Is Telepractice the Solution?

Lately, I’m seeing more and more of my colleagues doing teletherapy.  For many speech-language pathologists, it is the ultimate solution for busy lives with kids. As one therapist states: “teletherapy is still a GREAT fit for me and my young family.  The ability to work from home and be present and available for my kids at the end of their school day is extremely important to me and being a teletherapist has allowed me to do just that.” (https://bvgslp.com/teletherapy-what-to-know-before-starting/).

Therapists enjoy setting their own schedules and determining how many hours they will work.  For the most part, teletherapists are contract employees - self-employed rather than salaried employees.  There are, however, a few exceptions to that.

A friend of mine, Sarah Wu from Speech is Beautiful even wrote a guide called “Is Teletherapy Right for Me?” (https://speechisbeautiful.com/2017/03/is-teletherapy-right-for-me/), talking about the pros and cons and things to consider.

Recently, a company providing teletherapy reached out to me, in an attempt to spread the word about affordable speech therapy provided on their telepractice platform. They’re called Expressable, and are committed to providing “high-quality speech therapy services at a fraction of the cost of traditional therapy.”

This is what they have to say: “Expressable’s one-of-a-kind technology platform connects families to dedicated SLPs specialized for their speech therapy needs. Live therapy sessions are administered online with modern video conferencing software that clients can access from the convenience of their home.

In addition to providing a cost-effective alternative, Expressable also offers many advantages only available in their online platform. These include the ability for clients to securely message their therapist 5 days/week, personalized and recorded home exercises for continued skill building and parental involvement, and flexible scheduling with easy cancellations. “

The owner of Expressable has this to say, “The American Speech-Language-Hearing Association (ASHA) approved teletherapy as an appropriate method of service delivery in 2005. The lack of overhead costs in teletherapy means that a family’s money can go further. Without the barrier of geography, a clinician with a specialty is able to provide for a client living across the state. Teletherapy checks so many boxes for both clinicians and the families they serve.”

I don’t know a lot about them, and I am personally not embarking on a telepractice journey; having retired to the quiet life of creating curriculum resources, but if you’re a speech pathologist considering a change of pace or a parent looking for a therapist in an underserved area, you should check them out.

“Research demonstrates that online speech therapy is just as effective as therapy delivered in a practice-based setting.”  And, in case you have this unanswered question - yes, it is available to AAC use.

So, check out the possibilities of teletherapy. The world is changing with technology.

And of course, keep on talking!

p.s. If you are considering or already doing teletherapy, take a look at my BOOM card decks for use on tablets, computers -even smartboards. 

Where is the Opportunity for Control with AAC? Communicating in Group Homes.

I recently had a mom whose adult child is living in a group home ask me to provide some guidelines for staff to help them with using AAC.

For more than 20 years I have provided consultation to an agency that runs a few dozen group homes for adolescents with autism and adults with a variety of developmental disabilities and dual diagnoses.

Many adults with intellectual or developmental disabilities do not develop sufficient speech to meet their communication needs.  And once outside the school system, they are often unlikely to receive any direct services for speech-language therapy.  

Many do not have any speech. Many of those who do have speech lack adequate speech in many contexts.  And for all of these clients, we need to consider how to provide them with improved communication.

Adults with developmental disabilities are vulnerable for an inability to get their needs met.  They have the least access to sufficient communication systems or skill-building.  And even those who have had some alternative system when they were in school have frequently lost access to a system as they transition to adult services.

What we have is a system with

• Unique clients: who may have had no prior language interventions. (This is particularly true for older clients who were in school when there were fewer options and services.)  These clients may have developed ways to communicate that are not universally understood but have been established over a long period of time.
• Unique environments: where life is highly routinized, needs are all met, opportunities to exert control may be very limited, and there are frequently few opportunities for communication interactions.
• Unique partners: Staff in adult programs may have minimal education and training, often do not understand communication needs, have difficulty with consistency in the face of having to provide services to several clients at once, and who need strategies to use that give them step-by-step directions.

Our goal is to increase communicative intent, to increase communication in a way that we understand intent, and to improve quality of life by reducing frustration and anxiety.

The biggest bottom line is that communication needs to be motivating.  This can be difficult in group homes where needs are met routinely and opportunities for a single individual to exert control over what happens are limited by staffing ratios and other clients’ wishes.

I urged staff to consider what their clients - including this young man - want or like, what the environment allows them to have unique to themselves, what alternative response they can use to tell staff and how staff can consistently require that they use that response to indicate what they want.

I remind the staff to think of communication as power.  It is about having control over the environment.  Our clients need to learn that they can have this power.  Staff needs to consider ways and times when this is possible within the structured environment of a group home situation.

Until next time.... Keep on talking!

Have You Read My Story?

Recently I was contacted by a local magazine who wanted to interview me as part of a series of local women to know. I was flattered, of course, and readily agreed.  Me, a woman to know? Lovely thought.

So, the article is live, and it tells my story in brief. How I ended up where I did, doing what I do.
So, I am posting a link to the article here, in case you'd like to read about my voyage to AAC.

'til next time, keep on talking!

Stuck on AAC Implementation? My Five Step Plan for Intervention

Communicative competence was defined by Janice Light (1989) as:

"– the state of being functionally adequate in daily communication and of having sufficient knowledge, judgment, and skills to communicate effectively in daily life."

I advocate for a 4 step process to building AAC use: Choose, Plan, Prepare, and Implement.

Step 1: Choosing vocabulary - We want to make sure our AAC user has a robust vocabulary so that he can say whatever he wants.  We don’t fill the system with preprogrammed phrases that may not represent what he wants to say; but we may use some often-used phrases for speed of interactions in social situations.

Step 2: Once you have the vocabulary set in your AAC system, you wan to plan your intervention strategy.  Think about what words you want to target first. Are you going to focus on core words used in a single activity or those identified core words whenever they occur in the environment naturally?

Step 3: Next, Prepare. Prepare with a modeling plan. Become comfortable with the child’s AAC system sufficiently to be able to model the words you have set as targets.  This is important. You might even want to practice ahead of time.  But don’t worry if you make mistakes or have to stop and think about where a word is.  These are perfect times to use verbal referencing and talk about what you are doing.

Step 4: Implement.   Provide Aided Language Stimulation (ALgS)/Modeling.  The AAC system needs to be available at all times. The partner will model each of the words, showing the child how the word is used in that context and where to find it in the AAC system.  Be careful not to give directions, test, make the child perform.  Don’t ask the child to “Show me _” or “What is _?” or “Where is _?”  Remember that communication for real purposes and messages is the goal, not trying to find out how much the child knows.  Use expectant pauses, natural cues.

Step 5: Collect data.  Assess and revise the plan as needed.

It is easy to implement AAC in the classroom by

1 Offering choices as often as possible

2 Using consistent vocabulary and sequences within frequently repeated classroom routines

3 Sabotaging the environment during a routine task so that students need to communicate

4 Utilize simple scripts within routines so that staff are consistently modeling the same vocabulary and sentence types

5 Make sure to model vocabulary used during routines that goes beyond requesting; to include commenting, providing information, asking questions, and other communication functions

 AAC implementation does not need to take a significant amount of planning time or equipment.  Just think about the language you use routinely.

Looking for more information about AAC implementation?  Take a look at my book: Make the Connection!  Available on Amazon. (affiliate link)

Are You Drowning in Alphabet Soup?

We all use acronyms way more than we’d probably like.  There are acronyms everywhere; television stations, directions, and, of course, in our professional language.  

And sometimes we forget that not everyone knows the acronyms we use; especially in our clinical capacities.  Even using SLP can confuse some people.  Many call us Speech Therapists and have no idea of the full professional title.

So, I am going to clear up some of the confusion around acronyms used in AAC.  Let’s start with that one:

AAC - Alternative - Augmentative Communication; those modes of communication that replace or supplement natural speech.

PAS - Partner Assisted Scanning; a process by which the communication partner scans through the selections either auditorily (saying the words), visually (by pointing to the symbols) or both.  The partner scans through the choices available on the (no/low-tech)  AAC system, always in the same order, looking for an agreed-upon response from the individual to accept an option.  Partners present the choices in the same sequential order every time.  This strategy is usually used with an individual with significant motor or visual problems who has difficulty accessing an AAC system independently.

ALgS - Aided Language Stimulation is also called Aided Input (AI) and refers to the process of modeling use of the AAC system to the user while speaking.

AT - Assistive Technology; an umbrella term used to talk about assistive and adaptive devices or systems for individuals with disabilities. It includes any piece of equipment or software program or app that can be used to increase the functional abilities of students with disabilities.  This umbrella includes AAC.

CCN - Complex Communication Needs; used to refer to those AAC learners who have significant disabilities and needs beyond simply replacing their speech. These AAC users have a combination of physical, sensory, and other challenges that make communication difficulty

CVI - Cortical Vision Impairment; refers to a brain based vision disorder

SGD - Speech Generating Device; or VOCA (voice output communication assistant)

Voice output can be either digital (recorded speech) or synthesized (computer-generated) speech.  

Those are my top 7 picks for confusing acronyms I hear in IEP meetings that leave some people shaking their heads.  Do you have any others?

If you're looking for more information about AAC, morew terminology explained, and a step-by-step guide to implementation, try my book Make the Connection!  (affiliate link)

Modeling to the Max: Using Aided Input to Teach AAC

Much has been made of using modeling to teach AAC use to children.  The term Aided Language Stimulation was first coined by Carol Goosens et al.

They said, “A language stimulation approach in which the facilitator points out picture symbols on the [individual’s] communication display with all ongoing language stimulation. Through the modeling process, the concept of using the pictorial symbols interactively is demonstrated for the individual.” (1992)

Aided Language Stimulation (ALgS) is based on the idea that babies/children learn language the same way; through the models provided by others in their environment.  If we only provide spoken input, how will they learn to use pictures?  Instead, we need to use symbols to say real things in real situations.

Language should not be a specific time in the school or home schedule.  Instead, use of language happens all the time, in all situations, and we model the use of symbols in naturally occurring contexts.  

What we don’t do is to create false scripts or testing-like situations, where we’re always probing and asking pointed questions.

How do I do this?
We start modeling where the child is currently in his communication and move 1 step ahead.  So, if the child isn’t using any words, start y modeling single words.  If the child is using single words, begin modeling 2-word combinations.

Begin with the end in mind.  The child may be limited in his communication now, but where do you expect him to be functioning in a long-term objective?  I usually think about beginning with a 36 or 40 location set-up for children who are emerging. I might hide some of those keys early on, but I want to have them in their “reserved spaces” so that location of the symbols is static. (See my post on stability of location)

When you’re modeling, think beyond “I want.”  Making requests is often the first thing we teach, so that children can get their wants and needs met and make choices or requests.  But too often that’s where people stop.  And there are so so many more reasons to communicate.  What happens when the child is hurt or sick? Or when someone has been mean or is annoying?  How do they ask for something “different?” 

We should be modeling greetings, asking and answering questions, expressing feelings, making comments, and more.  

We should also be modeling self-talk.  By being verbal about what we’re doing to find symbols/words or make a correction the child can take in how we communicate and use language.

Model operational use of the system.  PODD is excellent at this, with the navigation conventions built into the communication book.  With electronic systems, we should be modeling how to use the ‘back’ button, the ‘clear message window’ button, and how to turn the system on and off, among other targets.  Operational competency is often forgotten.

Model while you communicate to the child in all opportunities. It's the way they learn language.  And that's what we're all about!

So, keep on talking!  And keep on modeling!
Looking for some easy to use resources to help staff with modeling core words? Try my AAC Core Word Modeling Plan Posters for Staff.

But He’ll Just Play With It! How a Communication Device is Not a Toy and How This is Not an Excuse

This blog post is going o begin with one of those, “If I had a nickel for every time I heard….” lines.  Over and over parents and professionals alike express their fears that the child will use the voice output AAC system like a toy; either banging repetitively on a single message or bouncing from page to page hitting random buttons.

It is the excuse heard most often after, “He isn’t smart enough.” (Never, of course put quite so bluntly.)  “He just plays with it,” - or some version of that - is tossed around by people who have clearly not learned how to teach a child to communicate. I say this with no disrespect; just a desire to have people be honest with me and with parents.

Yes, kids will often activate the same button repeatedly.  When a toddler says the same (usually new) words over and over again parents may despair, but none actually puts tape over the child’s mouth.  That is exactly what is being done, however, when the device is taken away from a child because he is “just playing with it.”

Yes, when verbal kids are bored they can talk to themselves under their breath or whisper to their neighbor.  And the teacher will admonish them. The AAC user who cannot adjust his own volume (or doesn’t recognize the need) can’t keep his boredom under wraps quite as easily.

And yes, there are undoubtedly kids who haven’t quite figured out the power of genuine communication yet, and just enjoy making verbal noise.

But teaching the child about the power of communication and how and when to use it; teaching the child how to use his AAC system, teaching the child about his ‘voice’ is our job.  I am a big believer in the notion that if a student doesn’t use his AAC system appropriately for genuine communication then we haven’t been successful in teaching him. We haven’t done our job. And we need to do better.

Step 1. Make sure the device is appropriate for this particular child and make sure it is core word based and robust. A system lacking the vocabulary a child wants to use isn’t going to be valued.

Step 2. Make sure everyone who interacts with the child with any frequency is familiar with the system and able to use it.  It’s hard to provide models when you can’t find the words.

Step 3. Make sure everyone is using Aided Language Stimulation - otherwise referred to as modeling.  Nonverbal children learn language through modeling just like their verbal peers. 

Step 4. Make sure the AAC system is always accessible.  Kate Ahern’s motto: “See me, See my AAC” is paramount.  The system should never be left in another room or on top of the filing cabinet.

Step 5. Make sure the environment and the people in it are all encouraging of genuine communication, are reinforcing the child’s communication attempts, and using appropriate strategies to encourage message production.

Playing with one’s voice should be a joyful thing. Don’t stifle that!  

Keep on talking, and let let your AAC users do likewise.

Looking for some materials to help staff know what to do with their AAC users?  Try these:

AAC Implementation Plan Handbook

AAC Core Word Modeling Plan

Make the Connection!: A Practical Guide to Parents and Practitioners....

Location! Location! Location! On the Importance of Stability or: The Number 1 Reason Why We Don’t Move System Symbols Around

In an on-line discussion recently a speech-language pathologist was looking for research that specifically discussed why we do NOT move symbols around on a  child’s AAC system. Doing so to “test” children, to make sure they really are discriminating the specific symbols, has nothing to do with communicating; a fact that practitioners of ABA don’t always “get.”

Now, I’ve worked in some very very rigid ABA programs myself, but there are some principles that we followed regardless of such issues.  

1. Symbols stayed in one place in a communication book (this was in the days before high tech).
2. Symbols were used for communicating, not testing.  Studies I conducted in one setting actually showed that teaching isolated discriminations may have resulted in the students knowing which symbol meant which word, but that definitely did not lead to using the symbols to communicate once they were placed in the communication book.  Modified incidental teaching in context did that.
3. Symbols were always available.  Students had their communication books with them at all times. Symbols were accessible for communicating at all times.  That’s the whole purpose, isn’t it?  You wouldn’t take your mouth off and leave it behind, would you?  

(Yes, that sounds silly, but really it’s the whole point.  Most of us have no idea what it’s like not to be able to speak when you have something to say.  I have often challenged administrators to spend a day with duct tape across their mouths and no pencils in their hands.)

PRC systems, which utilize core words and consistent motor patterns to access words says this:

          “ In typical speech, our attention is directed to the conversation, not to articulating/saying the words. In order for an AAC user to develop this same “speaking” automaticity, he can’t be consciously thinking about interpreting or locating icons.

For automaticity to develop, each word needs to be accessed by a unique motor plan that once learned, never changes. Two words cannot share the same motor plan.”

One analogy that works for some people is to liken the AAC system display to a typewrite/computer keyboard.  As I recall from my 3 weeks in a high school typing class touch typing relies heavily on the motor patterns of hitting specific keys in specific locations.  What typist would keep working if you were constantly moving they keys around?  I can barely find the letters as it is!

LAMP training tells us: 

“Speaking is a motor plan, as are tying shoes and typing. Once the plan is learned it becomes automatic.

     o We don’t have to think about how to make a word with our articulators

     o We communicate well because we have automaticity

     o LAMP helps develop automaticity in a way that other approaches do not.

     o If a motor movement changes each time we say a word, we do not develop automaticity. Consistency of that motor pattern is key for teaching language.

     o A word can be produced in 1-3 keystrokes along a unique and consistent motor pathway. The AAC user can devote more cognitive energy to interacting vs. navigating through category pages.”

In summary, [AAC users need a] “Unique and Consistent Motor Plan: stable word location leads to effortless communication due to low cognitive load”

On the Assistiveware blog is this: “Augmentative and Alternative Communication (AAC) is blocked when users are required to prove themselves as ready and worthy before they can get AAC. Instead we should be presuming competence and not requiring any prerequisite skills before they can be eligible for a full balanced AAC system.”

Our job is to make communicating as easy and possible.  Let’s not use unnecessary demands to make it more difficult.

Keep on talking!

Moving Stories Along

I’m talking some more today about narrative skills in students, including those who do not speak. I can’t stress enough the importance of developing narrative skills in children.

Narratives are important because they allow us to move away from the “here and now,” and to focus less on our personal experiences, while allowing students to talk about what is not immediate, but rather the decontextualized language of the classroom.

Narrative skills begin to develop in young children and are mediated by parental support.  These early interactions build the foundation upon which children build their narrative and academic skills (Boudreau 2008).  The narrative skills of preschoolers are predictive of academic success in school, as well as social success.  As students with narrative language deficits continue having difficulties in academic and social success, we are reminded of the importance of intervention at the narrative levels.

Shared Reading :

These early interactions [between parent and child] build the foundation upon which children build their narrative and academic skills (Boudreau 2008).  The narrative skills of preschoolers are predictive of academic success in school, as well as social success.  As students with narrative language deficits continue having difficulties in academic and social success, we are reminded of the importance of intervention at the narrative levels

“One of the most ubiquitous and powerful discourse forms in human communication is narrative.”  (Bruner 1990).  Narrative is crucial in human interactions, yet often receives the least attention.  Bruner went on to name the 4 areas of grammar critical to narrative production:

1. A means for emphasizing actions towards obtaining a goal,
2. A sequential order should be established and maintained; so that events are stated in a linear way
3. Sensitivity to what forms and patterns of language are acceptable
4. Containing a narrator’s perspective or ‘voice.’

Note:  Take a look at this resource here

     

Narrative has been found (Nelson et al 1989) to capture not only the events of daily interactions, but to encourage interpretation, imagination, and use of self-talk to solve problems. 

One factor that is shown to have an 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.

There are 3 basic types of narrative scripts: personal experiences, scripts, and fictional stories (Hudson & Shapiro, 1991). Personal narratives are the easiest place to begin in intervention with children.  And they are the most often used types of narrative.

 “By focusing on narratives in our language intervention, we can explore processing limitations, create opportunities for using decontextualized language, facilitate social relationships, provide practice in constructive listening, improve reading comprehension, and identify language learning strengths and weaknesses.” (Johnston 2008)

For AAC users, focusing on the use of core words and important fringe, and moving from single symbols to sequences of symbols for generating novel utterances (SNUG), we need to keep our AAC users moving on the "oral" - literate continuum.  This means teaching AAC users to construct messages and sequence ideas in order to engage in meaningful conversations.

Boudreau, D. (2008) Forword. Topics in Language Disorders, 28 (2), 91-92

Catts,H et al (1999). Language basis of reading and reading disabilities: Evidence from a longitudinal investigation. Scientific Studies of Reading, 3(4), 331-361.

Gillam, R, & Pearson, N. (2003)The Test of Narrative Language. Austin, Tx: Pro-Ed.

Johnston, J. (1982). Narratives: A new look at communication problems in older language-disordered children. Language, Speech, and Hearing Services in the Schools, 13, 144-155.

Johnston, J. (2008). Narratives: Twenty-five years later. Topics in Language Disorders, 28 (2), 93-98