AAC carryover: Buy-in is only the beginning

One of the biggest frustrations for clinicians who support AAC are the devices that don’t get used. You know, the ones that sit in the cabinet unless you’re in the room, or the ones that parents ask you not to send home. There are a lot of factors that contribute to this kind of device abandonment (can’t you just picture a lonely device feeling sorry for itself?). We need to understand these factors, so we can focus our work on the key ingredients that will promote AAC device use and help students—and their support teams—be successful.  

You won’t be surprised by two of the most common caregiver-related barriers to device success: 

1)    The adults don’t know how to use the device (or, they lack operational competency).

This includes finding words, programming, troubleshooting, and navigating the device settings. Parents and teachers often report that they don’t get enough training in this stuff.

2)    The adults don’t have positive attitudes about the device (or, they lack buy-in).  

Specific aspects of buy-in can include considering the device the child’s voice and believing that it should be available at all times.

These two barriers are important, for sure, but how important? And what else are we missing? This study delved into this issue, focusing on the operational competency and buy-in of parents and teachers of school-aged (3–16 years) children with autism, and whether they related to how frequently the children’s AAC devices were used. The 33 children in the study all used a personally-owned PRC device or the related LAMP Words for Life app as their main method of communication at both home and school. To measure how much devices were used, the researchers analyzed data from PRC’s Realize Language feature across three school days and one weekend. Parent and teacher surveys were used to measure operational competency and buy-in.

The good news? Overall, buy-in and operational competency was high for everyone. The bad news? No one was using devices that much. In this group, teachers reported greater buy-in (or at least answered their surveys that way, but that’s a whole different topic...), but parents and teachers were equally comfortable operating the devices. The devices were used more frequently at school vs. home (over half of the kids didn’t use the devices at home at all). 

15.png

A big grain of salt here: the study looked at really a pretty small window in time (Is one weekend at your house representative of how your family works?), and only one device company—that uses a relatively complex language system—was in the mix. We also don’t know if looking at students with diagnoses other than autism would make a difference. Even so, it’s clear that something’s going on here. We can see that good intentions, valuing the device, and being trained in its use just isn’t enough. It looks like we need a broader conversation about barriers, including the practicalities of incorporating a device into daily activities and routines, especially at home. We definitely need to address operational competency and buy-in, but our families and other stakeholders are likely to need more support than that. The authors remind us to keep communication at the center of the conversation, rather than the technology. After all, the device is only the tool—communication is the point.

 

DeCarlo, J., Bean, A., Lyle, S., & Cargill, L. P. M. (2019). The Relationship Between Operational Competency, Buy-In, and Augmentative and Alternative Communication Use in School-Age Children With Autism. American Journal of Speech-Language Pathology. doi:10.1044/2018_AJSLP-17-0175

Throwback (2015): What and how to teach AAC communication partners

We all know that communication is a two-way street—in order to be effective, there must be give-and-take, back-and-forth. Unfortunately, in the case of AAC users, the importance of the communication partner is often minimized. It makes some sense: using AAC is not intuitive, and there is a lot to teach, so we focus on the communicator. So, what’s the problem here? 

We’re neglecting the other half of the communication process!

Interacting with someone who is learning AAC is also not intuitive and often requires explicit instruction. So—what exactly should we teach partners?  And equally important, how should we do it?

3.png

This meta-analysis aimed to answer these questions by investigating the effectiveness of communication partner instruction on the communication of individuals using AAC. The authors analyzed 17 studies and 53 participants, including a variety of communicators (i.e., different diagnoses and age groups), partners (caregivers, educational assistants, parents, peers, and teachers), intervention approaches (teaching one skill at a time versus a set of skills), and outcome measures (pragmatic, semantic, or syntactic skills). They found that, in general, partner instruction led to improvements in the communication of individuals using AAC.

These are promising results, but what can we take away? What should we be teaching our students’ communication partners? Across the studies, the most frequently targeted skills included:

  • Aided AAC modeling
  • Expectant delay
  • Open-ended questions

And then, how should we teach those skills? Frequently-used instructional activities included:

  • Providing a descriptive overview
  • Instructor modeling
  • Guided practice
  • Role plays

When these skills were taught using these instructional strategies, a range of communication partners were able to modify their interaction patterns to better support individuals using AAC.  Evidence like this can help us advocate for dedicated staff training time in our workplaces, like after-school sessions with paraprofessionals and teachers. Make it your mantra: partner training is a communication intervention!

If you’re interested in the specific variables analyzed across the studies, check out the coding manual here. For more on this topic, check out our 2016 review of three more studies of communication partner training.

 

Kent-Walsh, J., Murza, K.A., Malani, M.D., & Binger, C. (2015) Effects of communication partner instruction on the communication of individuals using AAC: A meta-analysis. Augmentative and Alternative Communication, 31  271-284. doi: 10.3109/07434618.2015.1052153.

Predicting resolution of speech sound errors

Producing speech sound errors early in development is normal. Many children make errors in the preschool years that they simply grow out of in early elementary school. However, some kids don’t grow out of their errors. These are the kids that need speech–language pathologists’ attention, but how do we know which kids these are?

This study aimed to answer exactly that question—which kids just need time, and which kids need speech therapy? They examined 93 children at age four (all “identified as speech impaired” with the GFTA-2 or DEAP), categorized the children’s error types, then looked again at age seven, and found the following:

  • Total number of errors didn’t predict spontaneous resolution of SSD.
  • Type of errors, however did! Kids with speech sound errors best described as “phonologically delayed” (that is, those who use error patterns consistent with younger children, e.g. stopping or cluster reduction) were nearly twice as likely to spontaneously resolve as kids with speech sound errors best described as “atypical” (e.g. backing or initial consonant deletion). The kids who made the fewest atypical errors were most likely to improve over time.

What does this mean for SLPs? First, looking at the types of errors kids make may make more sense than counting the number of consonants errors. This may aid us in predicting who is more or less likely to grow out of their speech errors!

2.png

But, then what to do? Should we prioritize services for children with atypical errors, and wait it out for kids with more typical error patterns? Ehhh…. not so fast. First, we have to be cautious making decisions that apply to entire caseloads or entire school districts (as many of our supervisors want so badly to do!) To think on this, we also need to look more closely at the actual percentages, here: The authors state, “67% of phonologically delayed children had resolved by seven years (of age) compared to 35% of children making atypical speech errors.” So… if 67% of phonologically delayed children resolve, that’s great—but what about the 33% who don’t? Even though the authors have some nice data, here, categorizing kids this way clearly isn’t a perfect predictor of the future. There may be slightly better methods that are even more predictive than what was done in the current study (yay for more science!). Also—resolution of speech sound errors isn’t all that matters, here, when kids with phonological delay may be experiencing other difficulties as well (e.g. literacy). Clearly more data and more discussions are needed, before we attempt to make widespread procedural decisions. But this is a really good start!

Oh, and BTW—are you looking for research to justify working on speech sound errors at a young age, or single speech sound errors, because you have administrators who think the “speech kids” don’t need your attention? In the background of this paper, they review research on why we shouldn’t be framing this as just an articulation problem—“Children’s school achievement is often adversely affected (Hayiou-Thomas et al., 2016) as are their peer relationships, due to social, emotional and behavioral difficulties (Murphy et al., 2014). Persistent impairment in adolescence affects literacy, mental health and employment (Law et al., 2017).” You can get some real gems from this background of this paper!

 

Dodd, B., Ttofari-Eecen, K., Brommeyer, K., Ng, K., Reilly, S., Morgan, A. (2017). Delayed and disordered development of articulation and phonology between four and seven years. Child Language Teaching and Therapy. Advance online publication. doi: 10.1177/0265659017735958.

Throwback Pub (2015): Intervention on the playground—engaging children with autism with their peers

Searching for time in the day to work on engaging children with ASD with their peers? Look no further than recess! Kretzman, Shih, and Kasari developed Remaking Recess, an intervention designed to teach adults how to engage children with ASD during lunch and recess.

The researchers taught 35 school playground staff at four schools (one-on-one aides, classroom aides, playground aides) strategies to promote engagement among 24 children with ASD and their peers. The intervention included teaching the paraprofessionals about:

  1. the relationship between peer engagement and social development,
  2. strategies to use to improve peer engagement, and
  3. how to identify activities that could be added to recess to maximize peer engagement.

NOTE: The sequence and content of the Remaking Recess training protocol is outlined in Table 2 of the paper.

5.png

What were the findings? After receiving the Remaking Recess training, the paraprofessionals demonstrated a significant increase in their use of the strategies AND the children with ASD (in grades 1–5) were rated as more engaged with their peers on the playground.

This school-wide intervention shows promise for facilitating meaningful and generalizable engagement in children with ASD in elementary school, but not without a few caveats. First, the children in the study were fully included in the general education curriculum. Adaptations may need to be made for children with ASD who are not included in the general education curriculum because they may have different needs. Second, the paraprofessionals’ responsiveness and strategy use did not carry over at the 10-week follow up point. The authors stress the importance of assessing paraprofessionals’ buy-in and motivation. As SLPs, we have knowledge and skills needed to support peer engagement, and to teach others about how to facilitate engagement inside and outside the classroom. However, we need to draw upon best practices for collaboration to make adult-mediated interventions like this one as successful as possible.

 

Kretzmann, M., Shih, W., & Kasari, C. (2015). Improving peer engagement of children with Autism on the school playground: A randomized controlled trial. Behavior Therapy, 46(1), 20–28.

Perspective Pieces

Recall that TISLP doesn’t review Perspective Pieces. However, we do love them (sometimes our FAVORITE publications each month are Perspective Pieces), and think you should be reading these gems, too. There were a TON published this month. Browse the titles for topics you’re interested in, and enjoy!

·      Understanding Word Reading Difficulties in Children With SLI

·      Practitioner Reflection That Enhances Interprofessional Collaborative Practices for Serving Children Who Are Deaf/ Hard-of-Hearing

·      Using Multilinguistic Strategies to Improve Decoding in Older School-Age Students in a Contextualized and Motivational Approach

·      A Review of Psychosocial Risks and Management for Children with Cleft Lip and/or Palate

·      The Role of Semantic Knowledge in Learning to Read Exception Words

·      Technology Training in Speech-Language Pathology: A Focus on Tablets and Apps

·      Reading Longer Words: Insights Into Multisyllabic Word Reading

·      Small Group Reading Instruction: Activities for Teaching Phonemic Awareness, the Alphabetic Principle, and Phonics in a Tier 2 Setting

·      Speech Assessment in Children With Childhood Apraxia of Speech

·      Does Access to Visual Input Inhibit Auditory Development for Children With Cochlear Implants? A Review ofthe Evidence

·      Efficacious Treatment of Children With Childhood Apraxia of Speech According to the International Classification of Functioning, Disability and Health

·      Beyond Eyes and Ears: The Need for Movement Analysis of Speech and Nonspeech Behaviors in ChildrenWith Cerebral Palsy

·      Leading the Way With Supervision Training: Embracing Change and Transforming Clinical Practice

·      Perceptions of Mentoring SLPs and Clinical Fellows During the Clinical Fellowship

·      How Stuttering Develops: The Multifactorial Dynamic Pathways Theory

·      Examination of Coaching Behaviors Used by Providers When Delivering Early Intervention via Telehealth to Families of Children Who Are Deaf or Hard of Hearing

·      We’ve Got Some Growing Up to Do: An Evidence-Based Service Delivery Model for the Transition of Care for the Young Adult with Cleft Lip and Palate

·      Are We Slipping Them Through the Cracks? The Insufficiency of Norm-Referenced Assessments for Identifying Language Weaknesses in Children With Hearing Loss

Better Together: Interprofessional Collaborative Practice

This month, AJSLP published six articles on Interprofessional Collaborative Practice (IPCP). This is a very trending topic right now across health professions. Recent grads may recognize the terminology, because many of them have received Interprofessional Education (IPE) while completing their coursework, where students from different professional programs (e.g. SLP, PT, OT, Nursing, Education) learn together and work together early on.

For the school-based SLP, taking the lead to develop a more interprofessional environment requires consideration of many moving pieces. It’s not just what you’re doing. It’s what the teachers, PTs, OTs, social workers, school psychologists, principals, administrators, and parents are doing or willing to do, as well (yay for trying to move a mountain, lol!) Just because it’s tough to implement in some settings, and tough to try something new, doesn’t mean it’s not doable, though. A single PT–SLP pair, for example, can make a substantial difference if they simply start identifying and modeling better collaboration. Or one SLP–Reading Specialist duo. Or one SLP plus SPED teacher working together to improve AAC implementation…

On to the articles—so, I won’t review each of these articles in-depth, because they don’t fit the TISLP “empirical research” requirement. This set is more like a series of tutorials or perspective pieces. Nonetheless, I’ll give you a little guidance on what’s contained within each, so you know what you may want to prioritize:

Addressing the Communication and Other Needs of Persons With Severe Disabilities Through Engaged Interprofessional Teams: Introduction to a Clinical Forum

  • This one’s the “Intro”. Helpful for definitions and explanation of IPCP.

The Trifocus Framework and Interprofessional Collaborative Practice in Severe Disabilities

  • This one reviews the literature on IPCP and students with severe disabilities. It’s the most dense of the series, because it considers a theoretical model behind IPE and provides snippets of information from tons of studies. It may be the most overwhelming of the set, unless you’re ready to think about IPCP more deeply.

Effective Team Practices: Interprofessional Contributions to Communication Issues With a Parent's Perspective

  • This one presents a literature summary and guidance on what good teams look like.

Comprehensive Literacy Instruction, Interprofessional Collaborative Practice, and Students With Severe Disabilities

  • This one’s all about how to collaborate among professionals for literacy instruction. It provides a really rich set of evidence-based treatment options, in addition to discussing how they can be implemented across professions. So if you aren’t an SLP who currently feels as involved as you could/should be in supporting your students in literacy growth, this is a great article.

Cotreatment as a Vehicle for Interprofessional Collaborative Practice: Physical Therapists and Speech-Language Pathologists Collaborating in the Care of Children With Severe Disabilities

  • This one’s authored by PTs and an SLP, and is a set of stories/examples in which the two professions may work together to treat clients.

Mary's Case: An Illustration of Interprofessional Collaborative Practice for a Child With Severe Disabilities

  • This one reads like a story—an individual case of IPCP for a child with a severe disability. It walks you through “Mary’s Case” from birth to adulthood—so no matter what your current setting, there should be a portion of the story you identify with.

Peer communication support for teen AAC users

Screen Shot 2017-05-19 at 1.06.05 PM.png

This article identified a method for increasing peer communication in middle-school AAC users. The treatment program consisted of three pre-intervention training meetings with the students' teams, followed by classroom-based peer intervention, supervised by paraprofessionals. Four middle-school students, all using iPads with Proloquo2Go, participated. The pre-intervention planning meetings  ranged from a half hour to a little over an hour:

  • Pre-intervention meeting #1make a plan with the student’s support team (e.g. SLP, classroom teacher, SPED teacher) to promote appropriate peer communication. The group identified appropriate classroom activities and vocabulary that would be required, along with strategies the peers could use successfully.
  • Pre-intervention meeting #2: train the paras assigned to the child. This meeting was between the coach (in the study, the researcher, but in practice likely the SLP) and paraprofessionals.
  • Pre-intervention meeting #3: the paras train the peers assigned to each AAC user, supervised by the coach (researcher/SLP). The peers were taught several strategies, including: provide communication opportunities, use expectant delay, provide appropriate prompts, respond.


During intervention, the peers provided the majority of the communication support, with the paras supervising. A clear "pro" of this is that it allowed paras to more easily move around the room, working with multiple children, instead of being the sole supporter of one student. 
Before the peer intervention program, most of the paras were providing exclusively academic communication support (not social) to their AAC users. After intervention, these students (who at baseline communicated minimally or not at all with peers) were communicating regularly with peers, for both social and academic functions, and at a higher rate compared to pre-intervention. One student also generalized peer communication to other classrooms.

Biggs, E.E., Carter, E.W., Gustafson, J. (2017). Efficacy of Peer Support Arrangements to Increase Peer Interaction and AAC Use. American Journal on Intellectual and Developmental Disabilities, 122 (1). 25–48.

Characterizing the subtle communication of children with complex communication needs

This study offers an alternative to standardized approaches for identifying and quantifying the subtle communicative bids of children with severe to profound communication and learning needs. A structured observation of three children’s entire school day was performed, along with completion of four SCERTS checklists for each child.
The three children each had their own idiosyncratic methods for communicating—some as subtle as facial expression—and the researchers found that most adults working with the children recognized these communicative attempts. However, they also observed, “marked inconsistencies in the extent to which children’s bids for interaction developed into a reciprocal exchange,” meaning some communication partners were far more effective in either recognizing and/or responding to the children's communication than others. The authors emphasize that, “Understanding how children can be supported to exchange in reciprocal interaction is important because these interactions play a critical role in the development of children’s expressive language.”
Though this study may be a useful approach for recognizing and quantifying children with very low levels of expressive communication's expressive output (and adults' responses) two cons can be identified: (1) Total observation time is quite high. A clinician may have difficulty wiping the calendar to spend an entire day focusing on only one child, combined with time set aside to interpret the data, and (2) You can't replicate the methods used in this study without purchasing the SCERTS checklists.

Greathead, S., Yates, R., Hill, V., Kenny, L., Croydon, A., & Pellicano, E. (2016). Supporting Children With Severe-to-Profound Learning Difficulties and Complex Communication Needs to Make Their Views Known: Observation Tools and Methods. Topics in Language Disorders, 36(3), 217–244.