​A couple of days ago, I wanted to grab breakfast, so I thought I would be smug and order breakfast with  a common AAC program that I use during therapy.  I turned it on and got ready to give my order using core words... I pressed "I”  “want" and realized I didn't know where my foods were listed, With some page navigating, I found the food list, but sadly I couldn't find my simple order of grits and bacon, so I thought for a minute, I could add them to the food page. Ultimately, I went to the keyboard, which I had to modify to my level, to type my order. My 5 second order turned in to a 15 minute process. It was then that I had my “DUH” moment.

What if I was a kid who couldn't spell?
One that didn’t know how to edit?
Or navigate?
How long would it take them (if they even tried to finish)?
 
This is a "comprehensive speech device" and I couldn't get past 2 words! I did NOT want to use it and ultimately didn’t. Thankfully, I decided to practice before I went in so I did spare myself the embarrassment.  It was in that moment that I realized the importance of everyone involved being trained to use, model and modify the chosen communication system to the child’s individual needs. 
I am an SLP. A Speech Language Pathologist who is supposed to be specialized in all aspects of "speech" and I realized I’ve been wrong. Wrong in thinking I knew how to help those with communication aids. Wrong in how I approached therapy with my students with an AAC. I realized the skill development required for the use of an AAC system is no different than that of general technology used today, a cell phone for example:

What happens if you give a child a cell phone without showing them how to use it?

Do they automatically turn it on?
Can they get to the app they want?
Do they even know what they want to do with it?
How long would they play with it?

If you play a movie or song they like...

Do they show interest?

If you hand it to them while the movie is already playing...

Do they want to keep it then? 

Kids see cell phones used continuously throughout the day for various reasons such as, calling, texting, watching movies, playing music and games, giving directions, googling for information and even paying for our purchases. They want to use the phone after they've seen what it does. They see you and everyone around them constantly using the phone. When you give the phone to them, you initially do most of the work to get them started but, over time, they gradually stop needing help. 

Why is it then, that we don't use those same rules, almost innate actions, when it comes to a child using an alternate communication system?  I may not be speaking for all, but I think most people see a communication device as a sudden fix for the wordless. They believe the child will now “respond” without any further help. But they don't. Think of those children in the initial stage of communication:  

How do typically developing babies learn to talk?

We give a baby a least a year of speech models and interaction before we expect anything in return, and more than that for those who may have difficulties. So why do we not expect to have to do the same to someone who is just learning to talk with an communication aid? Yes, these students are older, but if you viewed them early developing language learners, how would your interactions and approach with them change? 
 
You know the saying it takes a village to raise a child? The saying rings true for a child’s success with an alternative communication system. 

Amy Bennett, SLP
Ware County Public Schools
Waycross, GA

The key to integrating AAC Tools & Techniques into your daily life (or school day) is to have a PLAN!  Like most endeavors, AAC implementation does not just occur spontaneously.  It requires the people around the AAC user to systematically analyze the environment, delineate communication opportunities, target specific vocabulary/messages and then make sure that there are means to communicate these messages (AAC options!).  We have several favorite tools available that can assist the family or team in implementation planning.  

Environmental Communication Teaching is an approach that trains classroom teams to select specific activities to target for communication, implement appropriate strategies and techniques for teaching, arrange the environment for learning and plan activity based objectives.

http://archives.gadoe.org/DMGetDocument.aspx/Strategies_of_ECT.pdf?p=6CC6799F8C1371F6D3463A8B7EF3CC2A275A85A6A991BEE8800BEEDD8FEA8AE8

We also use our own form of schedule analysis and goals delineation called the Dynamic AAC Goals Grid-2, distributed freely by Tobii-Dynavox.  www.mydynavox.com/Resources/AACGoalWriting. This tool gives a means for assessing a student’s current skills in AAC, delineating the communication environment, developing IEP goals and documenting progress.   

The SETT Framework is another highly recommended format for implementation of Assistive Technology.  Although it isn’t specific to AAC, it is well organized, well researched and applicable to our work in AAC, a subset of the field of Assistive Technology.  http://www.joyzabala.com/Home.php


We found a wonderful website this year that shares forms and tools specifically targeted at improving implementation of AAC.  The clinicians at RAST (Resources for AAC Services and Tools) Resources website provide planning forms for gathering information needed for team sharing, planning tools, vocabulary selection and more. http://rastresources.com/resources/ 

What are your favorite tools, forms or ideas for implementing AAC?  Share your ideas in our comments below!

We met this adorable little fellow, Michael, today who is an emerging communicator using the Speak For Yourself app. Michael has ABA specialists who help him learn many new skills. Our chat with his mother reminded me of this tip sheet I created a while ago to help our ABA professionals working with us to teach language to AAC users.  AAC users have unique needs when working with an ABA protocol.  Here are a few ideas that may help!

Implementation Notes: Because the student is producing language in an alternative form than speech, his training for tacting and manding will have some slightly different considerations than for speaking patients.  There are 2 types of prompts which can be used to teach communication via a speech generating device:  stimulus prompts and response prompts

Response Prompts:  Prompts provided by the partner (backward chaining with physical prompts, direct point cues, direct verbal cues, indirect cues and natural cues).  Independent tacting on an SGD (speech generating device) requires navigation to reach vocabulary.  Interventionists can remove this requirement to simply target tacting by using “partner assisted navigation” where the therapist goes to the page where the vocabulary item exists and then asks the patient to label the presented photograph by touching the corresponding symbol on the page.

Independent manding on an SGD also requires navigation.  If you want the patient to exhibit the skill of manding in isolation of the navigation demand, similar to tacting, the therapist uses partner assisted navigation to take the student to the appropriate page and then expects the student to select the desired item to request.

In order to achieve independent tacting and manding on his communication device, the student must master navigation.  Navigation is taught through backward chaining in the following sequence:

o   Therapist navigates to the appropriate page for the student, student is asked to mand/tact on that specific page.

o   Therapist demonstrates navigation to the appropriate page, student is asked to mand/tact on that page

o   Therapist navigates to one page that links directly to the specific page where vocabulary is targeted.  Student is asked to select the button that links to the targeted page and then asked to mand/tact on that page. ex: therapist navigates to a dictionary (“things” or “my words” page) and the student is asked to select the appropriate category button

o   Therapist gradually backs out of navigation, teaching one page navigation at a time until student can navigate from the main page to the specific vocabulary page.


Stimulus Prompts:  prompts that are embedded in the page sets    Stimulus prompts are visual and position cues that are part of the presentation of the vocabulary.  They can include the following:

·        color coding,

·        hiding extraneous buttons/messages,

·        shape cues and

·        position cues on the page of the device. 

If the training is completed on the student’s regular page set, the student will be able to use motor planning to assist him in navigation.  Clinical evidence and research indicates that this motor planning is often attained even in the absence of an understanding of categorical, grammatical or functional vocabulary organization.  Students simply learn the motor movements/locations on the screen required to get to the desired vocabulary.  They use visual images to assist in the initial learning stages but, like adults who type on a keyboard, students learn the position of the linking buttons to increase their rate of communication over time.

By simplifying learning through stimulus and response prompts, students can learn independent navigation of their devices in order to produce language spontaneously.  Prompting teaches words in the context of the student’s language system rather than on random pages that cannot be accessed independently by the student for future communication.

And remember, the most important thing about communicating using an AAC system, is COMMUNICATION!  Establishing social relationships is one of the most important functions of language development and communication so, whenever possible, sit down and have a good 'ole unstructured chat!

AAC plays an important role in helping our families navigate medical procedures, tolerate hospital/ doctor visits and, explain their healthcare needs.

Kasey's mom Tracey describes her experience after surgery, "Kasey was groggy and on lots of medication post surgery, but when offered her T10, she navigated to "more"! We'd been giving her sips of apple juice and she clearly wanted more."

Here's a blog post I wrote for PrAACtical AAC on the subject of AAC and serious medical procedures:

http://praacticalaac.org/praactical/a-praactical-look-aac-at-dynamic-therapy-associates/

Speak for Yourself (SFY) is a an AAC app that is, at first glance, very visually complex and slightly daunting looking.  Packing a whopping 5000 words right from the download, SFY simply has to have a lot going on on each page.  There are lots of keyboard sized buttons leading to second pages with lots more buttons.  

BUT, did you hear?  You can access 5000 words with only 2 button presses.  This is an out of the box robust vocabulary set that requires minimal navigation.  Minimal navigation means minimal attention and memory as people are building messages.  I first started looking at SFY for a particular patient who has a difficult time patiently constructing messages without getting frustrated and giving up (or becoming agitated and aggressive). He only has to tolerate 2 simple presses to get to the word he needs.   Although this young man has limited patience for message construction, he has high expectations for his device to give him to access an extensive, specific set of vocabulary words.  He rejects the device very quickly if it doesn't allow him to say exactly what he wants to say.  No judgement!  I think I would feel the same way!  With a 5000 word headstart, I find I only have a few select, specific words I need to add:  Disney, pictures of family, favorite t.v. shows and YouTube videos, so far.

The beauty of this search feature is that I can have my friend type his own word in and then independently follow the highlighted button pathway to teach himself new word locations.  Craziness!  I just hang back and watch him find his way around (not really, but it's pretty simple!).

The other awesome feature about SFY is that you can very easily hide and show buttons to decrease complexity when a user is first learning the system.  There's a quick one button press to hide all the buttons and then you can simply select the buttons you want to teach.  You can teach one word at a time until the motor pattern for that word is established and then add on until you have an extensive vocabulary.  Remember that search feature?  When  you search a word the app will learn the word you searched, even if it is hidden, so that the user can access it in the future.  I love that the users are able to participate in adding ("showing") the words that are important to them.

There are some additional features I like.  "Babble" is another unique feature which lets you show all the buttons to let a user play around with words and then quickly jump back to your simplified (hidden button) pages for supported communication. You can use text-to-speech to type your messages with the iPad keyboard.  You have access to all morphological endings to words (ex:  verb tenses).  

I am quickly becoming a fan of Speak For Yourself for certain AAC users.  AAC users who will definitely benefit are those who have good fine motor access to the keyboard sized buttons, good receptive language skills (who know what they want to say), who you are expecting to learn morphology and syntax (word endings and word order), and who benefit from a keyboard for literacy development or as a communication means.  In my mind, SFY is not for everyone, but it is stellar for many!

There are few items on my personal wish list for Speak For Yourself.   

• The symbols are a bit hard to see with very fine lines and minimal color saturation.  I find they are challenging to discriminate, increasing the demand on motor memory for access. I'd like to fatten up some of the lines to make them easier to see.  Maybe add some thicker borders to give a little visual "POP!"
• I might add a few quick, frequently used social phrases to increase rate of communication for  commonly used messages.  
  

Speak For Yourself was developed by speech language pathologists.  They haven't stopped at developing the app.  They consistently share resources, offer insight and train people supporting AAC users. Here's how to find them: 

My iPad has become an integral part of my weekly speech therapy sessions so of course I was happy to participate in the YappGuru Top 10 Apps of 2014 Linky Party!  Here's my Top 10 for the year.  Be warned, I was told everyone loves freebies (of course) but  only 2 of these are free.  However, these are high quality apps that REALLY do what they say they do.  They are worth every penny I've paid.  Although I do get freebies from developers at times, I chose to use my speech therapy budget for almost all of these apps.

ChoiceWorks by BeeVisual http://www.beevisual.com/ 

ChoiceWorks is a great little app that lets me set up a schedule of our therapy activities for each session.  When each activity is completed the students can move the icon over to the "All Done" column.  There is a timer you can set for each activity (great for limiting reward time!).  End of the session rewards are shown on the bottom and kids can pick from 2 different rewards.  This app has great possibilities for families and teachers to schedule across a longer period of time (daily schedules, for example). 

Story Creator: by Innovative Mobile 
I love this app!  I have patients pick out photographs either from a file of their own photos or from Google image searches.  We save the photos on our iPad and then write sentences to go with our photos.  Kids can then record their sentence, either verbally or using their AAC device.  This is a GREATLY motivating activity for most children as we choose their most favorite topics.  So far this year we've written about Disney, princesses, snacks, sports, Halloween, and travel destinations.  When we are done, we can email our books to our personal iPads or to our family's iPad to share at home.  Excellent app!

Tiny Tap by TinyTap Ltd is a great little app for developing interactive activities.  This little app allows you to create books, puzzles, quizzes and educational activities.  It is so simple that your students can create activities as well.  Not so creative?  That's okay, there is an entire community uploading activities you can download.  Some activities have a small cost but most are free.  GREAT when you want to create activities with very specific content for your patients.

Symbol Support by the Attainment Company
is a great little app to allow you to add symbols to text.  This has been a handy tool for helping students understand text.  We've used it to "translate" class notes into understandable visual images for social studies and science.  The app has an extensive library of symbols and if you can't find the symbol you need, it has an internet image search embedded into the program.  

News-2-You App by Assistiveware
Of course I love the News-2-You app.  This app lets us access all levels of the picture enhanced newspaper, listen to the pages read aloud (with highlighting), and use the interactive game pages.  The app requires a News-2-You subscription, which you should have ANYWAY, since it is a curriculum of materials for your students.  I have used News-2-You for speech language therapy for most of my career.  It's worth every penny!

ArtikPix by Expressive Solutions LLC
is a great app for targeting articulation practice for children who need clear, simple images.  I love that this app uses Symbolstix, a symbol set many of my students are already familiar with.  The app includes flashcards and a simple memory game.  It is SIMPLE with clear, easy to see images.  I find it works very well with my students who can't handle complex images and lots of distractable clickables.  This is easy, lets you collect data and record student attempts at production.  Perfect for my special needs students.

Speech Stickers by Serious Tree LLC
As long as we are on the subject of teaching articulation, this is a wonderful, motivating app that helps patients practice very early developing sounds and sound combinations.  All basic sounds are targeted in isolation or a consonant-vowel or vowel-consonant format.  Pick a sound and placement and then let your kids pick a character to make the sound.  The students imitate the sound and you select either a correct/incorrect placement and the counting gauge moves up.  Once the child has practiced 5 times they get to choose a reinforcer which makes all the characters disappear.  Characters are pushed off screen by a bulldozer, taken away in a bus or train, eaten by a shark, blown up by a bomb and more.  Well worth the wait for 5 practice trials!

School of Multi-Step Directions by Virtual Speech Center
is a great little app that teaches multiple step directions in the context of a chemistry, language or math class.  Directions include real classroom actions such as "underline," "highlight," "add to," "shake," "cross off" and "touch."  The app is engaging and the reward is a simple and fun little "pong" game that my kids love.  Very well done and useful app!

First Phrases by Hamaguchi Apps is a clear, simple, effective and engaging app designed to help patients who are just beginning to combine words into short phrases.  When children get the words in the correct order, they have the opportunity to record their new phrases using their speech (or if you are in my therapy room) their AAC device/app.  The reward is an animation of the new phrase they created with adorable little characters.  Visually clear and simple and useful!  Pretty much all Hamaguchi apps get a thumbs up in my therapy office.  They are all high quality and address the basic language my children need.

Counting Songs 2 by HelpKidzLearn
is a fun little cause/effect and counting app by one of the BEST app developers.  10 engaging songs let kids simply touch the screen to advance the song and count the characters.  I use this app to let kids experience cause/effect through touch screen OR switch access.  I post this as an example of one of the amazing apps available from HelpKidzLearn.  If you have students who are at an emerging level of interaction and participation, are switch users or have visual impairments, these apps are perfect.  Check out ChooseItMaker3 while you are at it, for creating your own visually clear, easy to access activities for your emerging communicators.

PHEW!  It's hard to stop here!  There are so many wonderful, effective apps out there.  Don't forget these are apps for you to use WITH your students.  Don't just hand over the iPad, even with these apps.  Jump right in there and have fun with your kids!

Happy Holidays!
Vicki

We had the opportunity this month to meet some very special boys who have complex communication needs and sensory impairment.  One of our boys is deaf-blind, ambulatory and nonverbal.  One youngster is functionally blind and has severe motor impairment.  He is nonverbal and nonambulatory.  Our last fella is nonverbal, has a severe visual impairment and significant sensory defensiveness.   All three boys are curious, focused when motivated and responsive.  They all communicate primarily through affect, unconventional gestures and vocalizations.

The sensory evaluation starts many days in advance with collecting a wide variety of items to present systematically to the children in the following sensory categories:  visual, auditory, tactile, proprioceptive, vestibular and olfactory.  Fun shopping, including some handy dandy toolbox organizers, and this is what we came up with!

Our Sensory Collection:
Olfactory:  snack boxes to hold extract soaked paper towels for vanilla, peppermint and almond; wax melt cubes in lavender and cinnamon scents; car air freshener rear view mirror tags, scentsicles
Vision:  light up spin toy, latch on/off star light, reflective Mardi Gras beads, flashlight, light up bumpy ball, rain stick, lava drip tube, toy tops, disc shooter, reflective pom pom, wind up toys, iPad apps including:  Big Bang Patterns and Big Bang Pictures (volume muted!), Little Bear Sees
Tactile:  rice bag (to put hands and feet in), floam, unscented lotion, light vibration bug toy, feathers, wiggly worm, felt squares, scouring sponge, bag of tiny pom poms, koosh ball
Auditory:  music box, environmental sound apps (Sound Touch app), different genre songs on iPhone, jingle bells, rain stick, tambourine, maraca
Proprioceptive:  sock full of beans/rice (tied off at top!), heavy frog, deep pressure vibrating bug.  We also use our bodies for deep pressure hugs, joint compression, massage
Vestibular:  classroom equipment including swings, rocking chairs, teacher's spinning office chair, sit n' spins; our bodies to bounce, swing and spin!
Gustatory: still in progress!


We packed up all our goodies in an old scrapbook rolling bag and had a great day meeting our new friends with complex communication needs!  The GREAT news?  These boys all had at least a few items/activities which motivated them enough to respond with affect, facial expression, vocalizations, or gestures.  We started a few communication trials and are considering auditory scanning, object symbol communication, high contrast symbols on a dynamic display device and co-active signing.  It will be such a pleasure to see what these boys do as they continue their communication journey!

Do standardized test scores accurately describe children with complex communication needs?  

No.

 They serve the purpose of confirming that, indeed, the child has complex communication needs. They tell us nothing about "intelligence."

Standardized tests are not standardized on nonverbal children. None of them.

Zero.

Even the nonverbal intelligence test is standardized on verbal children. It's a good attempt to describe cognition without the complication of verbal language but still, there is no standard for "normal" intelligence for nonverbal individuals. So should we use standard scores for speaking children to accurately describe nonverbal students?

No. 

We describe cognition in terms of a person's attention, memory and learning. These are actual functional skills we can measure, practice to improve and compensate for when necessary.  If we must describe cognition, we should do it only so that we can determine strategies for improving attention, memory and learning.  If we find that a child is struggling with attention we should be looking at sensory skills and needs, understanding of language, motivation and environmental demands. If memory is a concern, let's compensate. If learning is lagging, how about making connections, ensuring understanding with visuals, tactile cues, multimedia and real life experiences?

Seriously.

I've read some truly dismal psychological reports, comparing 16 year olds to 2 month olds. As required by Medicaid, insurance and schools, I've given the tests. I've reported the results as I was trained to, using age equivalences to describe language skills. For almost every patient I've ever seen I've reported that "<55" standard score. I've also heard our parents tell me they don't process anything on test reports except those dismal numbers. 

I hear you. 

I think I'm done with age equivalences and, since we can't use standardized tests, we will simply use checklists, describe well, listen better and creatively educate. 

Here is a parent's perspective that professionals should hear.

http://niederfamily.blogspot.com/2014/10/false-negatives-evaluations-of.html 

Standardized tests are a shortcut to allow professionals to document that they have met an evaluation requirement for a child with complex communication needs and little more.

Stop.

Cease.

Desist.

And watch, listen, watch some more, listen again and then describe.

And then do something to make a difference!

Kendal and I have had some wonderful conversations.  He's been telling me about his favorite music (country!), his new temporary home, his opinion about some of the people in his life...  Kendal and I have known each other for many, many years.  We've struggled through traditional therapy, YouTube infused visits, extremely short visits as he was determined not to join me and now we've settled down into this nice relationship.  I've always loved Kendal but now I can say I truly enjoy interacting with him.  The difference is that now Kendal and I really understand each other.  Kendal and I interact with both of us using his communication device as a "translator box."  Kendal struggles greatly with comprehending spoken language.  His social and environmental awareness greatly exceeds his understanding of verbal language.  Sometimes we think he hears that Charlie Brown teacher voice when we talk.  

The technique I use most with Kendal is Aided Language Input.  Very simply stated, I use Kendal's device, the NovaChat 10, to talk to him.  The visual symbols paired with my (Charlie Brown teacher) speech help Kendal understand me so that he can participate in our conversations.  I touch symbols on his device which correspond to the words I'm saying. The value of aided language input is that Kendal is able to see someone communicate the same way he does.  He has a model for how aided communication works.  There is no pressure for him to imitate my model.  If he wants to participate, awesome! If he just wants to listen, that's okay too.  Either way Kendal is learning language and building relationships.  Kendal's mom is amazing and she uses this technique as much as possible at home and in the community.   Kendal seems calmer and happier as a result of his improved understanding and ability to offer his own opinions.  He's found a great deal of satisfaction in being able to tell us about the other people in his lives and their ups and downs in caring for him.  We've also seen an increase in Kendal's understanding of our words.  He's responding more and more to our verbal language.

You'll see in our video that Kendal pays close attention to my symbol selection and then reads the message window text.  He obviously understands and "gets" my jokes as we take turns talking. Since Kendal primarily communicates using 1-2 symbols per message,  I used to simplify my messages to just a few symbols per statement.  Now I use 4-7 symbols per statement because he's shown me he understands.  There are some really wonderful resources on the internet to explain how Aided Language Input works. Here's a great compilation from PrAACtical AAC:   http://praacticalaac.org/tag/aided-language-input/


We thought we'd just show you! 

We DTA therapists have been working diligently for the past several weeks (or days) to bring you the quality of service, commitment and products you've come to expect from us. Countless hours of dedicated concentration and planning (and some cheating) have gone into the development of our Annual Pumpkin Decorating Contest Entries. Please take some time to carefully consider your choices as you place your vote for the Supreme Pumpkin Decorating Queen of the Year!  The Winner will have bragging rights  ALL YEAR LONG so, help us out and VOTE NOW for your favorite PUMPKIN OF THE YEAR!