCH, Talking Mats
• Wide use of software programs that make use of
  symbols
• More symbol users in mainstream e.g. storyboards
• Increased emphasis on accessible information and
  Plain English
• Something Special -CBeebies

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Functions of Low tech AAC

• Low tech AAC
• Is used alongside other communication skills

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Functions cont.

• Purely expressively
• Expressive and receptive- aided language
  displays/topic based boards
• Purely receptive e.g. schedules
• Temporarily- support language development /voice
  problems
• All of the above are dependent on a full
  assessment of receptive and expressive skills

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Success Stories

• A student who had become very distressed
  previously on the playground when he could not
  make his needs understood accessed the Aided
  Language Display pointed to a football. When
  asked if he wanted a ball his face lit up and he
  vocalise / gestured yes.
• I could not believe that he had been trying to
  tell me he wanted to go on the climbing frame
  quote about a student who would previously have
  become very distressed when they failed to
  communicate used an ALD when prompted.

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Practical

• Put the items in order of symbolic complexity

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Discussion

• 1 What features of the item did you need to
  consider to make your decision?
• 2 Were any of the items particularly difficult to
  place in the hierarchy?
• 3 What order did you place the items in?
• 4 Is this something you would need to consider
  in your place of work?

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Which symbol is right for me?

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Levels of representation

• Symbol hierarchy Mirenda and Locke 1989
• Objects
• Objects of reference
• Colour photographs
• Black and white photographs
• Miniature objects
• Black and white line drawings
• Colour symbols
• Blissymbols
• Traditional orthography

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TRANSITION

• Continue with the familiar
• Link the unfamiliar
• Use and introduce together

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Tea/coffee break
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Assessment issues

• Categorisation skills
• How items are organised in relation to each other
• Grouping objects / photos / symbols etc
• Conceptual understanding
• Literacy level
• Client rely on spelling for communication?
• Cognition
• Cause and effect / turn taking / memory

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• More than one language in the environment
• Identify first language / should AAC be
  introduced in more than one language
• Motivation
• To initiate communication
• What / with whom to communicate
• Memory and learning
• Most basic level - object permanence
• Visual perceptual skills
• Problem solving
• Needed for visual / auditory and motor learning

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• Interaction skills
• Communicative Intent / Initiation / Shared
  Attention
• Expectations (of client whole team)
• Realistic
• Support available
• Look at all environments
• Resources available to assess
• Communication Aids Centre (Frenchay) AAC
  Screening Assessment
• AAC Carepathway
• Scope Manual Module 5 Accessing equipment
• Module 7
  Foundation Program
• Module 9
  Children and adults with PMLD
• SMART assessment

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Sensory issues

• Vision
• Actual / Perceptual
• Auditory feedback and Partner Assisted Scanning
• Support understanding
• Support memory
• In presence of Visual Impairment
• Tactile
• Hypo / hyper sensitivity
• In presence of Visual Impairment increased
  auditory acuity

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Access issues

• Direct access
• Encoding
• Partner Assisted Scanning
• Turning pages - adaptations
• Single hand operation of book
• Eye-pointing
• Personal Choice

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Practical

• Video and practical resources to demonstrate /
  support the assessment process.
• Hands on

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Lunch
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• Vocabulary Selection Organisation -
• Practicalities of putting together a Low Tech
  system

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Symbol Systems

• Rebus
• Makaton
• PCS
• Signalong
• Blissymbolics
• Change symbols
• Ispeek
• Sigsymbols
• CALL Centre guide to picture and symbol sets (in
  pack)

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Examples of symbols
Line drawing symbols E.g. Widgit Literacy
Symbols Previously Rebus

• Colour picture drawings
• E.g. Picture Communication Symbols from Mayer
  Johnson
• Or Dynasyms

Or Makaton symbols
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Examples of symbols

• Bliss symbols

Written word Swimming
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Organisation of Books and Boards

• Text or Symbols
• Size position of symbols text
• Number of symbols on page
• Portrait/landscape
• Links to voice output machine
• Sensory considerations e.g. vision etc

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• Words v phrases (sentence building)
• Needs / wants / chat
• Taxonomic (categories) v Systemic (environments)
• Use of colour encoding (a) eye pointing (b)
  Language development e.g. Fitzgerald Key

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Forms of low tech AAC

• Communication boards v communication books
• Communication Passports templates available
  scope / call / sense
• Talking Mats
• Alphabet charts
• Etran frames
• Objects / Smells of Reference
• Use along side low and high tech

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Things to Remember about VocabularyWhitton,M.
1995 Lost for words? Vocabulary selection for
communication aids Communication Matters Vol.9
No.3

•  The vocabulary in the system is unique to the
  individual
•  The user should be included in the selection
  process
• Team approach - done in isolation by one person,
  collection is unlikely to be very
  successful        
• Collection, organisation is an evolving and
  continuous process as user develops / changes.
• There needs to be growing room in the system

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Collection Techniques

• Making a start
• Get organized!!
• Be thorough to start with, as things can be hard
  to alter later planning is crucial
• Try to collect widely people places
• How will you back up the records?
• Involve the user something thats is motivating
  for them will be more effective.

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Methods

•  Unstructured listing
•  Interview
•  Scripting (remember to get both sides!)
•  Vocabulary lists
•  An ongoing updating system for collection
•  Remember to review and revise the system
• F.A.I.R. Flexible, Accessible, Individualised,
  Respected.

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Practical Case studies

• Design considerations of a low tech chart
• Groups 3 or 4
• Choose a case study
• Describe the main features of a communication
  chart that could be designed for an individual to
  chat in a restaurant
• Feedback sheet to help guide your decisions.

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Useful Software

• Boardmaker
• PowerPoint
• Writing with Symbols 2000
• Communicate in Print
• Clicker
• Word Google images / clip art

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Tea / Coffee Break
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Environment issues

• Training for communication partners
• Training and resources to make and update
• Structures in the environment
• Having one system per environment or one for all
  places

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Practical Considerations

• What to do if it gets lost or chewed?
• How many personal details to put on the book
• Age appropriate language e.g. sexual vocab/
  swearing
• Needs updating

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Describing successful AAC

• Janice Lights (1988) 4 agendas of communicative
  interactions the successful AAC user needs to be
  able to access and use these purposes
• Expression of wants and needs
• Information transfer
• Social closeness
• Social etiquette

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These successes depend on 4 Communicative
competencies

• Communicative Competenceis the ability to
  communicate functionally in the natural
  environment and to adequately meet daily
  communication needs (Dr. Janice Light, 1989)
• Light 1989 4 competencies
• Linguistic
• Operational
• Social
• Strategic

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AAC Competencies References Light, 1989
Cottier, Doyle Gilworth, 1997 Light Binger,
1998

• Strategic Competence
• Strategic skills refer to compensatory strategies
  that may be utilised by individuals who use AAC
  to overcome functional limitations that restrict
  their effectiveness as communicators.
•  

 
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• Facilitator is as Supportive Role
• USE THEIR SYMBOLS/SIGNS
• Creating personal passport
• Modelling strategies in role play situations
• Expanding beyond the basic
• Modelling use of symbols or signs to augment/give
  clues.
• Strategic/Supportive Aims
• Identify new messages for class trip that should
  be programmed into the device
• Identify method for indicating that client has
  not got access to communication book

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AAC Competencies References Light, 1989
Cottier, Doyle and Gilworth, 1997 Light and
Binger, 1998

•  Linguistic Competence
•  Linguistic skills include receptive and
  expressive skills in the native language spoken
  by the family and broader social community (e.g.
  the skills to understand spoken English or
  Spanish).
• Linguistic skills also include skills in the
  "linguistic" code of the AAC system (e.g.
  learning the symbols of the AAC system, such as
  drawings, words, or signs learning how to
  combine these symbols to represent more complex
  meanings).

 
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LINGUISTIC/COGNITIVE Facilitator Role Add symbols
for everyday activities Use simple language and
reinforce new vocab with sign or symbol . Use
who what and where not is it x or
y? Establishing routines are understood Create
an environment where an individual can explore
cognitive concepts modelled by facilitator e.g.
more/finished Language and Cognitive Aims I
need to work on clause level 3 word expression
e.g. daddy kick ball Cognitive skills e.g.
memory, choice making, sequencing skills.
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AAC Competencies References Light, 1989
Cottier, Doyle and Gilworth, 1997 Light and
Binger, 1998

• Social Competence
•  
• Knowledge, judgement, and skills in the social
  rules of interaction.
• For example, the skills to initiate, maintain,
  develop, and terminate interactions the skills
  to develop positive relationships and
  interactions with others the skills to express a
  full range of communicative functions (e.g.
  requests for objects, protests, requests for
  information) etc
•  
•  

 
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AAC Competencies References Light, 1989
Cottier, Doyle and Gilworth, 1997 Light and
Binger, 1998

• Operational Competence
•  Operational skills refer to the technical skills
  required to use the AAC system(s) accurately,
  efficiently, and appropriately.
• For example, operational skills would include the
  skills to produce the hand shapes and movements
  needed to form signs or gestures correctly the
  skills to use a head pointer to indicate items on
  a communication board the skills to use
  row-column scanning with a single switch to
  control a VOCA etc
• Access Aims
• Ability to retrieve stored messages of a key
  character/story
•  Therapist to map onto AAC care pathway to
  facilitate mounting of VOCA on my new wheelchair

 
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Facilitator Role for operational competence Is it
there? Is it accessible? Preparation of
symbols/ALDs etc
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Means, Reasons, Opportunities Model
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Implementation and Resources
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Supported Conversation for Adults with Aphasia
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Social Model of Disability

• Disability is the loss or limitation of
  opportunities that prevents people who have
  impairments from taking part in the normal life
  of the community on an equal level with others
  due to physical and social barriers
• -Finkelstein and French, 1993

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Supported Conversation with Adults with Aphasia
(SCA)

• Aura Kagan 1989 describes supported conversation
  as a method where The partner acts as a resource
  for the Aphasic person and actively shares the
  communication load. Supported Conversation
  provides conversation partners with methods and
  materials for achieving this goal

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What is Supported Conversation?

• Supported conversation for Adults with Aphasia
  SCA
• competence can be revealed by conversation
  itself (Beyond Aphasia, 2000)
• SCA is based on the idea of conversational
  partnerships there is less emphasis on
  independent use of communication strategies by
  the aphasic partner and more emphasis on what the
  dyad achieves interdependently (Kagan, 1998)

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What is Supported Conversation?

• The partner acts as a resource for the aphasic
  person and actively shares the communication
  load. SCA provides conversation partners with
  methods and materials for achieving this goal
• Designed to reduce the psychosocial consequences
  of aphasia
• - Kagan 1998

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Props and Ramps

• Joint Reference
• Initiation
• Expanding

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Conversation Ramps

• Quiet surroundings
• Taking your time
• Writing
• Gesture
• Drawing
• Pictures magazines, newspapers, photos, books,
  SCA resource
• Communication books/ Communication passports
• Taking turns

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What can SCA bring to work with people using AAC?

• Underlying Philosophy Social not Medical
• Acknowledging Competence
• Revealing Competence
• Equal responsibility in a conversation
• Rejection of AAC is an option, not a failure but
  a choice.(social needs and info) Conversation is
  essential not a luxury.

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It takes two to talk Hanen 2004

• Let your child lead
• Follow your childs lead
• Take turns to keep the interaction going
• Add language to the interaction
• Then moves on to using these skills in different
  contexts e.g. play, music, books,

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Help to focus on getting use of AAC going

• Following the lead matches well with an error
  free approach to early attempts with AAC
• Taking turns matches well with modelling the use
  of the AAC system to the user.
• Add language matches well with extending AAC use
  with further modelling of AAC into growing room
  in the system

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How can symbols be successful?

• Opportunities
• Sabotage/ creating reasons
• Creative stupidity !
• Misinterpreting non verbal cues..

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How can symbols be successful?

• Joint Reference
• Cinema tickets / key rings/photos etc

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How can symbols be successful?

• Modelling
• Not just identifying the symbols but showing HOW
  they could be used

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How can symbols be successful?

• Prompting
• Hierarchy of prompts
• Time delay/contextual cue
• Indirect Verbal cue
• Search light cue
• Direct verbal cue
• Accomplice suggestions
• Momentary light cue
• Fixed light cue
• Physical prompt/rhythmic intention.

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How can symbols be successful?

• Accessibility
• Where are the symbols?

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Summary

• Revisit objectives
• Discussion
• Questions
• Hands on