Revisiting AAC abandonment: the SLP perspective

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Last month, we reviewed an article about parents’ perspectives on why their children’s AAC devices ended up rejected or abandoned. (Are you picturing a sad, dusty cabinet full of non-functional GoTalks and retro Dynavoxes? I am.) Now, we’ve got a natural companion piece from the same authors, flipping the script and talking to a group of Australian SLPs about similar situations.

Sometimes these interview-based studies tell us a lot of what we already know, and can lead to the pessimists among us getting bogged down in Barriers-ville. This one, though, has some thought-provoking and useful ideas for working with families to implement AAC systems more successfully.

First, commit yourself to family-centered practice. Specifically, the authors discuss:

  • Stepping up our counseling to help families move through any grief and increase their readiness for AAC.

  • Helping connect families of AAC users so they can support each other.

  • Moving away from a deficit mindset with families (they’re overwhelmed, they’ve got other priorities, they don’t have the resources…) and capitalizing on their strengths.

  • Focus on relationships, and bring families into the process as much as possible, through device trials, hands-on support, and follow-ups.

Next, orchestrate some early wins. Families may need to see their child being successful with AAC to overcome doubts, resistance, or previous negative experiences around devices. This might mean making an effort to share progress from speech sessions (via videos, maybe?) or even starting off with simpler systems like activity displays, to build momentum and motivation, before jumping into a complex device*.

Finally, this last point is the part where we clinicians need to humble ourselves a bit. Sometimes devices don’t work because the SLP didn’t recommend the right system for that child. We all have our favorites, the ones we know best, the ones we like most for many, totally valid reasons. But we can’t unilaterally impose that preference on our clients. That’s clinician-centered, arrogant, and just less likely to work. Clinician experience is also important here. The study authors suggest that having newer grads supported by seasoned AAC pros could improve device acceptance.

Selecting and implementing AAC is a complex balancing act between the user, the device/system, the family, the environment, and the clinician. Like the EBP triangle, but more of a pentagon? When we don’t consider all those factors, we’re risking another addition to that sad cabinet of lonely devices.  

*This is NOT to suggest that kids need to start with low tech AAC, or implying any prerequisites to using a robust language system.

 

Moorcroft, A., Scarinci, N., & Meyer, C. (2019). Speech pathologist perspectives on the acceptance versus rejection or abandonment of AAC systems for children with complex communication needs. Augmentative and Alternative Communication. doi:10.1080/07434618.2019.1609577

Communicating with families from a strengths-based perspective

"In writing from a strengths and abilities perspective, we write in a manner that is neutral and positive, limiting the extent to which we emphasize deficits in our interpretation of observed behaviors."

Many of us have been taught to write our evaluation and progress reports from a strengths-based perspective.The purpose of using strengths-based report writing is not only to be respectful and kind to the child and family (though that’s certainly enough!), but also because research has shown it improves the therapy process (e.g. clinician­–parent relationship) and outcomes (e.g. behavioral, academic); see article background for literature review. The authors state, “… documentation may be the anchor for how families have and share information…” and “…it’s important that … services occur in a way that leaves families with hope rather than despair.”

The purpose of this study was to evaluate current clinical practices. To do this, the researchers pulled 20 patient reports from an autism diagnostic clinic, collaboratively written by SLPs, OTs, and psychologists. They then analyzed 299 phrases from these reports, coding each as:

  • descriptive (e.g. “The child’s mother and stepfather accompanied him to the appointment.”
  • interpretive, positive (e.g. “Julie was easily redirected to tasks.”)
  • interpretive, negative (e.g. “Emily was generally unable to follow simple directions.”)
  • interpretive, neutral (e.g. “He exhibited a partial smile during the balloon activity.”)

Findings from the study demonstrated that, “…interdisciplinary providers… used phrases that were interpretive and negative significantly more often than other types of statements in their written diagnostic reports.” The authors state, “… clinicians may identify strengths and resources during a diagnostic evaluation, yet make intervention and programming recommendations around a specified diagnosis with little consideration for the identified strengths or family priorities.”

So, we may not be using strengths-based writing nearly enough. Now, an initial reaction from a clinician reflecting on his/her own writing may be, “Yeah, I use negative interpretive language. But it’s because I’m trying to get this kid the services he/she needs, and school districts and insurance companies don’t exactly pony up easily.” And the authors acknowledge this barrier—that reimbursement and service provision is deeply rooted in a deficits model. But does it have to be? Is there any data to indicate that negative interpretive language is more likely to result in service provision and reimbursement? Regardless, when the client, family, and intervention outcomes are the focus, writing from a strengths-based perspective has strong supportive evidence.

So, how can clinicians improve their skills? First, the authors suggest that some version of “active learning strategies”, with practice, coaching, feedback are likely to work better than passively listening to a brief CE course, for example. They also suggest clinicians may audit their own work by using Figure 1 from the article (which is basically a flow chart to figure out what type of language you’re using). Also, Table 5 in the article gives example of what strengths-based writing does and doesn’t look like, such as:

  • YES: “He hit his sister twice…” (descriptive)
  • YES: “He used happy and sad facial expressions on several occasions.” (neutral interpretive)
  • YES: “He maintained good eye contact…” (positive interpretive)
  • NO: “Social interactions were difficult.” (negative interpretive)
  • NO: “He was very impulsive in the waiting area.” (negative interpretive)

As can be seen, the use of descriptive, positive interpretive, and neutral interpretive is encouraged, and the use of negative interpretive is discouraged.

The authors state, “Providers are considered a guide or agent to the family, and their role is to assist them in identifying their own strengths and resources and help them realize their potential.” Also, “By focusing on strengths, we shift the starting point of care from problems (or deficits) to strengths and abilities.”

Braun, M.J., Dunn, W., Tomcheck, S.D. (2017). A pilot study on professional documentation: do we write from a strengths perspective? American Journal of Speech­–Language Pathology. Advance online publication. doi:10.1044/2017_AJSLP-16-0117

Self-advocacy during communication breakdowns

This article shows that some children and teens with neurodevelopmental disorders are at a particularly high risk for not speaking up (or gesturing, signing, using AAC) to indicate when they don’t understand what others trying to say. Self-advocacy during communication breakdowns is particularly challenging for boys with comorbid Fragile X and Autism, and also challenging for those with Down Syndrome. In addition to clinicians simply being aware of populations at particular risk for challenges, this article is also useful because their tasks for measuring non-comprehension are well-described. Thus, clinicians could reasonably use some of the tasks as inspiration for probing non-comprehension and resultant communicative behaviors in clinical settings.

Martin, G.E., Bartstein, J., Hornickel, J., Matherly, S., Durante, G., & Losh, M. (2017). Signaling of noncomprehension in communication breakdowns in fragile X syndrome, Down syndrome, and autism spectrum disorder. Journal of Communication Disorders, 65, 22–34.

Factors in language development, birth to age seven

This longitudinal study of nearly 2000 children found that the effect of early life and home factors are clear in the early years, but that these “…have played out by age 4.” They also found that “…language abilities are more stable between 4 and 7 than between 2 and 4 years.” Meaning, it’s easier to know if a child will persist with a language disorder by measuring skills at age four than by measuring skills at age two (which many of us have figured out, clinically).
Also, the quality of life was found to be particularly low for the seven-year-olds with low language. These children “…experience significant limitations in school and psychosocial functioning at twice the rate reported in peers with typical language,” including low literacy skills and social–emotional and behavioral skills. Further, the authors state, “Health-related quality of life (HRQL) was measured on the parent-reported Pediatric Quality of Life Scale and “limitations” in HRQL were defined as scores falling ≥1 SD below the sample mean, a level found to be similar to that of children with severe or chronic health conditions such as rheumatic conditions and newly diagnosed cancer in a large population sample.” They state, “…it is a significant concern that children with low language were experiencing (HRQL) limitations at more than twice the frequency reported by their peers with typical language.”
 
McKean, C., Reilly, S., Bavin, E.L., Bretherton, L., Cini, E., Conway, L. Mensah, F. (2017). Language Outcomes at 7 years: early predictors and co-occurring difficulties. Pediatrics, 139(3).

“Girls Night Out” program for teens with autism

If you’re looking for a social communication intervention to use for teen girlsthis article on Girls Night Out (GNO) is a great place to start. GNO is a peer group therapy program, consisting of weekly evening sessions (2 hours) with a handful of teens with a disability (primarily ASD) and at least equal number of trained peers. GNO teaches: “...(1) relating to others, (2) self-care, and (3) self-determination in social competence and self-perception.” Topics like “Finding My Fashion” are designed to appeal to teen girls, with fun features like “GNO bucks” as part of a token economy. 
The primary function of the article is to describe GNO in detail, while summarizing the evidence behind its design. In some ways, the extensive background section is one of the most valuable parts of the article— the authors do an excellent job of describing the relevant research (e.g. for social skills training). This article is also unique in addressing concerns for older female children with autism. The authors suggest that, “Adolescent females with ASD may experience a “double whammy” as they try to negotiate the increased complexity of social experiences inherent in female adolescent relationships… alongside their impairments in communication and social reciprocity related to ASD.”
The authors conclude with analyses of four years of GNO groups. The range of activities and participants across this extended timeline present challenges for drawing conclusions. Nonetheless, the preliminary data is promising, demonstrating positive gains in self-perception and the girls’ ability to connect with others.

See: Jamison, T.R. & Schuttler, J.O. (2016): Overview and Preliminary Evidence for a Social Skills and Self-Care Curriculum for Adolescent Females with Autism: The Girls Night Out Model. Journal of Autism and Developmental Disorders. Advance online publication. doi:10.1007/s10803-016-2939-6