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Sunday, September 24, 2017

So, How Long Does it Take?

Almost every time I do an evaluation or consult with a family, they ask; “How long does this take? When will he be able to communicate?
Unfortunately, there is no answer to that question. 

To be blunt; it takes as long as it takes. Every child is different, every classroom is different, every family is different. And even if I knew someone was going to provide Aided Input /modeling consistency for X hours per day, I still couldn’t answer that question. 

create communication opportunities

The truth is, none of us can predict the rate at which a child develops skills; particularly communication and language skills. Even neurotypical kids learn at different rates. And for the kids we’re working with, language is probably the most difficult thing we ask them to do.

We do know a few things, however, that influence the course of intervention.

1. Model: The more consistently we provide aided input, the faster our AAC users learn what the symbols mean, where to find them, and - most importantly - when and how to use them.
Use of Aided Language stimulation or Aided Input cannot be stressed enough.  It makes a huge difference.
And I know there are communication partners out there saying, "But I've been doing this, like, forever!" (note the Valley Girl whine in the tone of voice, here).

I wish I could say, "Do this for 6 months and all will be revealed." But it doesn't work that way, much as we'd like it to.
create communication opportunities
And I can honestly say I've had students who "get it" inside of a couple of weeks, and others who are still struggling after a couple of months - or years.  There are so many variables, as each student is unique unto himself.

2. Tempt and Sabotage:  There need to be sufficient opportunities in the student's day to both observe models and use the system.  Some say it takes 200 opportunities per day for an AAC user to become competent.  

Those 200 opportunities should be taking place inside of the naturally occurring situations or contexts of the student's day.  But sometimes the environment isn't stimulating enough, or the teacher talks too much, or the student just requires additional structured opportunities to communicate.

So, what can we do?  We can introduce communication temptations into their day.  Provide activities or items that are motivating, and about which the student will need to communicate something to get to them.
Sabotage or engineer the environment. Put favored items just out of reach or away.  Create a 'need to communicate' in order to get to an item, activity, or person or place.

Look at all of your interaction and communication with your AAC user and look for all of the ways you can infuse real communication into those opportunities and model how to do it.

Keep modeling and.........keep on talking! 

Sunday, September 17, 2017

Let's Talk About How Many Words Your AAC User Needs!

The debate is still on about which words we provide to our beginning AAC users, how to organize that vocabulary in AAC systems, and how to teach AAC users to use those words?

AAC vocabulary size

It’s not a new debate, and you may have very strong opinions.  However, in recent years there’s been a much more cohesive concept in the AAC community about what AAC systems and AAC instruction should look like.

When I do presentations around the country, I always talk about where we have been (the bad old days of whole message systems)  and where we are now (with more emphasis on spontaneous utterance generation) in that discussion.  How we manage this is so crucial to the individuals whom we serve.

One quote I always use that comes from Porter & Kirkland pretty much sums up the importance of this issue:

“..a child who uses speech will independently select the words she wishes from the vast array she hears/uses everyday.  A child who uses aac will independently select the words she wishes to use from the vocabulary other people have chosen to model and, for aided symbols, made available for her to use.”

Which words we choose to provide will have a profound impact upon that individual’s ability to communicate what she wants, when she wants, to whom she wants.

As SLPs we need only look to the ASHA Glossary for direction:

the illusion of communication
“Communication is based on the use of individual words of our language.  True communication is spontaneous and novel.  Therefore, communication systems cannot be based significantly on pre-stored sentences.  Communication requires access to vocabulary of individual words suitable to our needs that are multiple and subject to change.  these words must be selected to form the sentences that we wish to say.”

So, core words or fringe?  It is not an either or proposition.  It is a matter of balance, of measuring power, and of matching to the individual.  

I did a study many years ago (presented at ASHA way, way back in the 1980’s) where I analyzed language samples of the minimally verbal severely disabled students I was working with at the time.  What I found was an overwhelming preponderance of nouns that provided them with little power to communicate anything more than tangible items that they wanted.  
This same finding has been repeatedly seen and talked about over and over since then - and probably before then, too.  

As Carole Zangari (  so eloquently put it  - let’s not throw the baby out with the bathwater. 
Core vocabulary is powerful. It contains the words we use to communicate the many messages that are i important to us.  And for students who often want mostly to tell us to go away, leave them alone, give them a break, provide something different, or tell us what is bothering them, a vocabulary of nouns is rarely powerful enough.
But let’s not forget the words they need to talk about their family and pets, their environment and activities, and - invariably - the things they want.

So, I’ll end with another quote - and a FREEBIE -  and a different metaphor - this time from Janice Light - “There is more to life than cookies.”

This is the perfect time of year to get started building more vocabulary.  Kids “want” food and presents and more, of course they want “more” of all those things - not to mention more hugs, more songs, more fun - “no” to the things they don’t like, “stop” to their siblings who might  grab and push, “like” is the perfect comment to the great times with families and friends, and “love” is the one word we all want to hear.

Keep on talking!

Sunday, September 10, 2017

It's Football Season Again; How Much Do You Know About Traumatic Brain Injury?

Over the past few years, I have been seeing more and more students who have had Traumatic Brain Injuries.  It’s sad - and scary - to see the amazing growth in this population. 

It is also sad to see how under-served this population is in special education.  Often, families believe that once the child is dismissed from rehabilitation that further services are not needed.  Unfortunately, this is rarely true.

treating TBI in speech therapy

What, exactly, is traumatic brain injury (TBI)?  Broadly defined, it is an alteration in brain function caused by an external force.  Usually, this external force is a motor vehicle accident, a fall, a sports injury, illness, or abuse.  The impact upon the student’s performance  can be anywhere from mild to profound.  

The areas of impact include social competence (social interactions, social adjustment, social skills), language, reading, hearing loss, attention & memory problems, increased time to process information, difficulty with learning new things, difficulty with organizational skills, unintelligible or inconsistently intelligible speech, and more.
treating TBI

Unlike some disruptions to functioning, being younger at the age of impact is not a positive.  While we sometimes equate being younger at diagnosis with improved outlook, the opposite is usually true with TBI.  The younger the child, the more likely there will be disruption to normal development as well as long-term consequences.  
While an adult’s already developed brain may show some improvement back to normal function following an injury, the young child’s brain is more vulnerable and has no developmental level to return to.  
Additionally, because of the often fluid nature of the injury, there may be increased consequences as time goes by. and more complex functions are required of the brain.


Unfortunately, for SLPs there are not many good assessment and treatment tools for us to use, and the problems faced by students with TBI are often more complex than the cognition & language deficits seen in other populations.  
They are often much more multifaceted in the foundational skills involved.  
When assessing students with less profound impact, we need to look carefully at social cognition, pragmatic language, and executive function as well as general language form and content.  Discourse analysis is crucial; evaluating story retelling and conversational skills, as well as ability to speak on a topic.  

Often, a student finds it much more difficult to learn, remember, study, and organize than he used to.  This can be overwhelming and frustrating.  He may become angry.  He may become socially isolated;  as interactions with peers are more difficult.  

Students with TBI may also become impulsive; grabbing at items and people, running off, having tantrums or outbursts, being rude and insulting.  The student may have mood swings, may fatigue more easily, and is usually easily overwhelmed.  
Therapies will likely be required long-term, and the transition beyond school can be more difficult.

In the students that I see, the language impact is so severe that use of AAC (augmentative communication) systems is necessary, either as a primary mode of communication, or as a repair strategy to augment speech when the student is unintelligible or when (s)he cannot retrieve the words needed.

There is evidence in the literature that context-dependent, functional intervention is more successful for students with TBI than our usual impairment-based interventions.  Students need direct functional experiences with skill building for the specific contexts in which they will use the skills.  

Any strategy or skill that is taught needs to be put into real world application explicitly.  Material needs to be repeated and paired with visual and auditory cues.  

Creating a plan for each language activity needs to become automatic.  The student needs to learn not only the strategy to apply, but the process of planning which process to use, how to apply it, and reviewing/self-monitoring whether it worked.  
Unlike much of our language intervention, we need to address specific situations, rather than individual skills.

What else can we do?  Work with teachers to make sure that the student has frequent breaks to address fatigue, has directions and tasks broken down into smaller units and presented one at a time, is given additional processing time for directions and explanations as well as additional time to formulate responses, is provided with an environment that is less distracting, and it given explicit direct instruction with ample feedback.

We can also work in speech-language therapy on vocabulary building, understanding of non-literal language and nonverbal cues,  problem solving skills and conversational skills, ad formulation skills.

Obviously, every instance of TBI is unique.  Location of the brain injury is crucial in understanding what functions and behaviors are impacted.  Understanding that the underlying language problems often go beyond what our standardized testing covers will help clinicians plan for assessing and intervening with these students.

Sunday, September 3, 2017

3 Little Words That Mean a Lot

I find a lot of professionals and parents alike who don’t really understand what AAC means.
So, first, to break it down, let’s look:

A= Alternative
A = Augmentative
C = Communication 

Alternative is typically what we’re talking about in AAC.  These students need an alternative to speech because they are completely non-speaking, or because they have so few words that they cannot meet their communication needs at all.

Augmentative is the one part people tend to forget.  To augment is to add to.  And that’s what we do with AAC for individuals who have some speech, but not enough to meet all of their communication needs. It’s also what we do for individuals who have speech, but their speech is unintelligible so much of the time that  they need a functional repair strategy, so that they can fix the breakdowns in communication when others don’t understand them.

One of the biggest groups I see with this difficulty is those individuals with cerebral palsy whose speech is so dysarthric that it is unclear to most of their listeners much of the time.
Another group I see with this need is children with apraxia of speech who may have some speech, but it does not function for their all of their needs.

AAC as a repair strategy is a novel idea for some, and is a “hard sell” sometimes.  We speech-language pathologists take the ‘speech’ part very seriously. But when we’re not meeting the needs of our students, we need to step back and remember that our goal, really, is communication; that last pesky letter in AAC.

AAC as a way to augment what speech the user has is often delayed while teams work on speech to the point where students themselves are frustrated with their inability to communicate.

One of the most persistent myths about AAC is that it shouldn’t be used for students who have some speech.  That it will delay their speech further or become a “crutch.”

However, research now tells us that far from delaying speech, AAC used consistently can actually help students develop their speech skills more.
And, far from being a crutch, it is a tool that helps students develop their language and communication skills.

So, what, exactly, is communication?   According to the National Joint Committee for the Communication Needs of Persons with Severe Disability, it is:

  • “any act by which one person gives to or receives from another person information about that person’s needs, desires, perceptions, knowledge or affective states.  Communication may be intentional or unintentional, may involve conventional or unconventional signals, may take linguistic or nonlinguistic forms, and may occur through spoken or other modes”
This definition puts the focus on the extent to which there is shared meaning between the communicator and his partners - NOT on whether the interaction is spoken.

AAC refers to all modes that make communication easier; and can include gestures, facial expressions, alphabet or pictures, computers, and signs.

So, before you say, "He's note ready for AAC,” remember - even babies communicate. No one is too impaired to learn some communication skills.
I’m pretty sure that if you look at your students who “aren’t communicating,” that you will find that they truly are.

Ascribe meaning to what they do do, and……… keep on modeling.

Want some year-long help with meeting the needs of your aac users? Here is a kit to get started and keep you going all year.