Monday, February 19, 2018

You Have to Stop Listening to These!

It’s been more than a decade since Romski and Sevcik wrote their article about the myths of AAC. They wrote that “Despite the advances, the inclusion of AAc services and supports into early intervention service delivery for young children has been hampered primarily by myths about the specific types of roles AAC plays.”

Here we are more than 12 years later, and many of these myths still run rampant through our service delivery - or lack of it. Romski and Sevcik addressed the ways in which AAC can facilitate the development of children with communication disabilities.

Children need both comprehension skills and expressive skills. Routines create consistent language environments (did you read last week’s post about routines? Or this older one here?), and consistent opportunities for partners to create learning opportunities. Research by Hollich et all (2000) is cited in the article as indicating that children rely “…on comprehension to build a foundation for later productive word use.”

Romski and Sevcik list 6 myths of AAC:

1. AAC is a “last resort” in language intervention
Research has shown that it is actually important to introduce AAC before the child fails so that he has a communication mode before frustration sets in.

2. AAC hinders or stops further speech development
Research again has shown that use of AAC can actually help children develop speech.

3. Children must have a certain set of skills to be able to benefit from AAC
As the exact relationship between cognition and language is unknown, we do know that many children cannot demonstrate their abilities without a way to communicate.

4. Speech Generating Devices are only for children whose cognition is intact
Advances in technology mean that advanced cognitive skills are not necessarily needed to use high tech systems and, as a wide range of options are available, there are many tools that children can bee taught to use effectively

5. Children have to be a certain age to benefit from AAC
Again, research shows that providing children a mode of communication early is beneficial and will not hinder speech development.

6. There is a representational hierarchy of symbols from objects to written words.
Romski and Sevcik site the research that shows that children do not actually learn less abstract symbols better or faster. To the child, all symbols work the same way. We just need to teach them consistently.
(Did you read my last post about the myths here?)

Romski and Sevcik go on to discuss the important role parents play as interventionists. Certainly, family is all-important in providing intervention when children are young. The article concludes with the reminder that it is never too early to begin using AAC for language and communication support, and that AAC is a tool; not the end goal. “AAC is not a last resort but rather a first line of intervention…” 
 The message of this article is as important in 2018 as it was in 2005.
 I, for one, am saddened that these myths still abound in our profession and in the minds of other educators. It is about time that we acknowledge that ALL children can communicate.
Please, keep on talking!

Sunday, February 11, 2018

Is This Routine? Why Not?

I’m trying not to sound like a broken record, but some strategies are so important that they need to be said over and over again:  We begin to build language with routines.

Research tells us that routines are at the heart of symbol and language development.  Routines are sequences of actions or events that are repeated over and over again.  
Every routine can be broken down into smaller and smaller components.  Each of these components is influenced by the responses and reactions of those involved.  The reactions and responses become symbols that are used in this interaction to signal to each other.  [Remember, symbols are signals that are interpreted the same way by at least 2 people.]  

When the routine always follows the same sequence, the signals between the two people involved become shared symbols.  Routines help us build symbolic awareness, and symbols become communicative when they come to have a more standardized or conventional meaning among a larger group.  

This helps us realize why it is important to develop routines in thinking about intervention for AAC (Lonke, 2014) and for understanding the impact of aided language stimulation.
Aided Language Stimulation is a strategy I have written and spoken about repeatedly, because it is the single most important strategy for getting AAC users started as communicators.

Once use of Aided Language Stimulation has been established to introduce word use to the individual, explicit teaching activities need to be implemented to teach the new words.  Facilitators need to teach explicitly, then elaborate on the meaning and use of the word through a variety of meaningful activities.  The AAC user needs to be exposed to the word repeatedly and consistently.

Von Tetzchner (1997) and Porter (2009) both refer to the differences in language environments between typically developing children and AAC users.  Children are typically surrounded by examples of others using the communication systems they are learning.  Typical 3 year olds in middle class families hear 6 million words per year.  Typical deaf children with deaf parents see 6 million signed words per year.  Typical AAC users see others using symbols to communicate effectively approximately 0 times per year.  
“The average 18 month old child has been exposed to 4,380 hours of oral language at the rate of 8 hours/day from birth.  A child who has a communication system and receives speech/language therapy two times per week for 20-30 minute sessions will reach this same amount of language exposure in 84 years.” (Jane Korsten).

Hart and Risely (1995) found that typical children in working class families hear approximately 1,250 words per hour and accumulate a listening vocabulary of 6 million words by the time they are 3 years old.  Miranda (2008) then posited that children with ASD who are using AAC need to be presented with, literally, hundreds of opportunities to have symbol use modeled throughout the day.

According to Von Tetzcher (1997) “the difference between their own expressive (and for some also receptive) language and the language used by significant people in their immediate surroundings” is a critical factor in the acquisition of language for AAC users.  There is an assumption in all major theories of language learning that the individual is surrounded by others in the environment using the same language system.    Even in second language learning the importance of immersion has been noted. Learners of second languages need to participate in an environment that exposes them - immerses them - in experiences with that language in order to become competent communicators. 

The opportunity to be immersed in an environment using aided language is very rare.  For AAC users and learners, there is little if any opportunity to even observe others using an AAC system, let alone be immersed in an environment of AAC users. But without this, children learning to use AAC systems constantly need to figure out how to use a language system they have rarely - or never - seen used to communicate.  Not having models of others using aided language results in the student not knowing how to use a language system they have never seen used.
Because this type of immersion environment is rarely provided (although beginning to find foothold) to learners of AAC, there is a great discrepancy for them between the language environment to which they are exposed, which uses verbal language, and the language system they are being asked to use, which is a picture-based language.
Whatever the environment you are in, you need to think about the activity you want to engage him with, think about the language skill you are targeting, and plan what support is needed for the student to achieve the target.

Language intervention techniques that increase early expressive communication skills include Aided AAC Modeling, Expectant Delay, Open-Ended Wh Questions, Brief Verbal Prompting, and Increased Responsivity.

The same strategies used for all students/children apply to your AAC user. In a read aloud activity, for example, you can reference the text (“Look at the boy running!”), a cloze procedure (“The boy is _”), expansion (“Yes, the boy is running”), binary choice (“Is the boy sitting or running?”), modeling (in this case posting to pictures in the AAC system rather than verbal only model), open-ended questions (“What is the boy doing?”).

The Bioecological Model of Human Development. Bronfenbrenner, Urie; Morris, Pamela A. Lerner, Richard M. (Ed); Damon, William (Ed), (2006). Handbook of child psychology (6th ed.): Vol 1, Theoretical models of human development. , (pp. 793-828). Hoboken, NJ, US: John Wiley & Sons Inc, 1063 pp.

Bruno J, Trembath D. (2006)  Use of aided language stimulation to improve syntactic performance during a weeklong intervention program. Augment Altern Commun. Dec;22(4):300-13. 

Goosens, C., Crain, S., & Elder, P. (1992). Engineering the preschool environment of interactive, symbolic communication. Southeast Augmentative Communication Conference Publications. Birmingham, AL.

Hart, B. and Risely, T. (1995)  Meaningful Differences in the Everyday Experience of Young American Children. Brookes Publishing, 1995 

Henneberry, Solana, Jennifer Kelso, and Gloria Soto. "Using Standards-Based Instruction to Teach Language to Children Who Use AAC." ASHA, Perspectives.Web.

Kent-Walsh, Jennifer, Cathy Binger, and Zishan Hasham. "Effects of Parent Instruction on the Symbolic Communication of Children Using Augmentative and Alternative Communication During Storybook Reading." American Journal of Speech-Language Pathology 19 (2010): 97-107.
Light, J. (1989). Toward a definition of communicative competence for individuals using augmentative and alternative communication systems. AAC. Vol. 5, No. 2 , Pages 137-144

Light JC, Beukelman DR, Reichle J (Eds.). 2003. Communicative competence for individuals who use AAC: From research to effective practice. Baltimore: Paul H. Brookes Publishing Co.

Lonke, F. Augmentative and Alternative Communication: Models and Applications for Educators, Speech-language Pathologists  Plural Publishing. 2014

Pragmatic Organization Dynamic Display Communication Books: Designing and Implementing PODD Books. Porter and Burkhart 2009. Seminar

Von Tetzchner, S. (1997) The use of graphic language intervention among young children in Norway. International Journal of Language & Communication Disorders
Volume 32, Issue S3, pages 217–234, December 1997

American Speech-Language-Hearing Assoc (2001a). Competencies for speech-language pathologists providing services in augmentative communication. Asha, 31(3), 107-110.

Banajee,M., DiCarlo, C., Striklin, S.B., (2003). Core vocabulary determination for toddlers. Augmentative and Alternative Communication, 19, 67-73.

Binger,C. & Light, J. (2007). The effect of aided aac modeling on the expression of multisymbol messages by preschoolers who use aac. Augmentative and Alternative Communication, 23(1), 30-43

Musselwhite,C.R., Erickson,K., Zoilkowski,R. (2002 ). The Beginning Literacy Framework. Don Johnston Inc.

Musselwhite,C.R. (2006).  R.A.P.S. Writing Tips!  Learning Magic Inc. ASHA’s site contains position documents, and documents outlining their stand on the knowledge and skills, roles and responsibilities of slp’s regarding aac

Wednesday, February 7, 2018

Who Doesn't Love a Giveaway?

This terrific group of SLPs on TPT are giving away gift cards so you can fill your wishlists!  Check out their resources, wander through their Instagrams, and enter to win.
There will be 1 $100. gift card and two $50. gift cards.

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Sunday, February 4, 2018

Think Your AAC User Can't? Bet You He Can!

One old-time SLP staple in terms of therapy materials has been Barrier Games.  Barrier games are great for working on giving and following directions, using and understanding descriptive words and spatial concepts, and, if done in pairs or small groups, with working on cooperation.

Barrier games, for those who have not heard of them, are played with 2 people, usually, seated facing each other but with a barrier between them that keeps them from seeing each others’ desks or spaces.
Each student has an identical scene or flat mat/paper in front of him, and an identical selection of images.  

One student gives directions to the other one about where to place specific items.  At its simplest, barrier games are played with multiple colors of shapes, which students assemble according to the directions they are given.  For more fun and better engagement, use pictures that are fun and motivating.

Recently a SLP asked me how on Earth you could use barrier games with students who use AAC.  Actually, barrier games are perfect for those same skills for students who use picture-based or text-based communication systems.
And, they are perfect for focusing on core words.

Think about what words are needed in a barrier game activity. Aside from the words for the specific objects, which are those pesky nouns, players need descriptive words and locative words, action words for “put” and “move,” for example.
Students need to use and understand color words (the green one), prepositions (put it under), other adjectives (the big one, the striped one).  These are all in core. And descriptive words are all on the same page or at least within the same folder. Prepositions are going to bee on the same page.  And in some systems, rather than taking up space with opposite concepts, users are supposed to learn “not” + adjective; as in “Not big.”

When I first came across barrier games about 30 years ago, they were construction paper shapes in different sizes and colors.  SLPs these days are more inventive and decidedly better at finding thematic images to motive students more.

And don’t think you need to play with just 2 students.  One very popular activity I used to do with Middle School students with language disorders  called for one student to stand at the chalk board (yes, that long ago), while I showed the rest of the class a picture of an “alien.”  Students in the class had to provide descriptive details to the student at the board, so that he could draw an alien that looked just like the one I was showing the class.

Kids found the resulting drawings hilarious, and the student drawing never felt badly about not coming up with the “correct” drawing because it was all just plain funny.

So, enjoy barrier games with all of your students, and….. keep on talking!

Sunday, January 28, 2018

What’s One More Evidence Based Intervention Tip for Students with ASD?

Naturalistic Intervention has been shown through research to be EBP for building communication and social skills for students of all ages and cognitive levels.

Naturalistic Interventions are a group of strategies to address behavior, specific interaction types, and environmental engineering.  They target building specific skills through use of the student’s interests.

The checklist the National Professional Development Center on ASD provides includes steps to identify a specific target behavior or skill and identify baseline, train team members, identify contexts for providing intervention, arranging the environment in a manner that will elicit the target behavior, engage the student, and use specific strategies to teach and intervene.  
Modeling is a specific strategy identified, as are a time-delay strategy and incidental teaching.

One of the parts of this model that easily overlap with AAC implementation strategies is the planning out of the student’s day and identifying contexts in which to model.  We speak of listing out the student’s daily activities, the partners involved and the vocabulary or function to use, as well as engineering the environment to ensure that the opportunities exist to elicit the target skill.

Just as we, in AAC implementation, want to ensure that the user is engaged in genuine communication interactions, so Naturalistic Intervention speak to following the individual’s lead and “engage the learner in language-rich, learner-directed, and reciprocal interactions…”

The Naturalistic Intervention Module was developed by the NPDC on ASD in 2009.

Sunday, January 21, 2018

AAC and Autism: What's the Evidence?

I have been using voice output devices (VOCA) - otherwise known as speech generating devices (SDG) - for as long as they’ve been around.  And most of my caseload over the years has been full of kids on the spectrum - autism spectrum, for the uninitiated. 

And as concerned as I’ve always been with Evidence Based Practice (EBP), AAC has not always been considered EBP; if only because there weren’t sufficient research studies to make it so.

(Whoo - what a lot of acronyms in that first paragraph!)

The National Professional Development Center on Autism Spectrum Disorders compiles what it considers to be EBP for persons with ASD. To quote them, “ To be considered an evidence-based practice for individuals with ASD, efficacy must be established through peer-reviewed research in scientific journals using: 

randomized or quasi-experimental design studies. Two high quality experimental or quasi-experimental group design studies,
single-subject design studies. Three different investigators or research groups must have conducted five high quality single subject design studies, or
combination of evidence. One high quality randomized or quasi-experimental group design study and three high quality single subject design studies conducted by at least three different investigators or research groups (across the group and single subject design studies).”

They have now, however, found sufficient studies that meet their criterion using AAC.  They have created a checklist for implementation that is well worth a read if you practice in AAC.

Their checklist includes some things we might consider obvious, but I’m here to tell you that I often find these things NOT happening with kids who need or use AAC.
And some of the points for practice are in line with ABA strategies, but not necessarily best practices for AAC.

So, what is a clinician to do?  Read. Consider. Balance. Interpret. And consider again.

For example, after identifying an appropriate device (well, that’s a hurdle right there), they tell teachers and clinicians to introduce the device with only a few symbols and with many blank buttons.

While using a larger grid and hiding buttons is an appropriate tactic for introducing an AAC system, we don’t want to use too few symbols.  We know that our AAC learners need sufficient vocabulary to meet their needs, as well as needing sufficient vocabulary for partners to provide Aided Language Stimulation (modeling, for short).

I have often seen the practice by ABA practitioners of moving buttons around, in order to ‘ensure that the students are really discriminating and not just memorizing location.’  

However, AAC research and practice has specifically taught us that stability of location is important; that language acquisition through motor planning is a real phenomenon.  And that moving vocabulary around only serves to make learning more difficult and to make students frustrated.

They do instruct clinicians and teachers to provide opportunities for exploration with the device, and to provide “engineered” opportunities within the student’s day that are naturally occurring.  They also remind practitioners and other partners to provide minimal prompting.  Too often I have seen well-meaning communication partners reach out and take the individual’s hand and provided Hand Over Hand guidance.

There is no mention of Aided Language Stimulation or Aided Input, which I see as a major flaw to their checklist.  They address using the least prompting necessary to get a response from the user, but do not allow for a period of modeling without requiring a response.

So, while the evidence is there for use of  AAC with kids on the Spectrum, we want to be careful of what evidence we're following.  Research, learn, and educate yourself - for the good of your clients.

Sunday, January 14, 2018

From Research to Practice: Narrative Studies

As a follow-up to my post last week about narrative skills and abilities in research, I am writing this time about the next article in the Topics in Language Disorders Vol. 28, No. 2; Narrative Abilities: Advances in Research and Implications for Clinical Practice, by D. Boudreau.
Dr. Boudreau notes the importance of narrative skills in academic success and the difficulties of students with language disorders with connected discourse, particularly as they enter the higher grades.
Narrative discourse is defined as, “at least two utterances produced in a temporal order about an event or experience (Hughes, et al, 1997).  Students with language disorders tend to miss the ability to integrate background knowledge with pragmatics - or social language - to formulate an organized recounting.  Boudreau posits that this difficulty in narrative discourse is greater than in conversation.

The author goes on to cite studies showing that 

  • students whose narrative skills are greater than their syntax skills performed better than those who had age appropriate syntactic skills but poorer narrative abilities or tasks for story comprehension and re-telling,
  • the single best predictor of students’ future need for remediation or special education or retention was their earlier performance on tasks of narrative abilities,
  • that narrative abilities in Kindergarten predict students’ vocabulary and reading comprehension skills in 7th grade  
  • that there is a correlation between students’ narrative skills using wordless picture books and their Math skills in school,
  • and more evidence for the role of narrative discourse skills.
So, while we know from the research that narrative difficulties in early years - particularly difficulties with vocabulary flexibility, syntax, and story elements - correlated with academic success, what does this mean for our clinical practice?
Unfortunately, there are studies that contradict the findings of correlation, but for those SLPs who are providing services for these students with impaired narrative skills, we need answers as to what to do.  The bottom line, says Boudreau, is that discourse abilities are crucial in academic success, and, in order to make students with this profile successful, we need to provide remediation in both comprehension and production of narratives.

One factor that is shown to have influence on students’ skills in narrative discourse is early interactions around books and experiences.  The interactions with parents or other adults that provide scaffolding of story telling / experience retelling, that co-construct narratives with children and gradually decrease that support, are critical.  By providing opportunities to interact with partners who provide quality exchanges students develop the narrative skills that they need.
Improved literacy and language skills have been correlated with shared reading.  However, not all shared reading is equally helpful.  Again, the quality of interactions is important particularly interactions that preview the book, predict throughout, providing quality activities before and after the book is read that focus on some aspect of language (retelling, acting out, discussion of elements of the book).
Another factor is the quality of interactions with adults who provide adequate scaffolding and quality exchanges at dinner time. The quality of these interactions is crucial.  It sounds obvious to us SLPs, but parents whose exchanges with their children utilized open-ended questions, contained more complex language and better scaffolding provided better impact that parents whose exchanges were brief, unelaborated, less supported and more brief.
One interesting finding (Spinello & Pinto, 1994; Schneider & Dube, 2005) is that students formed more elaborate narratives when they were not shown picture cues.  Use of picture cues resulted in less elaborate narratives, and those that were more informal rather than what would be expected in a written narrative.
In addition to the elicitation-dependent measures, text-dependent measures were also found to be important.  Students have been found to more reliably remember specific details if the narrative or story presented to them is a more complete episode, than if they hear only fragments of information in less structured contexts.  And if the episode tells about the characters’ goals, motivations, and feelings, students are more likely to remember and retell parts of the story.
In discussing clinical implications of the studies reviewed, Boudreau reminds clinicians to understand the impact of the method they choose to elicit narratives and the types of scaffolding supplied to maximize narrative production.  Clinicians should vary the types of narrative tasks they provide in intervention, so that students can take advantage of the scaffolding of different styles of narratives.  Of particular importance is understanding and use of the causal network that underlies a story.
Also important for clinical practice is parental/caregiver training that strengthens parents’ - especially mothers’ -  strategies used to elicit responses.  Talking about daily experiences, using open-ended questions, describing things, and listening carefully are listed among the parental activities that strengthen children’s narratives.
Boudreau also cites studies that have shown that explicit, structured teaching of story grammar enhances students’ understanding and use of these elements in their narratives.
They key take-aways from this article that reviewed research about narrative abilities and the impact of various intervention types on narrative abilities?
  1. Narrative skills improve when directly targeted in structured intervention
  2. Teaching specific story mapping or story grammar elements is an effective therapy strategy
  3. Providing scaffolding in the narrative production of very young children shows an impact in later academic years.
I encourage all SLPs working with children to remember to include narrative skills in their evaluation processes, and to use more than 1 type of elicitation technique; and to include specific structures of narrative style and story grammar in their therapy plans.

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Susan Berkowitz, M.S.,C.C.C., M.Ed. has been a speech-language pathologist for 40 years. She has worked in a variety of settings, both as a SP and as an administrator. She speaks at local, national, and international conferences, and has published research in peer-reviews professional journals. She is currently the Director of Print Content at 

Boudreau, D. (2008). Narrative Abilities: Advances in Research and Implications for Clinical Practice. TLD (28:2) 99-114

Hughes, D. et al. Guide to Narrative Language: Procedures for Assessment. Eau Claire, WI; Thinking Publications

Schneider, P. & Dube, R.V. (2005) Story presentation effects on children’s retell content; Amer. Journal Speech-Language Pathology, 14, 52-60.

Spinello, A.G., & Pinto, G.  (1994). Children’s narratives under different conditions: A comparative study. British Journal of Developmental Psychology, 12, 177-193.