Transcript AAC Presentation - SCATP - University of South Carolina

Devices and
Strategies for Adults
with Communication
Disorders
Carol A. Page, PhD, CCC-SLP, ATP
South Carolina Assistive Technology Program
Center for Disability Resources
University of South Carolina School of Medicine
Training Objectives
Participants will:
Identify four components of an augmentative
and alternative communication assessment
list two types of adult communication skills
that are impacted by some disabilities.
list three low-tech communication set-ups.
list two strategies for facilitating
communication using visual supports.
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Keep in mind...
The equipment, software, ideas and
examples presented today represent a
starting place and are not specific
recommendations or endorsements. The
suggested intervention techniques should
be implemented only after careful
consideration and under ongoing
consultation from a qualified SpeechLanguage Pathologist.
3
Myths -- True or False
Delay providing augmentative and
alternative communication (AAC) until the
individual obtains a certain level of
cognitive, language, or motoric functioning.
Individuals who are stubborn,
uncooperative, “not listening,” easily
frustrated, unorganized and off-task, are
not able to benefit from AAC or visual
supports.
Cognitive, language, and motoric
limitations make it difficult for individuals to
use AAC systems.
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Myths -- True or False
In patients whose cognitive, language, or
motoric functions will change, it is hard to
select an AAC system.
In patients who will recover speech, AAC
should not be used.
Select an AAC system that will last an
individual a lifetime.
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Prerequisites
for the Use of
AAC
NONE!
Kangas & Lloyd, 1988
Beukelman & Mirenda, 1998
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Benefits of AAC or Visual Supports
Facilitates expressive communication for
individuals who are verbal, limited verbally or
nonverbal
Enhances comprehension
Assists with processing information
Assists with organization
Increases independence
Improves or modifies behavior
Teaches time organization, time management,
sense of time
Improves social skills and social acceptance
Provides reminders of what is important (can be
on the spot reminders)
Assists with multi-step tasks
Builds predictability/ provides predictability
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Benefits of AAC or Visual Supports
Assists in keeping track of information and dealing
with it effectively and efficiently
Improves planning
Decreases anxiety and stress
Develops sequential memory
Increases attending
Improves memory
Influences development of word recognition
Provides clear visual and physical boundaries
Highlights important information
Assists with following directions and rules
Provides alternative means to process information
and alternative means to demonstrate knowledge
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Multimodality AAC
More than one form of communication is
needed to meet needs and social
expectations.
Visual supports are most beneficial when
used in conjunction with spoken language,
gestures, and/or sign language.
Typically many of us use two or more forms
of AAC or visual supports as we talk.
Multiple symbol systems may need to be
taught or refined.
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AAC and Visual Support
Assessment
Participation Patterns and Communication Needs
- Activity inventory
- Participation barriers/effectiveness
- Participation of family, friends, etc.
Opportunity Barriers
- Policy, practice, attitude, knowledge, skill
- Opportunity, natural ability, and AAC system interventions
Access Barriers
- Current communication
- Prognosis for growth and ability to use AAC
Plan and Implement for Today and Tomorrow
- Provide instruction in natural contexts
- Address specific skills
- Train communication partners
Intervention Effectiveness
- Is person participating?
Participation Model
Beukelman & Mirenda, 1998
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AAC Assessment
IDENTIFY
COMMUNICATION
NEEDS
ASSESS
OPPORTUNITY
BARRIERS
ASSESS
ACCESS
BARRIERS
PLAN & IMPLEMENT
INTERVENTIONS FOR
TODAY & TOMORROW
EVALUATE
INTERVENTION
EFFECTIVENESS
Participation Model
Beukelman & Mirenda, 1998
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Loss of Speech After Trauma
Requesting is basic communication skill:
- Eye gaze
- Change in behavior or maladaptive behavior
- Vocalizing
- Facial expression
- Body posture or body language
- Pointing, reaching or grasping
- Tapping
- Verbalizing
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Success for Communicators after
Trauma
Arrange environment to create
communication opportunities
Create environment that is motivating for
communication
Provide supports to assist the person in
participating in the communication exchange
Follow communication behavior with a
consequence
Make sure consequences are meaningful
and not artificial
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Progressive Loss of Speech
Individuals with ALS should be encouraged
to use residual speech as long as possible
- 90% with limb onset (spinal) ALS. Speech is
affected late in the progression.
- 10% with bulbar ALS. Speech and swallowing
affected early.
Maintain the individual’s personal (e.g. lowtech) ways of communicating as long as
possible.
- Yes/No questions and 20 questions
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Progressive Loss of Speech
Suggest communication options with
sensitivity to “technophobic” individuals and
their family members.
Plan for change. Make sure the system has
room to grow.
Consider “voice banking.”
Consider privacy issues for letters, e-mail,
phone.
Periodic re-evaluation will be needed.
15
Continuum of AAC Symbols
Continuum:
objects (easiest-concrete)
- objects with pictures
and words
- photos, pictures and
words
- text (most difficult-abstract)
-
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Why Objects Work
Concrete (low cognitive demand)
Static or permanent (low memory demand)
Iconicity (close obvious relationship to referent)
Easy to manipulate
Tactile discrimination
Support expressive and receptive
communication
Elizabeth Rush, MA, CCC-SLP, CPM
Mary Joan McClure, MS, CCC-SLP
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Using Objects to Communicate
May need to use the actual object at first.
Use a duplicate object (symbol) as soon as
possible.
Begin exchange system.
Mount object on board or voice output device.
Change color, size or texture of object.
Introduce second, but very different object
symbol.
Elizabeth Rush, MA, CCC-SLP, CPM
Mary Joan McClure, MS, CCC-SLP
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Basic Considerations of
AAC Devices
Size
Weight
Display size
Battery life
Does the device
meet current and future needs and
expectations?
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Message Selection
Requesting wants and needs
Making choices
Confirming or denying
Rejecting and protesting
Gaining attention
Providing greetings, farewells, social
niceties
Expressing feelings
Making comments
Asking for information or help
Telling jokes
Connecting with peers
Asking questions
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Message Selection
Message Selection for Communication
System:
- If neurological and physical potential
for speech exists, a preference will be
shown towards speech.
- Speech is easy and highly accepted.
(Burkhart, 1993, p. 38)
- It is typical for an individual to use the least
restrictive mode of communication.
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Message Selection
Message Selection for Communication
System:
- Avoid starting with messages that are
abstract in nature (ie. “yes” and no”).
- Avoid programming messages that can be
gestured or spoken (ie. “yes” and “no”).
- Change messages as interests and wants
and needs change.
- Include peer-level language.
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Message Selection
Core Vocabulary:
- A few hundred words that make up
approximately 80% of what a person says.
- Note that the most frequently occurring
words of older adults (using real voice or
synthetic voice) do not include many
nouns (see handouts).
- Nouns and verbs are the easiest to
represent in a concrete format. Other
vocabulary is abstract when illustrated.
Message Selection
Core Vocabulary:
- “Total communication” is the combination
of general core vocabulary and extended
vocabulary.
- Combine general core vocabulary and
personal core vocabulary for fastest
communication.
AAC Institute
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Message Selection
Communication Intents:
- I want something
- Something’s wrong
- I’ll tell you what I think (or I like and I
don’t like)
- It’s time for something
- Let’s chat
- I’m asking a question
- I have an idea
- I’m telling you a story
Linda Burkhart
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Message Selection
Quick Words:
- more
- done
- different
- me, mine, my turn
- you, yours, your turn
- someone else
- hurry
- uh oh!
- help
Linda Burkhart
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Message Selection
Use single-word messages
whenever possible because they
allow for generative language and
utterance expansion.
(Anderson & Baker, 2004)
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Message Selection
Why single-word messages can be
more efficient:
- Communicating using single-word messages
allows more flexibility than sentence messages.
- Generating a message using single-word messages is
easier overall than communicating through sentence
messages.
- Single-word messages can be used across
environments.
- Sentence messages rarely reflect speaker
intentionality.
- Language acquisition takes place when single-word
messages are combined to make multi-word
messages.
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Message Selection
Effectively programming
sentences:
- Use sentences for messages that are
used repeatedly.
- Use sentences as a complement to, not as a
replacement for, single-word messages.
May consider messages such as:
- “I want to say something that’s not on my
device,” “change overlay" or "Please ask
yes-or-no questions."
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Layout of Messages
Pick Your Colors and Be Consistent!
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Make sure communication system is
available throughout the day.
It is necessary to teach
a person to use AAC.
This involves:
- Instructing
- Provide prompts
- Modeling
- Practice
- Systematic trial-and-error
- Reinforce desired communication
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Where Do We Start?
Start with success!
- The first level of intervention
should be the highest level of
the individual’s performance and
add next small degree of
difficulty.
- The number of symbols
provided should be within skill
range.
- Include highly-motivating
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messages.
Some Types of AAC
•Aided Language Stimulation
•Choice Formats
•Communication Boards on
Everyday Objects
• Alphabet and Topic Boards
• Partner-Assisted Scanning
• Simple Voice Output
• Carrier Phrase Setups
• Conversational Skills Designs
• AAC Software
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Choice-Making
Make sure you are really creating an opportunity for
choice making.
Choice making increases attention.
Empowers and motivates the individual.
Provide multiple opportunities throughout the day.
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Example of Choice-Making
Choice Board using product
labels
Choice Board using
objects and picture
communication
symbols
by Adaptivation
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Topics for Choice-Making
- Foods and Drinks
- Object Choices (magazine, book, remote, flowers)
- Activity Choices (card or board games, computer,
gardening, swimming)
- Places (stores, restaurants, library, park)
- Clothing and Shoes (colors, clothing items)
- Actions (go, stop, come, eat, drink, sleep)
- People
- Feelings (happy, sad, angry, like, don’t like)
- Songs
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Low-Tech Communication Aids
Add Communication Symbols to everyday objects
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Low Cost AT Solutions:
Communication Devices
Alphabet Board
Topic Board
http://www.setbc.org/pictureset/resources/letter_boards/letter_board.pdf
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Low-Tech
Communication Aid
Flip ‘n Talk
by Mayer Johnson
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Low-Tech Eye Gaze or Direct Access
Communication Aids
TALK
CHART
http://www.kean.edu/~designct/
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Low-Tech Eye Gaze or Direct Access
Communication Aids
Wong-Baker FACES Pain Rating Scale
http://www.mdanderson.org/pdf/pted_painscale_faces.pdf
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Low-Tech Eye Gaze
Communication Aids
Choice Board swivel
frame made of PVC
Eye-Link
http://www.cini.org/
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Two-Step Eye Gaze
Communication Aids
1) Look at block border to select color
background of letter or number.
2) Look at block to select letter based
on the color border selected in step #1.
MegaBee
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Partner-Assisted Scanning
(Two-Step Eye Gaze)
Communication Aids
Layout according
to frequency of
letter use
http://education.gsu.edu/PhysicalDis/high_frequency_alphabe
t_layout_f.htm
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Partner-Assisted Scanning
(Two-Step Eye Gaze)
Communication Aids
Alphabet
Scroller
http://www.aacintervention.com/Alphabet%20Scroller%20Desc.pdf
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Written, Picture, Audio
Reminders
All examples
of AAC!
Recording Memo
www.maxiaids.com
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Developing Conversational Skills
Individuals with communication disorders
may:
Start talking without getting the other
person’s attention first.
Dominate the conversation.
Focus the topic on their special interest.
Not know when to end the conversation.
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Developing Conversational Skills
Conversation Game:
Communication instructions are printed on cards (e.g.
“Initiate a new topic” or “Ask a question related to the
current topic”).
Place the cards face down on the table and take turns
drawing a card and following the instructions.
Conversational Rules Business Card:
Print conversational rules on a card for individual to
keep in his/her pocket (e.g. “First, get the other
person’s attention” and “Let the other person have a
turn to talk”).
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Voice Output Communication Aids
Will individual’s stop using their natural speech if
they use voice output devices?
Compilation of studies in Silverman, 1995:
- Total of 435 subjects across 25 studies
- Included diagnoses of autism, aphasia, apraxia,
dysarthria, and mental retardation
- Impact of device on speech attempts:
- Increased speech attempts: 132
- No impact on speech attempts: 204
- Decrease in speech attempts: 2
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Always have a lowtech back-up system!
Keep it Simple!
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Low-Mid Tech Voice Output
Go Talk 20 by
Attainment Co., Inc.
Partner One/Stepper
by AMDi
Sequencer by
Adaptivation
Tech Speak by AMDi
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High Tech Voice Output
Communication Aids
VMax by Dynavox
TuffTalker by
Words+
Say-It Sam-2
Communicator by
Words+
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High Tech Voice Output
Communication Aids
Tech Touch
Deluxe by AMDi
Alt-Chat by
Saltillo
Vantage Lite by
Prentke Romich
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High Tech Voice Output
Text-to-Speech
Communication Aid
LightWRITER by
Dynavox
Lightwriter
SL40 by tobii
ATI
Polyana 4
by Zygo
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Cell Phone Use
Strategies for using cell phones:
Take pictures of where you park your car.
Take pictures of food that you need to buy
at the store.
Call and leave voice message with "to
do" items.
Some phones have calendars/to do lists
and built in alarm clock/timer feature for
attention/organization.
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Cell Phone Use
Hands-Free Cell Phones from SAJE
Technology
http://www.saje-tech.com/news.html
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Voice Amplifiers
Califone Voice Saver
ChatterVox
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Feedback on AAC Intervention
6 Adults Temporarily Unable to Speak
in an ICU:
- 85% reported success with AAC
interventions
- 5/6 adults preferred the alphabet
board
- The phrase board and electronic
devices favored the least
(Fried-Oken, Howard, & Stewart, 1991)
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Facilitating Strategies
It’s never enough to just give an individual a
communication system:
- Provide intervention in natural and varied
contexts for:
• Better response generalization
• Better stimulus generalization
- Create an expectation for the individual to
respond and initiate communication.
- Encourage spouse, family members and
friends to use the system.
- Introduce the adult to a proficient peer AAC user.
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Facilitating Strategies
Hearing Impaired or Deaf Individuals:
- Consider room lighting, avoid clutter.
- Adequate lighting so that communication
partner's face/lips can be seen, use body
language and natural gestures
- Check hearing aids
- Sign key words
- Introduce communication board in 1:1 setting
- Add Braille to book along with print
(commercially available for make own with a
Braille labeler).
- Enlarge pictures and text as needed.
- Vary pitch and intonation of voice.
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Types of Access to AAC
Direct Selection
- Use a finger, head pointer, mouth stick, or
eye to select the desired message
- Low, Moderate, or High Cognitive Demand
- Low, Moderate, or High Physical Demand
Indirection Selection
- Use one or two switches to move through a
series of potential messages to select one
message
- Higher Cognitive Demand
- Low Physical Demand
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Direct Selection: Eye Gaze
Eye Gaze Systems
- Shiny glint on eye is seen by camera
and moves the mouse
http://www.tobii.com//default.asp?sid=553
http://www.eyeresponse.com/
http://www.dynavoxtech.com/products/eyemax/
http://store.prentrom.com/cgi-bin/store/E14EG.html?id=SMfTwmBT
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Indirect Selection
Switches: Access to AAC
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Indirect Selection
Switches: Access to AAC
Head Mouse
Desirable for individuals who do not have use of
their hands or have better motor control with
their head than with their hands
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Indirect Selection:
Electrical Signals
http://www.brainfingers.com/
Uses electrical signals from
muscles
Cyberlink headband detects
electrical signals from facial
muscles, eye movements, and
brainwaves.
Brainfingers software decodes
these signals into virtual fingers
or brainfingers which trigger
mouse and keyboard events.
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Indirect Selection:
Brain-Computer Interface
http://www.asha.org/about/publications/leaderonline/archives/2007/070904/070904d.htm
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Helpful Websites
http://www.onionmountaintech.com/item.php?id=660
http://www.clearenvelopes.com/?category|CCS
http://www.independentliving.com/products.asp?dept
=131&deptname=Bar-Magnifiers
http://www.gutenberg.org/wiki/Main_Page
http://maxiaids.com/
www.cini.org
www.alsmndalliance.org
www.alsa.org
www.ninds.nih.gov
www.projectals.org
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Primary References
American Speech-Language-Hearing Association. (1997). Maximizing the
Provision of Appropriate Technology Services and Devices for
Students in Schools. Technical Report.
Beukelman, D., & Mirenda, P. (1998). Augmentative and Alternative
Communication, Management of Severe Communication Disorders
in Children & Adults (2nd. ed.). Baltimore, MD: Paul H. Brookes
Publishing.
Brodin-Lennon, D. & Rinehart, C. (2002). Songs to Communicate. Solana
Beach, CA: Mayer-Johnson, Inc.
Browder, D., Flowers, C., & Wakeman, S.Y. (2006). Level of symbolic
communication classification for students with significant cognitive
disabilities. Manuscript submitted for publication.
Burkhart, L. (1993). Total communication in the early childhood classroom.
Baltimore, MD.
Donnellan, A. (1984). The criterion of the least dangerous assumption.
Behavioral Disorders, 9, 141-150.
Downing, J.E. (2005). Teaching communication skills to students with severe
disabilities ( 2nd ed.). Baltimore, MD: Paul H. Brookes
Publishing Company, Inc.
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Primary References
Glennen, S., & DeCoste, D. (1997). The Handbook of Augmentative and
Alternative Communication. San Diego: Singular Publishing Group.
Goosens’, C., Crain, S., & Elder, P. (1994). Communication Displays for
Engineered Preschool Environments. Solana Beach, CA: MayerJohnson.
Kangas, K., & Lloyd, L. (1988). Early cognitive skills as prerequisites to
augmentative and alternative communication use: What are we
waiting for? Augmentative and Alternative Communication, 4, 211221.
King-DeBaun, P. & Musselwhite, C. (2002). Presentations given at Closing
the Gap 2002, Minneapolis, MN.
King-DeBaun, P. (1993). StoryTime Just for Fun! Stories, Symbols,
and Emergent Literacy Activities for Young Children. Park City,
UT: Creative Communicating.
Millar, D, Light, J, & Schlosser, R (2006). The impact of augmentative and
alternative communication intervention on the speech production of
individuals with developmental disabilities: A research review. Journal
of Speech Language Hearing Research, 49, 248-264.
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Primary References
Light, J. (1989b). Toward a definition of communication competence for
individuals using augmentative and alternative communication
systems. Augmentative and Alternative Communication, 5, 137144.
Light, J. & Binger, C. (1998). Building communicative competence with
individuals who use augmentative and alternative communication.
Baltimore: Paul H. Brookes Publishing Co., Inc.
Quattlebaum, P. & Nalty, L. (1998). A Practical Guide to Augmentative and
Alternative Communication: Assessment and Intervention
Strategies. Greenville, SC. Super Duper Publications.
Rouse, C. (2002). Ideas for Using Classroom Materials to Teach
Academics to Nonverbal Children and More! Solano Beach:
Mayer-Johnson,Inc.
Silverman, F. (1995). Communication for the speechless (3rd ed.). Needham
Heights, MA: Allyn & Bacon.
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For more information or to borrow
AT equipment, contact the
South Carolina
Assistive Technology Program
803-935-5263
800-915-4522
www.sc.edu/scatp
With special thanks to Mary Alice Bechtler
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