The Humble Switch

Imagine mastering those everyday tasks with the magic of assistive technology…

Hi, I’m Laura, and as a Therapy Assistant in the Barnsley Assistive Technology Team (BATT) and Occupational Therapy apprentice at Huddersfield University, I witness those AHA! moments every day.

This blog post discusses how less really can be more, by describing two clients who unlocked success with the humble switch instead of ‘high-tech’ alternatives. Please note that pseudonyms have been used to protect confidentiality and links have been provided for further information on potentially unfamiliar terms, such as ‘access method’, ‘switch’, and ‘environmental controls’ (EC).

At the end of last year, I was asked to give a short presentation on my role to include some client stories that showed my involvement throughout the assessment process. Now, I had only been in the team approximately 4 months at this point, and public speaking has never been my strong point! Although, presenting on teams alleviated some of these nerves, and I was keen to show what I had been up to since joining the service along with how I could support clinicians and clients in future assessments.

I chose two clients that I had been working with who differed in age, diagnoses, goals, and of course, personality. My aim had been to give a range in all areas, however, what I hadn’t realised at the time of preparing for this presentation was that both of these clients actually had one thing in common: they had both began their journey with assistive technology as users of more complex access methods, and had both found that what suited them the most was the humble switch.

Client one:

Ashley is 50 years old and has a diagnosis of Cerebral Palsy and a mild learning disability. Ashley was referred to BATT for an AAC assessment, as their main communication method was speech, but this was often unintelligible, especially to those who don’t know them. Ashley also used a range of gestures and facial expressions to communicate, but often became frustrated when misunderstood and found mending communication breakdowns extremely difficult. Ashley lives in an apartment in an assisted living complex with frequent carer visits, and is an electric wheelchair with joystick control user.

Ashley was assessed by a BATT Specialist Speech and Language Therapist (SLT). The initial outcome of the assessment was to trial a Grid Pad with a symbol-based vocabulary and a joystick as the access method, as this was something Ashley was familiar using. I became involved at this point to support the trial period and assist Ashley in both learning the vocabulary and practicing the joystick control. Ashley proved to be a very competent joystick user, however, Ashley’s motivation and engagement in the support sessions I was providing decreased over time. Following a conversation with the clinician, we identified an exciting possibility: introducing Ashley to BATT’s Service User Representative whose integrated joystick system, controlling both communication and mobility, could have been just what Ashley needed. We were all excited to see if it sparked a connection, so we arranged a meeting for Ashley to see this first-hand.

The meeting was a great success and Ashley was very receptive to witnessing another AAC user’s demonstration of how they navigate their device and swapped between controlling their chair or communication aid using a joystick and a single switch. However, Ashley let us know that due to shoulder pain Ashley did not want to use the communication aid in this, which explained the reduction in motivation. Instead of the joystick, the Service User Representative proposed switch scanning and showcased their foot switch and row-scanning setup. Ashley showed immediate interest in this alternative method, and eagerly agreed to trial a switch in place of a joystick.

At this point in my presentation, a really valuable discussion was had with the team wondering if this suggestion had additional value coming from an AAC user, rather than myself or the clinician. I would argue that it did, as it added an authenticity and element of lived experience that we could never offer. This appeared to inspire Ashley to continue a journey with AAC, and Ashley went on to trial switch access with new-found motivation and great success.

Client two:

Sam is 70-years-old and has a high spinal cord injury, which resulted in Tetraplegia with limited right upper limb movement. Sam lives in a nursing home and had goals that were EC based, including TV controls, bed controls, and accessing various apps on an iPad.

Sam was assessed by a BATT Specialist Occupational Therapist (OT). The outcome of the assessment was to trial using voice control on Sam’s personal iPad with a HouseMate transmitter and app. This proved to be very successful during the initial assessment, and the clinician requested that I provide some support sessions to assist Sam in learning the commands and navigation of the system. These support sessions proceeded with varying success. Sam’s voice was found to vary in its reliability, often being affected by fluctuating levels of fatigue and wellbeing. Sam also found remembering specific commands to be difficult and tiring, often becoming frustrated if the device did not respond. I fed this back to the clinician and we arranged a joint visit with Sam.

During this visit we presented switch scanning as an alternative, and Sam took to this right away. Sam responded well to the visual aspect of following the highlighted cells, and was very successful with the timing of scanning. It transpired that speed was not a priority for Sam, and accuracy along with reduced cognitive load were more important, as Sam often experienced periods of fatigue but would still want to be able to use the device. Sam went on to achieve all of the EC goals using single switch access, and was very grateful for the change this has made to their independence.

Reflections

One might wonder why switch access was not the first option that was considered for these clients. Following my presentation, multiple clinicians reflected that they can sometimes discount switches in the beginning of an assessment in favour of ‘faster’ options. They acknowledged here however that, as in the case of Sam, this might not be as important to some clients as we may assume. One clinician suggested that for some AAC users, speed of communication may be a goal expressed by their regular communication partners rather than the client themselves, which perhaps highlights a need for raising awareness on the importance of patience and understanding, rather than focusing on the quickest method of access. Furthermore, the allure of “cutting-edge” technology, such as Eyegaze, can overshadow the effectiveness of switches, leading clients to underestimate their value.

During this discussion, it became apparent that the switch can sometimes be unappreciated and overlooked, despite its significant strengths, such as ease of use, the minimal physical ability required, and availability of visual and auditory prompts. However, it is important to note that the switch is not suitable for every client, as it can be considered cognitively demanding in terms of attention and timing, slow, and inefficient in comparison to other methods.

Ashley and Sam were both heavily involved in the decision-making process during their assistive technology assessments. In each case, the clinician took a client-centred approach that ultimately prevented any risk of unintentional bias towards more ‘high tech’ systems, and led to the provision of the most appropriate access method for each individual in their current context – the humble switch.

If at first you don’t succeed…

My reflections on applying for the HEE & NIHR Internship.

by Helen Robinson, AAC Service Lead and Assistive Technology Clinical Specialist.

For a long time, I found it hard to image a day where I would actually start my career in research, yet here I am, one month in to my nine-month internship with Sheffield Hallam University, funded by Health Education England (HEE) and the National Institute of Health Research (NIHR). I knew from other colleagues that the journey into a career as a clinical academic is never easy, and that it was typical to be rejected several times when applying for funding, which offered some reassurance as I received my rejection email for the second year in a row. I was amazed to finally be accepted at the end of 2020, having submitted my third application with little expectation of success. It was a welcome ray of hope after such a challenging year working in the NHS.

I may have been just as pleased as I am today, had I been accepted the first or second time around, yet I feel that having the three years to consider, reflect on and develop my research ideas has been immensely beneficial, and ultimately led me down a better path. I’ve spent these three years networking, reading and attending research groups and seminars. I wonder if I would have got quite so much out of this internship had I been accepted on my first, or second, application?

The what and the why

My first two applications to the scheme were linked to existing research projects. Whilst I was genuinely interested in the projects, I realise now that I was very much attempting to make them ‘fit’ the internship scheme because they were easily available at the time of the applications, rather than following an idea I was passionate about. I was starting with the internship and working backwards to find a research interest. That clearly showed during my interview, and after the second rejection the feedback given was that I should follow my own clinical interests to develop a research question of my own. This advice felt a little daunting. With little research experience since the couple of lectures in statistics whilst studying for my degree almost twenty years ago, I felt apprehensive about embarking on a solo project. Thanks to an experienced supervisor and my colleagues in the Barnsley AT Team, I gradually started formulating ideas for a research question.

Beginning my internship

My hope is to follow the HEE and NIHR’s Integrated Clinical Academic Programme, starting with the Internship, then progressing through the Pre-doctoral Clinical Academic Fellowship (PCAF) and onto the Clinical Doctoral Research Fellowship to complete a PHD. If I am to do this, I knew I needed to focus on a subject that I felt passionate about, that would be worth putting my heart and sole into for quite a few years to come (though I try not to think too much about the duration!)

Due the COVID 19 Pandemic, it’s not been the start I might have hoped for, with all university sessions taking place online. However, I’ve found it to be a thoroughly enjoyable start despite this. We’ve all had a year to settle into the world of online meetings, so I don’t feel my learning or experience has been diminished as a consequence.

Having been a student almost twenty years ago, I have been amazed at how much the university experience has progressed! Most lectures have been recorded and made available, as have the presentation slides. There are discussion boards where I can chat with other programme participants, and endless offers of support from University staff. The scope of the online library has amazed me, so many of the books I’ve wanted have been available to view online immediately without me having to leave the house. Sheffield Hallam’s student website also offers a wide range of live webinars relating to carrying out research, and countless downloadable guides and links to other websites. My only criticism is that It’s easy to get lost in the web of resources available and suddenly find yourself far from your original goal with tens of web pages open and new routes to investigate!

Going around in circles!

Pinning down my research interest has been a challenge, as my job as Assistive Technology Clinical Specialist covers a broad spectrum of client groups within the field of AAC, most of which ignite a spark! Many times, I’ve convinced myself I knew what my research interest was, only to wake up the next day with a totally new idea. It was a relief to finally settle on a research question and submit my internship application. Whilst waiting for the programme to start, I allowed myself to put the idea aside, confident that I would approach it fresh in the New Year with the start of the programme.

I am completing the internship one day a week, whilst continuing in my clinical role for the remaining four. This change has been very welcome, it feels like a luxury to be given this time to really immerse myself in the research process, without the guilt of unanswered emails and phone calls. I spent my first 3 sessions exploring the wealth of resources available to me, as well as attending the two online study days which are part of the internship scheme. Then, it was time to look back at that research question. As I did, that familiar niggle hit me again, why did I decide that was a good question? How was that achievable? Was that even what I wanted to know?  What seemed so certain and so comfortable a few months ago, suddenly didn’t even feel like I’d even written it. I found myself full of doubt and self-criticism.

I spent some time with my supervisor, who helped me to unpick and re-frame my question, which actually turned into five questions. I was encouraged to think about the finer details, using tools such as SPIDER and PICO. I found these helped me to clarify my ideas, as they enabled me to reflect on the finer details and what would make a suitable research question. After a morning looking at this, I felt rather disheartened, having felt so sure of my project four months earlier, and having spent several months getting to that point, I was left feeling like I was back at square one! The more I stared at the questions on the screen, the more unsure I was. It was time to step away from that laptop.

I went back to pen and paper, making notes of anything that came to mind; what I was interested in, what bothered me, what assumptions I had, what I knew to be true and what questions I wanted to answer.  I then photographed this and saved it to come back to. My preference is always for neatness and order, but it’s these scruffy notes and key words that I found represented my ideas most clearly.

Using my clinical interests to determine my research question

When I first started working in the field of AAC, around 12 years ago, ‘Core Vocabulary’ wasn’t a familiar term, but very quickly this terminology became common place. Symbolised vocabulary packages which had previously often been structured around topics and activities soon became based on a list of ‘core words,’ with topic or ‘fringe’ vocabulary sitting alongside. This approach made sense to me, we were told these core words made up the bulk of spoken utterances in the English Language, such as ‘want’ ‘help’ ‘more’ and ‘go.’  Topic words alone could be ambiguous, especially without context (what does ‘ball’ mean? Want ball? Lost ball? Your ball? My ball?) It certainly makes sense that both ‘core’ and ‘fringe’ words are needed to give a complete message.

Symbolised vocabularies continue to base themselves around these core word lists, often organising words left to right across the screen in subject-verb-object format, to support the formulation of sentences, or ‘language learning.’ For example, ‘I want (the) bubbles,’ ‘you go home’ ‘I see (a) cat.’ The final noun is often accessed through several levels of category folders (i.e. the user has to select a folder and then one or more sub-folders to find the word.)

In my current role, many of the AAC users we support have complex physical and sensory needs, and therefore often find accessing communication aids effortful, sometimes using switches or eye gaze. They become skilled at communicating their messages in as few words as possible: good communicators, but not always linguistically competent. My assumption is that complete sentences are rarely the aim, and if one word will work, why use more? With a supportive, familiar communication partner present, I have observed that AAC users are most likely to use nouns (fringe vocabulary), accompanied by other modes of communication such as eye pointing, gesture and vocalisations. In other fields of Speech and Language Therapy, a core vocabulary approach would usually refer to the topic words as being ‘core,’ which seems to reflect my clinical observations with my AAC caseload. I find myself considering what the goal is for the children I support; is it ‘functional communication’ or ‘language learning?’

When I introduce a family to a core vocabulary package, they are pretty much guaranteed to ask me to hide the core words, and make the topic vocabulary easier to find. I find myself been asked to explain and justify the organization of vocabulary packages frequently. I have also worked with plenty of literate children and adults, and noticed that even they lean towards typing the key words, not grammatically complete sentences. This leads me to question which words are important for symbolized AAC users and how should we be organising the words within communication aids? I am fascinated by the conversations I am part of and reflect on how valuable these interactions could be in designing AAC systems. If we give symbolized AAC users ‘core’ words, do they actually use them? Would they prefer using a ‘fringe first’ approach?

The core vocabulary approach uses list of words based on the language of older, verbal children (Laubscher and Light, 2020) and assumes that AAC users are aiming for comparable language (in terms of the words they use and how they order them) I feel that we should not compare the language development of AAC users with the language of speaking children, nor presume that their communication goals are equal, as this presents an ablest view of language. I argue that we should value one-word on a communication aid, accompanied by a smile and a glance, just as much as a string of ten words. This isn’t to say we shouldn’t give symbolised AAC users access to a rich vocabulary, and shouldn’t be presuming competence and supporting their language development, I have also observed plenty of examples of core vocabulary being used successfully!

What I presume matters most to the majority of AAC users, is getting their message across successfully and efficiently.  I hope to be able to explore these ideas through my research, and as such have finally settled on my question for my internship: Are there any studies that have collected language samples from AAC users and used these to develop symbolised AAC systems?

I will be competing a literature review to answer this question and then asking patient involvement group to review my findings and support me to establish further questions for research. It’s felt like a long process already, but I feel very privileged to have been given this opportunity to pursue my clinical interests through this research pathway and am exited by the journey ahead.

If you would like to follow my progress or get in touch, you can find me on twitter @HelenATSLT or email hrobinson@nhs.net.

AAC in Speech and Language Therapy: Reflections from Remote Teaching

Our team offers an Introduction to AAC seminar to Speech and Language Therapy students undertaking the Human Communication Sciences degree courses at the University of Sheffield.

Due to the Covid-19 pandemic, this was the first time we have had to adapt the course to online teaching.  Danielle Diver and Gemma Sleman (Assistive Technology Specialist Speech and Language Therapists), along with Jamie Preece (Service User Representative) and his partner Emma Sullivan, delivered the session in December 2020 via Zoom to over 50 students. As this was the first time we have delivered this lecture remotely, we have reflected on these sessions by gathering feedback from students following the session along with our own discussions throughout the process.

Our typical session for this module would run face to face and lasts approximately 3 hours, consisting of a presentation and activity-based learning, using video materials and breaking students into smaller groups for discussion. The students are provided with opportunities to interact with and see demonstrations of different AAC tools and resources.

Jamie and Emma have also been involved in delivering this session for a number of years, providing students with opportunities to hear about real life experiences and views of an AAC user and their communication partner. This is typically a highlight of the session, and gives students the opportunity to ask questions and spend time engaging with someone who uses AAC on a daily basis.

Our remote seminar required a number of changes to the typical delivery, and we attempted to provide opportunities for learning in alternative ways.

Things we were unable to do	changes we made
Students were not able to directly engage with AAC tools from our department.	Students were provided with demonstrations via video call or links to videos on our service website demonstrating different AAC tools and ways these are used.
Students were not able to meet Jamie and Emma face to face and did not have the opportunity to interact with someone using AAC in person.	Students were able to meet Jamie and Emma via video call to ask questions and hear their stories. Jamie was able to receive questions in advance from students so prepare his responses. Jamie was also able to use videos captured of himself talking about his AAC experiences and Emma was able to demonstrate how she supports Jamie from a communication partner perspective. Using Zoom Jamie was able to share his AAC device screen to show the students his vocabulary system.
Students were not able to complete smaller group activities or engage in group discussion face to face.	Students were facilitated to form smaller groups for activities and discussion through use of breakout rooms on Zoom with the session facilitators supporting in each group.

Table 1: Restrictions to activities and changes made to provide alternative opportunities

Reflections

We found that group discussions and activities were difficult to support remotely as we needed to have larger groups of students due to the smaller number of facilitators leading the session. It was sometimes difficult to facilitate natural conversations as students could not always see one another and some students later fed back that they were less confident contributing to discussions than they would have been if face-to-face. Some students used the chat function for this instead of speaking out, providing another method of engagement.

We decided to run the session for the typical 3-hour length with a break. We felt that the level of focus and concentration required for an online session was more demanding than face to face and delivering the content remotely for this period was also more challenging (managing breakout rooms, changing between hosts, sharing slides and videos with audio, etc). Students also fed back that they found the session too long and would have preferred shorter sessions, with suggestions of parts being pre-recorded and made available to them beforehand.

The interaction with Jamie and Emma remained a positive highlight of the session from the feedback from students, particularly the section where students were able to directly view Jamie’s device screen. This led to a lively discussion about how Jamie’s vocabulary is organised, how he navigates this and how he accesses his system. This is not something that has been considered in previous years but may be a consideration going forward for either remote or face to face sessions.

On the whole, students fed back that they found the theoretical content combined with ‘real-life’ examples of people using AAC valuable. We hope this will inspire students to develop their skills in this area of Speech and Language Therapy.

Screenshot of the group taken during the session, replacing the usual group photo we capture during face-to-face sessions.

Seeing Beyond our own Clinical Specialism

It is easy as an SLT working in a specialist area to be focused upon your specialism; to set off down a “main road” containing all the skills and knowledge relating to that specialism, noticing the sign posts off to the left and right that lead you to linked areas of work, but not always having the time to take a diversion to check out what is down each side street. You may have known some of those side streets pretty well in your days of more generalist practice, but since then, a set of new road markings have been painted, further junctions added and when you do stop to take a look down an adjoining street it doesn’t look all that familiar any more…….

As an SLT working as a Clinical Specialist in the Barnsley Assistive Technology Team (BAT), the analogy I describe above was brought home to me in a very real way just a matter of weeks ago.

We hold in-service training sessions regularly within our team, allowing team members to share their professional specialist interests, knowledge and experience and allowing us then to consider this information in the context of our daily practice within the area of Assistive Technology. We invite local professionals along if they have shown interest in an area. At a recent update session on autism held by one of my colleagues, a local SLT’s comments made us reflect upon our current practice within the area of autism and highlighted gaps within our knowledge regarding current models of working being used in the region we cover. Looking at ways to address this , I was asked to become the departmental “ champion” for autism; creating a link between current practice within the area of autism, updates and changing evidence base, and the daily practice of the clinicians working within the Barnsley Assistive Technology Team.

As a starting point it was decided that I would attend an “Introduction to the SCERTS Framework ” , as this was something many of the local teams we work with seemed to be using. The online course , presented by the co authors of the framework , Amy Laurent and Emily Rubin, was engaging and gave a fascinating insight into the research behind the “Social Motivation Theory” of autism, as well as outlining the framework in terms of assessment and onward goal setting.

In contrast to my perceived fear that we had been working with our client’s diagnosed with autism in an outdated way, by the end of the presentation I was reassured that our foundations as a team in the area of autism meant that the majority of our practice stood firm , supported by the current evidence base and this particular framework. In fact , considerations taken from the SCERTS model dove-tailed well with our current thinking in terms of motivation and initiation of communication whilst posing questions regarding potentially expanding our expectations of this client group’s functional communication, and more specifically their expressive vocabulary and word combinations. The central theme of emotional regulation is one that as an SLT I was aware of, but definitely had not been thinking of as a priority when working towards successful communication. The course gave me practical ideas in terms of signposting resources for local teams relating to this area, that may well underpin a client’s success in terms of more specific language goals set.

I fed back from the course in a follow up session for the clinicians within BAT. This was really successful, generating discussion and points for consideration pertaining to our current referral, assessment and provision guidelines as well as our goal setting and general practice within this clinical area.

In summary, the idea of having identified team members as links with specific clinical areas e.g. autism, to enable timely and appropriate updates on current research and evidence base seems, within this example, to be useful so far. Within the area of autism we have already identified team actions from what we have learnt so far, and identified further areas within the field of autism that I need to explore further.

Hopefully as a team we are visiting an increasing number of the streets adjoining the “ main road” of Assistive Technology , and doing so more frequently and with purpose, allowing ongoing professional development, and most importantly ensuring best practice for our clients.

 

Frontline Insights on the Rapid Implementation of Video Consultations

Working in patient-facing healthcare during the Covid-19 pandemic has come with its many challenges. One such challenge was the rapid implementation of video consultations to enable continued provision of care in the place of face-to-face appointments.

At Barnsley Assistive Technology Team, we implemented video consultations very quickly in response to Covid-19 and as a way to continue assessment and care provision with our clients. This came with a number of other significant changes to our day to day procedures of installing assistive technology equipment, responding to fault calls, and liaising with local professionals while minimizing patient contact.

Me and my colleague Emma Barrington, both Assistive Technology Clinical Specialists, had the opportunity to engage in a research project led by the Q Community looking into implementing video consultations in NHS services.

Project Aims and Methods:

The project aimed to support those implementing video consultations at speed and scale to reflect on this new way of working to improve practice and support learning from peers. A further aim was to uncover insights relating to video consultation implementation within the context of Covid-19 to share learning and inform future needs at a wider level.

As identified ‘improvers’ (someone who is implementing video consultations but seeking to improve and establish best practice) our engagement in the project involved completing fortnightly learning logs reflecting on a number of open questions relating to changes in our service, and the challenges and successes of video consultations. We also participated in webinars facilitated by the Q Project team, which involved reflecting on video consultation experiences and sharing these with other project participants.

The project took place over a 12 week period from April to June 2020.

Personal Reflections and Learning:

From engaging in this project and implementing video consultations over the past 6 months, I was able to reflect on the positives and the challenges that resulted from this way of working.

Things that made me feel proud	Things that have been a challenge
How quickly my team was able to adapt to continue providing our service remotely to patients.	Working remotely has been challenging in terms of maintaining close working relationships with colleagues and it can feel like you are working in isolation despite attending video meetings.
How resilient and positive we have been as a team and how we have supported one another throughout this challenging time.	The video consultation platform we have used has not always worked effectively and this has caused issues when trying to provide remote support.
How as a specialist regional service we have been able to think innovatively and develop a huge amount of resources to remotely support local services and patients, carers, and families.	A lack of equal access to technology has meant that many people have not had opportunities to engage in video consultations. What is more, not everyone we have worked with has the confidence or skills to engage with the technology for video consultations.

Table summarising personal reflections of the successes and challenges of implementing video consultations

Overall, I feel that the following need further consideration and development both locally and organizationally:

• The development of robust procedures for implementing video consultations.
• How to measure outcomes of video consultations and ensure we capture patient feedback.
• Understanding the need to continue with some face-to-face consultations as video consultations are not appropriate for all patients or all situations.
• Ensuring there are back-up options in place for when things go wrong, such as having different video consultation platform options available.
• Development of quality measures around video consultations due to the potential to miss information that adds to the bigger clinical picture.
• Addressing digital poverty and inequalities for accessing technology for video consultations.
• Supporting team members’ health and well-being in relation to changes in clinical practice and potential isolation due to remote working.

Q Project Findings and Future Projects:

Findings from the Q Project revealed similar insights from approximately 50 participants. Please see the Q Project Blog for details regarding the insights from this project: https://q.health.org.uk/news-story/video-consultations/

One outcome was the need for further research around video consultations, more specifically relating to the following priorities:

• Can video consultations provide the same quality of communication as face-to-face consultations?
• Which patient group will benefit most – and least – from video consultations?
• What solutions are needed to support video consultations in the long-term?

It is clear that further research is required into the use and outcomes of video consultations in patient-facing healthcare settings.

For patients with communication needs who use assistive technology, specific questions and challenges will continue to surface. As a service, we are continuing to measure the impact of our input using Therapy Outcome Measures[1], whether this is provided remotely or face-to-face, and we are currently developing a means of collecting client feedback specifically around remote working. In the future, we hope to be able to analyse our collated data alongside other specialised assistive technology teams, which will offer further insight relating to the effectiveness of different ways of working.

Our focus now turns to creating sustainable change in the implementation of video consultations, and supporting patients and professionals with this ‘new normal’.

Danielle Diver and Emma Barrington, Assistive Technology Clinical Specialists

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[1] Enderby, P. & Alexandra, J. (2015). Therapy Outcome Measures for Rehabilitation Professionals (3^rd Edition). J & R Press Ltd.

Placements in the time of Covid – SLT Student Placements with Barnsley AT

This is a guest post by Anna Chivers and Rob Hall, SLT students at the University of Sheffield:

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We are two students currently on placement with the Barnsley AT team this summer in our second and final year of the MMedSci Speech and Language Therapy programme at the University of Sheffield. We have been on placement for two weeks now and despite being fairly new to the world of AAC we both share a keen interest in this domain and its different applications to supporting individuals with communication difficulties.

Placement in a time of Covid

With new restrictions and adaptations put into place due to the current situation with Covid19, our placement this year looks much different compared to previous years. Normally, our placements would be face-to-face, but this year placements are running remotely. We have been delighted to see that although things might be running differently, we are still being offered so many different opportunities and proves that vital clinical opportunities such as this can still be offered effectively.

We, as students, have faced many changes on our course as a result of the pandemic restrictions. Although a lot of our content was moved online, the key questions have been how placements would be conducted and assessed. With us being in our final year and clinical placements being a huge part of our qualification and assessment, there has been large uncertainty of how this part of our degree could be measured.

It has been fantastic how the University of Sheffield and Barnsley AT have been able to put this placement together, and we’re being given a wide breadth of opportunities and activities to experience. Even at this early stage with Barnsley AT, it is evident that we’re not going to feel disadvantaged or feel we’re missing out on any clinical placement experience despite the Covid19 situation.

Team meetings

We have been able to attend team meetings remotely, through Microsoft Teams and have been part of client feedback meetings and case study presentations to the group. This has given us an opportunity to see how the Barnsley SLTs and other professionals (OTs, Clinical Scientists and Engineers) work as a team, how the service runs, how they triage, and support each other.

It has also been really interesting to see how the profession, therapists and clients have been affected by the pandemic. Within the meetings, all staff have been sharing their experiences of working to assess their clients. This has included some face-to-face interactions but mainly tele-health, highlighting the efficacy of remote working. All issues/questions are open and considered whilst being dealt with very constructively. It is clear that tele-health is a learning curve for everyone, but people are adapting in their own ways and sharing their experiences to help develop this approach.

Client Visits:

We have both been able to attend and observe SLTs conduct tele-health sessions so far on this placement. This has included interventions with both adult and paediatric clients. It has been invaluable to see how AAC devices can support individuals with various communication difficulties.

As discussed in the team meetings, the challenges faced by all involved in a tele-health intervention are self-evident; just having a strong, reliable internet connection is a huge plus-point! It is heartening to see how SLTs and clients work together to overcome any technical challenges that tele-health may bring. We’ve been able to observe how tele-health can be an effective form of intervention delivery as well.

Projects

We have also been working on several projects with the SLTs on the team. One of these projects was to create a leaflet providing information on telehealth guidance to clients and their families/carers. We found this to be especially relevant given the current situation and emphasised the importance of keeping care client centred by making sure that clients are reassured and kept up-to-date with any modifications/adaptations to how sessions are run and what to expect. If telehealth does become a staple of how intervention is delivered by services in the future, then having some accessible information will prove to be very useful for those inexperienced/less confident in using technology and enable both clients and SLTs to maximise therapy sessions. Hopefully we’ll come up with an effective document that can be used by all!

Being part of the team

Throughout the placement, we’ve been given access to engage with some of the technology, AAC resources and programs to help familiarise ourselves to what is used in client intervention by the Barnsley AT team. We’ve been able to download and access AAC programmes like Grid 3, NuVoice, Mind Express and Snap Core First to our personal laptops. This gives us an opportunity to explore the technology, then have an idea of how it is used functionally by clients within assessment sessions. It has been fascinating and at times mind-blowing to see how complex and intricate these communication systems can be, but at the same time can be tailored to each individual client. Being able to use these applications, plus having our own student access to the Barnsley AT system with our own NHS email certainly gives us an idea of what it feels like being part of the team!

Anna Chivers and Rob Hall, SLT students

IoS 13 Mouse Access

This post was written by Ryan Longley, STP trainee with our team:

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As part of my Scientist Training Programme (STP) I visited the Barnsley Assistive Technology (AT) team as part of a two week placement, which formed an integral part of my Rehabilitation Engineering rotation. The Barnsley AT team gave me a detailed introduction to their department and the different areas in which they specialise.

The purpose of the AT team is to try and improve the independence of individuals living with disabilities through the assessment, provision and support of Electronic Assistive Technology. As well shadowing staff members throughout various duties, such as home visits and equipment set-up, I was also tasked with a small project on testing and reporting on different mice types for controlling an iPad with the latest iOS software. This blog post reports on the work carried out for this task.

IoS13 Accessibility

iOS 13 has seen Apple add to their accessibility features. One of these additions has been to provide iPads and iPhones with the ability to connect with various computer mice or joysticks without the need for a connectivity device, such as the AMAneo BTi (the AMAneo BTi being a Bluetooth interface between the iPad/iPhone where a USB mouse or joystick is plugged into the AMAneo and this is paired by Bluetooth to the iPad/iPhone).

My job was to see if various mice would connect to an iPad (running iOS 13.1.3) and would they function effectively. Having tested several different mice. The table below reports on the connectivity of each mouse with the iPad and comments on the mouse working with the iPad.

IoS13 Mouse Access

My work (see Table) showed that all types of mouse trialled were found to connect to the iPad successfully apart from the Headmouse Nano. Initially the Headmouse Nano worked when the Lightening to USB connector was powered from the mains, but the connection was intermittent. It is hoped that this will be addressed in future. The option to connect the Headmouse Nano to the iPad would give clients who don’t have the ability to use their hands a potential means of accessing iOS devices.

Multiple joysticks worked effectively on the iPad. This provides clients with the potential to navigate an iPad when they are unable to directly access the touchscreen. Another significant feature of iOS accessibility is that adjustments can be made to the control of the joysticks and how the user can operate with them. If clicks via the mouse itself or a connected switch are too difficult, there is potential to use “Dwell Control”. This allows selection of an option on screen by simply holding the mouse pointer over the button for a pre-defined period of time. Buttons/control options can also have their functions changed depending on the client’s needs or the different functions that the control interface offers the client. The possibility of operating the iPad and any of the apps they may wish to use, opens access to communication, EC and entertainment.

Overall, this is a positive testament to robustness of this accessibility feature. The simplicity and effectiveness is also evidenced by the fact that all mice that operated successfully could be connected to the iPad in less than one minute. This new connectivity aspect of iOS 13 will hopefully allow AT staff easier and quicker access to different control possibilities for Apple devices. This will lead to cheaper, quicker and more flexible options during setup for EC or communication aid systems which use an iPhone or iPad running iOS 13 or later.

Testing Ios13 Mouse Access

Mouse Type/Model	Worked on iPad (<1min)	Connection	iOS Settings	Comments
Logitech wireless mouse (normal PC mouse)	Yes	Lightening to USB adaptor	Accessibility on iPad settings	Normal PC mouse connects easily to iPad. It can be used in the same way as a mouse on a PC.
Headmouse Nano	Works for a short period of time on some occasions BUT intermittently loses connection with message saying ‘this accessory requires too much power’	Lightening to USB     Lighting Adaptor needed to power iPad while Headmouse Nano is plugged into it	Accessibility > Touch > Assistive Touch > Devices > Connected Devices	Switch successfully added to Headmouse Nano to enable clicking.   iPad settings can be adjusted in Accessibility to add Dwell Control etc.
Point-It (Joystick Mouse)	Yes	Bluetooth	Accessibility > Touch > Assistive Touch > Devices > Bluetooth	Buttons on device (yellow/red/green) all worked on iPad (left click/right click etc.)
Optimax Joystick	Yes	Lightening to USB adaptor	Accessibility > Touch > Assistive Touch > Devices > Pretorian Optimax	Red (left button) and yellow (right click) both work. Left button set as a mouse click and right button set to bring up iOS menu – e.g with options for home, control centre, device etc
R-Net Omni 2 (Wheelchair joystick Computer Mouse)	Yes	Bluetooth	Accessibility > Touch > Assistive Touch > Devices > Bluetooth	Tested with Omni 2 and wheelchair joystick. Option chosen for PC/Android (not iOS). Mouse directions ok. Flick joystick to left for left click and to the right to bring up iOS menu
Yumqua mini roller ball wired	Yes	Lightening to USB	Accessibility > Touch > Assistive Touch > Devices > Gaming mouse	Connected as expected using assistive touch.  Can customise buttons to actions (e.g. so can make one of them go home) in  Accessibility > Touch > Assistive Touch > Devices > Gaming mouse
Yumqua mini roller ball wireless	yes	Bluetooth dongle into Lightening to USB	Accessibility > Touch > Assistive Touch > Devices > Gaming mouse	Could only get button one to work so need to use assistive touch menu for home or any other actions

Table created Nov 2019 from testing initially with mice connected to an iPad running iOS 13.1.3. At the time the apple device had to have iOS 13 or later in order to have the “Accessibility” page on the Settings. This is what allows mouse connection without the Amaneo.

Table created Nov 2019 from testing initially with mice connected to an  iPad running iOS 13.1.3. At the time the apple device had to have iOS 13 or later in order to have the “Accessibility” page on the Settings. This is what allows mouse connection without the Amaneo.

Summer SLT student experiences

Our team tries to host as many students as we can – as a way of spreading the word about Augmentative Communication and Environmental Control.This post was written by our most recent Speech and Language Therapy students (and the videos mentioned below will be on our website soon!).

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We are two students on placement with the Barnsley AT team for 3 weeks as part of our speech and language therapy master’s course at the University of Sheffield. We were really excited to start the placement as we are both really interested in AAC and were keen to see how this is integrated into practice in a specialist service. We have both enjoyed this placement and it has helped us to develop our clinical skills. We have written about a few of our experiences here.

On our first day we attended a Clinical Excellence Network (CEN) meeting hosted on site. The meeting focused on eye gaze technology, which is a way in which clients can access AAC and EC using eye gaze. Clinical excellence networks allow professionals working in the field to come together to talk about new develops in research and service development. It was great to meet lots of other professionals working with assistive technology, including speech and language therapists and occupational therapists! This really helped to develop our understanding of how different professionals work together as part of a multidisciplinary team.

We had lots of opportunities to go out on visits in the community and see clients using different communication devices, such as those using symbol or text-based systems. We also saw clients using a range of access options to access communication and control things in their environment, for example, joystick controls, switches, direct access and eye gaze. The assistive technology team really work hard to provide individualised support and work in partnership with the service users and their families. It has been great to be part of the team for the last three weeks!

School Mentoring

Along with SLT Andrea and service user Jamie who volunteers for Barnsley AT, we did a talk for a class of 8-year-olds and the staff who work with them in a mainstream school to help them support a student who uses a communication device. It was a really interactive session, and we were really impressed with the insightful answers the pupils were coming out with! We talked about what makes a good talker and a good listener, and who they can show this through their words, actions, and body language. We demonstrated this through some role plays so now Claire and I will be remembered as the ‘good’ and ‘bad’’ chat buddies!

In order to normalise using the device in the classroom/playground and make it fun and motivational for the service user, we played some games with the pupils using the iPad. Finally, the children had an opportunity to ask Jamie questions about his communication aid as well as his life; they were very interested in his bike!

The staff were really keen on continuing working on the topic of good and bad chat buddies. We have created a template of the session with the intention of the service using it for similar training in the future.

Videos

One of the projects we were asked to do was to create some videos to go on the website, demonstrating the use of the Laser Pointer and Talking Mats resources for other professionals. We planned our scripts and rehearsed with Jamie who was once again the star of the show!

Review of AAC: an Interactive Clinical Casebook

This post is a brief review of an AAC an interactive clinical casebook by John W. McCarthy and Aimee Dietz, Speech and Language Pathologists specialising in Alternative and Augmentative Communication.

This CD-ROM presents 13 detailed case studies of people who were being supported by their speech and language therapists to use AAC systems to support their communication. The case studies include a range of acquired and developmental conditions of different ages, with some of the clients discussed also having physical, learning, sensory and/or cognitive difficulties. Further details of the chapters included can be found on this website, where the CD-ROM can be purchased:

http://www.pluralpublishing.com/publication_aac.htm

The cases are displayed in a multimedia book (for Windows or Mac). Each case presents as an interactive story detailing in sections the assessment process and intervention plan as narrated by the speech and language therapist or clinician who was supporting the client. The sections are  divided into clear headings including the following:

1. Case history (birth, therapeutic, medical, unique aspects)
2. Assessment (often identifying formal and informal tools)
3. Communication needs (e.g. what, where, who, when)
4. Barriers and supports (AAC facilitator, opportunity, public policy and practice)
5. Motor speech
6. Cognitive-linguistic skills (e.g. expressive, receptive, cognition,literacy, symbolic language, social skills).
7. Motor, sensory and perceptual skills (e.g. fine motor, gross motor, vision, hearing)
8. Arousal and response mode
9. Message representation
10. Vocabulary
11. Alternative access (discussing a range of access methods)
12. Intervention (e.g. therapy, compensatory strategies, training others)
13. Communicative competence (mapping the client’s skills to Janice Light’s model)
14. Motivation and attitudes (how to encourage motivation, attitude, confidence and resilience)
15. Multimodal communication (exploring the multiple aided and unaided communication modes used by the client)
16. Goals for today
17. Patient and caregiver perspective
18. Ongoing evaluation

 

What I liked about this CD ROM

• The cases and chapters within each case can be accessed in any order, which enabled me to find sections which I felt were most useful for my learning.
• The cases are introduced by giving a definition of the diagnosis, symptoms and other common factors.
• Many of the case studies included several videos of the clients interacting which would be a useful resource for training or presenting a case to students.
• Many of the case studies included sample assessment forms, sample notes and sample reports, which supported my understanding of the case studies.
• The benefit and often importance of speech and language therapists working with other clinicians (such as occupational therapists and physiotherapists) to support AAC assessment and implementation is emphasised.
• The clinicians refer describe informal assessment approaches and often refer to formal assessments used such as the AAC profile, the Western Aphasia Battery and the Receptive One Word Picture Vocabulary Test. This is likely to be very useful for clinicians new to AAC and for students to increase their awareness of communication assessment approaches. I found for example the informal observations described by speech and language therapists when formal language assessments were not possible to carry out valuable.
• The clinicians refer to a communication needs theoretical model and then Janice Light’s (2014) model to support decision making and assessment.
• Goals for intervention are clearly stated in each case, supporting students and clinicians further with a guide to planning intervention to meet similar objectives.
• The resource covers the implementation of a range of AAC modes (low-tech, high-tech, unaided communication), covering well how holistic AAC is and its benefits for many people with moderate-severe communication difficulties. It also covers how low-tech AAC can be used to support people with Dementia with regards to their comprehension and engagement in activities of daily living.
• Demonstrates well how information gathered during assessment can support the decision making with regards to AAC strategies and implementation (such as the prognosis of the condition, the amount of vocabulary likely required, likely literacy needs, likely access method required, positioning, portability factors and mounting).
• Discusses the role of the communication partners and the environment in the AAC journey.
• Gives examples (modelled well in videos) of strategies to support people with communication difficulties, such as supported conversation and communication passports.
• Discusses the impact of other factors, such as behavioural factors, medication supporting clinicians and students to consider the benefit of a comprehensive and holistic assessment.
• Special chapter for clients in intensive care (e.g. adapting AAC in acute care settings)
• The resource provides links to research and online resources for further information.

Possible limitations

The CD-ROM refers to a communication needs model and several formal assessments used by the clinicians which I was not familiar with and it was assumed that these are not frequently used in the UK. This resource would therefore be a useful tool to support AAC assessment and implementation approaches however it would be recommended for students and clinicians to explore further the range of assessment models, frameworks and formal assessment tools online and in their place of work or study.

Summary

Overall, I believe that this resource would be useful for anyone who would like to broaden their understanding of AAC, AAC assessment and implementation approaches. The content on the CD-ROM would be useful for people new to AAC with sections and videos which can be specifically selected for an introduction, however the information presents as targeted for students, clinicians and professionals requiring a deeper understanding of AAC assessment and implementation strategies.

I found the resource insightful, learned of AAC strategies to support my personal development in my current role as a specialist practitioner.  It was useful for me to be able to skip to specific chapters on specific conditions related to clients I was working with at the time.

I liked most of all the way that the CD-ROM looks at AAC in a holistic and multi-modal way by drawing in the benefit of combining unaided strategies with low-tech and high-tech AAC approaches. It would present as a valuable resource for students and the videos could be used in lectures and training events.

Emma and Gemma’s Blog for European day of SLT

This blog post is about Emma and Gemma’s experience of using communication aids to speak, as part of marking the European day of SLT in March 2018.

We wanted to try to put ourselves into the position of our AAC users, and experience what it is like to rely on AAC while out and about doing fairly regular, day to day tasks. We had arranged to set up a stall in the hospital outpatients area later that morning, so thought it was a good opportunity to begin our day with a couple of these tasks. We also hoped that by using AAC out and about, we would raise awareness of AAC with members of the public that we met.

We decided that we would do one job each,  and the other person would observe what was going on from an outsiders perspective. We would only use unaided, non-verbal communication, and one method of powered (or high tech) AAC. Both tasks were very straightforward, and actually required only a very small amount of AAC to get by. Despite this, we found our experiences to be highly valuable and insightful, giving us a snapshot of how it feels to be an AAC user.

Emma’s task- buying a stamp using predictable on an iPad

My task was to go into a shop to buy a stamp. I decided to use an iPad with Predictable; an app which I am relatively familiar with and works on both iOS and android devices. Before we set off, I made sure to add some pre-programmed phrases, so that I could quickly communicate what I needed. I was amazed at how anxious I felt before setting off. We were going to a local shop- what if they recognised me? What if they responded in a negative way? What if other people stared? – all things which surely go through the heads of our AAC users when we ask them to practise in real life situations with devices, apps, access methods and software packages that may be completely new and alien to some clients.

When walking to the shop, I also felt empathy with users that had commented to me that they didn’t feel confident to have their device accessible when out and about, in fear of their public safety. I was only carrying my iPad and still this thought crossed my mind. What about our users who need their device mounted to a wheelchair, or those that wouldn’t physically be able to defend themselves if anything happened?

When I got to the shop, it looked fairly quiet, which reassured me. I went to the counter and was greeted by a member of staff. I used the iPad to say good morning, and ask for a stamp (both in my saved phrases). The lady nodded and said “first class?” I panicked, and rather than just nodding my head, I went into my phrases to confirm “first class” back to her. The lady quickly got me my stamp and I gave her the money, and said “thanks”. I wanted to make sure that we told them a bit about what we were doing before we left, so I (again using pre-programmed phrases) said that we were from the Barnsley Assistive Technology Team and were using this to demonstrate how people may use technology to support their communication. The lady nodded, and I left the shop.

As we left, I reflected on how strange the whole interaction felt, in comparison to if I had been a speaking customer. I know the staff are very friendly, and usually would have asked a question about what we were doing, or offered a comment about the day. Today, the conversation was limited to just what was needed, and it was as though because I wasn’t talking, my communication partner didn’t talk either. I was really surprised about how it had made me feel , and because of this, I had forgotten to ask for some change. I found that I could stick to the routine with my pre-planned phrases, but if anything about the conversation went off track, I found it very difficult and panicked. I could have very easily used the keyboard to type something out, however this would have taken up more time, and I didn’t want to keep other people waiting. It was very difficult to combine using the app with more natural means of communication such as using eye contact and smiling, which again added to my anxiety of trying to include being polite and friendly, while at the same time trying to use a different system. Gemma noticed that as a short queue built up behind me in the shop, other customers were immediately looking at me and the iPad, which as someone who hates being the centre of attention only added to my anxieties!

I think if I had the choice of someone else being able to carry out this task for me, for ease and speed, I would happily accept their help. It is no wonder that many of our AAC users report that they sometimes let someone else do the talking for them in such situations, and similarly demonstrates how driven, motivated and inspirational the clients that do use their devices while out and about are.

Gemma’s task- buying milk using the speech assistant app

My task was to ask for help finding the milk, and then to purchase this at the shop. I used the Speech Assistant app on Samsung smartphone, which is a free text to speech app available on Android operating systems. I decided to go with using an app on my phone because it could fit in my pocket, and if I was to use AAC, I would prefer something portable and small where possible.

I had tried using the app the evening before with my husband in which I was free typing out all of my messages to him. I found that typing out my message on each turn in the conversation was slowing me down, and when I tried to speed up typing, I was making mistakes with pressing letters on the keyboard. I also found that whilst typing, I was unable to give eye-contact to my husband. I decided for my task the next day, that I would set some pre-programmed phrases as I had a good idea about what I was going to ask at the shop. I felt this would support my social engagement with the conversation partner.

I was like Emma, feeling anxious before this and had similar thoughts running through my head. I visit the shop regularly so wondered if someone may recognise me. I felt somewhat self-conscious. I was anxious of how the people I communicated with may respond.

I first approached an assistant to ask where the milk was using the AAC app. I tried a different approach to Emma of informing the shop assistant before asking my question using a pre-set phrase that I am using an app on my phone to help me communicate. The shop assistant put me at ease as her approach was warm and understanding. I asked her where the milk was using the app and she showed me.

I then stood in the queue at the check out. The lady at the checkout was having a conversation with the customer in front of the queue, making jokes. She looked to me as she was joking. Perhaps if I was verbally speaking, I would have joined in and commented, but I realised I did not have a phrase ready on my device to respond, and was also anxious of their reaction if I used my phone instead. When it was my turn to pay for my milk. I informed the lady at the checkout that I was using an app to help me communicate. I then asked how much the milk was and thanked her. Her response was supportive, and she used some unaided strategies to support the conversation. I did feel a contrast to the previous customer, as the lady did not engage in as much ‘small talk’ with me. Perhaps she was feeling unsure too how to respond? I too like Emma, felt my communication was focussed on what I needed.

The experience enabled me to empathise so much with the clients I support in my role. Previously, I may have underestimated how it could feel to use AAC to support social communication. I considered how I may have set targets previously and offered recommendations for using AAC, without having the experience myself.

I considered Janice Light’s model of communicative competence, in which perhaps the area I was working on was ‘social’ competence, adapting to use AAC as a method of communication socially. I considered that for many of the people who use AAC, there are many other goals and targets they may be working on first, such as learning to access a system, learning to use symbols, learning the location of vocabulary, learning to build sentences. Many people with AAC too may have physical or sensory difficulties where learning to use a device in a social situation is just one part of their AAC journey.

Janice Light 1989

I was glad to have Emma with me as someone else I could share the experience with. This further consolidated my feeling that clients using AAC may benefit from meeting other AAC users, such as in AAC user groups, aphasia cafes, and charities such as ‘the stroke association’ and ‘One Voice’.

Following this experience, I have shared my experience with some of the clients and carers I have since visited, and I have found this to be a positive way of demonstrating that I can personally identify with some of the experiences they may have using AAC. I feel so pleased that I tried this, as now I understand more than ever, what it can be like for someone using AAC to support their communication.

Summary of our experiences

As mentioned above, we were both using very simple apps, a direct access method and a text to speech system. Throw into the mix the often complex access methods, symbol systems, and navigation around software packages that some of our users have, it is not surprising that clients (sometimes with additional cognitive difficulties) often find it highly challenging to use their devices in public places or to carry out everyday tasks with unfamiliar communication partners who know very little about AAC. It will definitely make us think twice when setting goals with clients, and certainly help us to empathise with clients who find this aspect of AAC use more challenging. We would recommend anyone who works with AAC to have a go at something like this, in order to experience first hand exactly how it feels.

We also raised £20 on our stall which we have donated to communication matters. Thank you to everyone that came to talk to us!

References

Light, J.C. (1989). Toward a definition of communicative competence for individuals using augmentative and alternative communication systems. Augmentative and Alternative Communication, 5,4, 137-144. You can read the original article here with thanks to ISAAC for making this available for free: https://www.tandfonline.com/doi/pdf/10.1080/07434618912331275126

Light, J., & McNaughton, D. (2014). Communicative competence for individuals who require augmentative and alternative communication: A new definition for a new era of communication?. Augmentative and Alternative Communication, 30, 1-18. doi:10.3109/07434618.2014.885080
The Speech Assistant App can be downloaded for free from: https://play.google.com/store/apps/details?id=nl.asoft.speechassistant)

The Predictable app is available on IOS and Android operating systems, and can be purchased from:

(https://www.therapy-box.co.uk/predictable)