How to prepare a child for an Augmentative C ommunication Device

1. How to prepare a child for an Augmentative Communication Device Mickey Rosner, CCC-SLP, ATP GA Speech Language and Hearing Association Conference February 10, 2018

2. financial and non-financial disclosure statement I have no relevant financial or non financial disclosures

3. Who am I Mickey Rosner CCC-SLP, ATP Children’s Healthcare of Atlanta 496 bed hospital/Two main campuses • Inpatient rehab • Comprehensive Inpatient Rehab Unit • Day Rehab • Outpatient Rehab (9 centers) Started the Assistive Technology program in 1993

4. Why • The more information we have the better we are able to do an assessment • There is a difference between an evaluation for a device and a consult • Assessment can be done in outside situation where you can take your time to get accurate info • Receptive language testing (i.e. PPVT, TACL, ROWPVT, BRACKEN, TONI) • Expressive language testing (to demonstrate a gap) • Articulation or intelligibility testing

5. Overview of today’s presentation • Myths and common concerns • Checklist of areas to cover before the assessment • Specific strategies for preparing a child for direct access • Specific strategies for a child who is stuck in their body • Indirect access (developing switch site and use) • Eye gaze (moving from objects to pictures)

6. Common myths and concerns regarding augmentative communication devices. Myth “AAC will replace a child’s voice and should be the last resort” • FACT: AAC does not impeded speech. Research has demonstrated that AAC aids speech production (Romski et al., 2010) • FACT: Impossible to predict the future (Beukelman & Mirenda, 1992) • FACT: Normal developing children can use signs before spoken language (Sigafoos et al., 2004), (Bartman & Freeman, 2003), (Holmes & Holmes, 1980) • FACT: Children who are unable to communicate effectively are at a greater risk for developing cognitive, social, emotional and behavioral problems (Berry, 1997) Beukelman & Mirenda (1992); Berry (1987); Daniels (1994); Romski & Sevcik (1993)

7. Common myths and concerns regarding augmentative communication devices. Myth: “The iPad is the answer” • FACT: One device does not fit all (Light & Drager, 2007) Myth: “A young child is not ready for AAC” • FACT: There are NO cognitive or other prerequisites to using a device (Kangas & Lloyd, 1988), (Branson, D. & Demchak, M., 2009) Myth:“High-tech AAC is better than low-tech” • FACT: Low tech can be just as effective as high tech (Branson, D. & Demchak, M., 2009)

8. Common myths and concerns regarding augmentative communication devices. Common Parental Concern: “My kid will never understand how to use a communication device” • FACT: Children w/ severe cognitive deficits are capable of learning and benefiting from AAC (Beukelman & Mirenda, 1992), (Branson, D. & Demchak, M., 2009) YAACK: Does AAC impede natural speech—and other fears

9. Take home message • A device will not hinder verbal speech development • There are no prerequisites to using Augmentative communication • Low-tech can be just as effective as high-tech • Everyone has something to say • You don’t have to wait for the specialist to begin training communication strategies • It takes time to learn language

10. Checklist of things to know before referring a child for an AAC assessment • Vision • Hearing • Preferences (what do they like) • Communication at home, school, & other locations • Are they making choices? • What types? (Objects or pictures) • How (looking, reaching, vocalizing, other) • Do they look at what they are reaching for? • How do they show you they like or dislike something? • Is there another home or outside program in place? • Language (receptive and expressive) • Do they recognize pictures? • real • Abstract (PCS, Symbolstix, Bliss, Min Symbols) • Types (nouns, verbs, people, etc) • Number (optimal field for recognition) • Size and or configuration • Validity

11. Who can use direct access? • While you are waiting for an assessment or you wish to provide more comprehensive treatment options try doing the following: • Developing choice making with objects • Developing choice making with pictures • This method is for children who have goal directed reaching. That is they reach and look at where they are reaching. • Note: If a child does not look at what they are reaching for, do not accept responses as reliable. Exception children with field cuts. Also, employ the assistance of an OT. • They can have some motor impairments but they need to have enough strength to reach quickly with some range.

12. Where to start with Direct Access • To train a child to look and reach for pictures you may need to start with • Objects. • Training hierarchy when starting at the very beginning • (For children who are a low cognitive level) • Objects • Real symbols of the familiar objects/people (ex. pictures) • Like symbols of familiar objects (ex. PCS symbols) • Abstract symbols and harder concepts • For children who are higher functioning cognitively you can start with abstract symbols. Research says they will learn whatever you put in front of them.

13. Common Mistakes in vocabulary selection from adults found in children who have nothing to say • Not presenting messages a child is motivated to communicate! • Not recognizing other issues like overriding sensory needs • The child can already speak or sign the vocabulary • Not taking environmental limitations into account • Choosing messages a child could care less about

14. My mantra No one ever rose to lower expectations

15. When choosing vocabulary to start • Pretend you are the child • What motivates you? • Want do you want to say? • What do you like a lot? • What do you not like? THE Golden RULE The motivation must exceed the effort!!!!!!!

16. How to move from objects to pictures “The Plan” 1. Choice making between objects • Children should have opportunities all day long to make choices • Watch for patterns in reaching such as always choosing the one on the left. • Make sure they see both items before selecting

17. 2. Pair the exact picture of object with the object itself when presenting the object for choice making.

18. 3. Keep the picture near the object. Placement should be consistent.

19. 4. Show the object with picture and then put object down on the same side as the picture. If child is unable to choose between pictures then present objects again and encourage a choice. Then show pictures again and show how to choose the intended one. Try again until the child is able to choose the picture of desired object.

20. In direct access using Eye Gaze: -For a child who has good vision but cannot use their hands functionally. • Populations this might apply to • Cerebral Palsy • Rett Syndrome • Traumatic Brain Injury • Other neurological based handicaps -Many of the same principles used to explain developing symbol understanding with goal directed reach, apply here. -Typically, these are the children who already “speak” by looking at what they want. -We need to teach them that they are communicating with their eyes by looking at a symbol.

21. Review of Instructions for developing responses • Sit across from the child. • Review choices using the light as you go. (shine the light on one choice at a time from BEHIND the board) • Once you have shown them all the choices then start communicating with them with aided language stimulation • Use aided language stimulation, that is talk about the choices (label each choice) as you momentarily shine a light on one at a time • Watch their eyes so you know where they are looking when they respond • If they are looking at a symbol then reinforce them with their choice • If they do not look at anything then go back to fewer symbols (ex. Hold up 2 pictures) • You should have separate pictures of everything represented on the activity specific boards. This way if you are not sure you can have the child communicate in a simpler way. • ALWAYS give them time to respond • Watch their behavior (it may tell you what they want or don’t want!)

22. Teaching Eye Gaze: (The same principles covered in choice making using a reach apply here. The only difference is that they are using their eyes instead of their hands to make choices) 1. Begin by holding up two objects. The objects should be familiar and motivating. Hold the objects far enough apart so that you can tell what they are looking at. The child needs to know what the objects are. Provide the child time to think about what they want and time to respond. The child should then make a choice by looking at the desired object. 2. To which you respond with verbiage such as, “Oh I see you are looking at the ball. Do you want to play ball?” or “You told me you wanted to read brown bear with your eyes.” “Good job!” You can use a variety of words but you want to let the child know that they told you something when they looked at the object. 3. Once they have made their choice, give the object to them to play with for a few minutes and then repeat.

23. Other ways to train eye gaze • For children who already understand symbols and can do this then train them to put words (symbols) together or go from a general choice to a specific choice using eye gaze (ex. “to sing + 5 Little Ducks”). These skills are very important when choosing the correct language system for them. • For these children you will need a Lucite picture frame, activity specific board, and a bright squeeze light.

24. Examples of other activity specific boards

25. Confirm their responses • Once a child selects a symbol then hold up the same two objects on the same side and ask them to show you what they asked for. This may seem like duplication and it is. We only do this part for a short time in order to make sure they understand (validate) what they are requesting. Otherwise, responses may just be random and you have no way of knowing. Only do this in the beginning to establish validity or if you are not sure. Once established there is no need to keep doing a validity check • If a child chooses the wrong item then go back and show them how to choose the correct picture.

26. For children who have motor and vision impairments Head versus hands Look for the easiest volitional movement under their control that is reliable. Hands/arms Touch Come near Reach Head Turn Tilt Lift

27. Key Points Head versus hands • Hand is more concrete but head might be easier • Use of head keeps eyes up where as use of hands encourages the head to drop as child recruits movement • Frequently use of a tray helps children use head neck muscles better • Some children can get on the switch but not off of it with either head or hands • Remember you are looking for a volitional movement that a child can recreate with ease.

28. Posture is important for movement • Do not feed the asymmetric tonic neck reflex • Child should be upright if possible • Shoulders should be over the hips

29. For people with motor and visual impairments“Partner assisted scanning” • Listening to choices and activating a switch or giving some formal response to affirm once they hear what they want to say • Give predictable choices. • Let them know in advance what messages are before expecting them to make a formal choice. • Limit distracters. • Present at least one highly motivating choice • Record single shot message “yes” or “yes that is what I want” and then let them know what will happen when they select the switch or press the message. • Wait at least 3-5 seconds at least between choices, may need more if person has a long response time. • Sometimes the choice is “none of these” • May need physical prompt to hold hand over the switch or assist in accessing to begin with. Fade this quickly. • Give several passes. • Watch body language and redirect if necessary. • Typically they will communicate initially within a motivating activity. • Whenever possible try to confirm choice by behavioral response to limit miscommunication.

30. Once one switch site emerges a second usually follows. This opens the door for two step scanning • One switch moves the second switch selects. This provides the child with complete control over the scanning process. • The child may require physical assistance • Other ways to practice switch access. • According to Linda Burkhart “Research on motor learning shows that developing a motor skill to the level of automaticity requires practice that includes thousands of repetitions with intent, purpose and variation. Automaticity of motor skills means that the individual is able to use a particular movement to Achieve a desired intent without conscious thought toward the execution of that motor task. The intent may originate consciously or unconsciously, but is focused on the purpose of the movement, not the movement itself”. That is projected to be 200 switch hits a day. • Practice…. Practice….. Practice….. • Songs • Scripted messages • Adapted activities

31. Free Switch Activities Online Anything to help with switches: activities, free games, toys, and helpful websites. Switch accessible apps on the iPad (need switch converter to work) http://www.janefarrall.com/switch-accessible-apps-for-ipadiphone-non-aac/ Switch Activated Toys (not free): http://www.beyondplay.com/CATALOG/ADA1.HTM http://www.flaghouse.com/Special-Needs/Ability-Switches/Adapted-Activities-PN=1&navlink=true Music Games/Activities: Chuck Rock Dance http://www.oneswitch.org.uk/4/MUSIC/index-03.html Music Player/Shortcutter https://github.com/ATAccessGroup/Scripting-Recipes-for-AT/tree/master/Autohotkey/MusicSwitcher Free Switch Activated Games online: http://www.priorywoods.middlesbrough.sch.uk/page_viewer.asp?page=Switch+%2F+Touch+Screen+Videos&pid=74 - 65 activities: music, action games, building games, books, slideshows, and videos. http://www.oneswitch.org.uk/2/switch-downloads.htm - some free games http://www.specialbites.com/switch-activated-games/Angry-pig-cause-and-effect-switch-games-teaching-learners-with-multiple-special-needs.php - similar to angry birds Sports games: http://www.idiombox.com/oneswitch/Bullseye%21.swf - darts http://www.specialbites.com/switch-activated-games/selection-of-cause-and-effect-switch-games.php - baseball, soccer shootout, http://www.scottmckay.com/ - 6 games at the top of the website are free (mini golf, soccer, Spiderman and curling) http://www.bltt.org/software/greatfishrace/index.htm - fishing Sensory games: -http://www.specialbites.com/Easy-Sensory-Games-for-special-needs/Selection-of-online-sensory-early-play-and-learning-switch-and-touchscreen-activities-games-for-special-needs-students-developing-fine-motor-skills.php - fireworks -http://www.levelgames.net/accessibility/single-switch-scanning.htm free 1 month trial website: -12 games -http://www.shinylearning.co.uk/freegames/index.shtml - fireworks, chicken dropping eggs Helpful Resources: http://www5.esc13.net/thescoop/vi/2012/08/30/free-and-low-cost-switch-activities/ http://atclassroom.blogspot.com/2009/04/switch-use.html

32. I help people to communicate! What is your superpower???