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.

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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)

 

 

Being a Field Servicing Technician in the Assistive Technology Team

In this post Phill, one of our new Field Service Technicians tells us about his role.   If this is something that interests you, or someone you know, then we have a position out to advert at the moment so please have a look and get in touch!

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Tell us what the job of Field Servicing Technician in the Assistive Technology Team involves?

Phill, one of our Field Service Technicians

No two days are ever the same. One day you may be refurbishing equipment that has been returned ready to be returned to another client or setting up a device for other members of the team. You could be installing a system for a client or carrying out a routine service. But the best part of the job is that every day you can make a real difference to someone’s life. This could be something as “simple” as letting someone control their TV using a different style of controller to enabling someone to communicate who may not be able to speak.

What was your previous field servicing experience?

Previously I worked as a service engineer for a large international company on high end devices from numerous manufacturers. The equipment I worked on was in almost every sector from Healthcare to banking, Small single offices to international  companies.

How does this role compare to your previous field servicing experience?

Previously I was just a number in a service division of an international company. Now I’m part of an amazing team of people who are all working towards providing the best possible service possible. Everyone goes the extra mile to help our clients.

What would you say to someone else coming into this role?

If you really like helping people and working with technology then this is the job for you.

Tell us about a client you recently visited, what did you do?

One of the first visits I attended was to watch a colleague install an environmental control system. After we had completed the install the reaction from the client and her Husband  was fantastic. Being able to control the TV and adjust her chair made such a difference. A more recent visit I have attended was for a young man who is not able to communicate or use standard devices to control his TV, Radio or go on Facebook. All this is now controlled from one device. Although he couldn’t talk we still had a laugh with each other after I told him I was going to make his device tune the TV to Classic FM. We settled on Heart FM

Anything else?

The Barnsley AT Team

If you want a new challenge in a rewarding field, working as part of a fantastic team in a great environment then this could be the move your looking for.

Work with us!

The Barnsley AT Team

We are recruiting to a number of positions in our team – we are looking for Technical staff and also Speech Therapists and Therapy Assistants.   If you wish to apply, or know someone who may be interested, please see the listings on NHS jobs below.

Technical Staff: Do you have a technical background but want to work in a more rewarding role, making a real difference to the lives of individuals with disabilities? We are looking for Technicians, Field Service Engineers and Clinical Technologists to work in our nationally recognised Assistive Technology Team.

If you have a technical background and an interest in electronic Assistive Technology, we have a number of posts open, according to your skills and experience:

• Equipment Technician (Assistive Technology)
• Mechanical Technician (Assistive Technology)
• Field Servicing Technician (Assistive Technology)

If you are a registered Clinical Technologist, or have a defined route for completing registration:

• Clinical Technologist-Assistive Technology Mechanical Specialist
• Clinical Technologist – Assistive Technology Electronics Specialist

Therapy Staff: Are you a Speech Therapist or Therapy Assistant with a specific interest in AAC and Assistive Technology?

• Speech & Language Therapist (Assistive Technology Specialist)
• Therapy Assistant/Technical Instructor

Find Out more about our team and the services we provide on our website.

Unspoken voices: Gathering perspectives from people who use Alternative and Augmentative Communication (AAC)

This blog post is from Katherine Broomfield – Speech and Language Therapist, Gloucestershire Care Services NHS Trust. Kath has recently been successful in achieving an NIHR Doctoral Research Fellowship, will start her PhD with Prof Karen Sage of Sheffield Hallam in 2017 and will be working with our team as part of this.

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I lead the local AAC service in Gloucestershire; part of the adult speech and language therapy service. We assess and provide basic communication aids such as low-tech, paper-based systems and direct-access, high-tech devices. In a quest to improve our service, I was interested in how to reinforce the quality of the assessment and support that we provide to people in need of communication aids. I also wanted to understand how to improve people’s experience of using them. In 2014, I secured funding from Health Education England South West to carry out a clinical academic internship at the Bristol Speech and Language Therapy Research Unit, under the supervision of Professor Karen Sage.  The objectives of the internship were to: a) search for research literature about how to best support the implementation of communication aids, b) carry out interviews with service users and c) consider areas for further research.

The literature search uncovered limited information about why some people use communication aids effectively and others do not; nor what ‘successful communication’ means to people who rely on communication aids and what they feel best supports them to achieve this. The services users I interviewed reported very different views on successful communication aid use. They also provided some interesting insights into how to improve the support that NHS services provide when issuing AAC equipment. The number of participants in the interviews was small however and they were all adult users of one particular device. By the end of the internship, I had generated more questions than I had answered.

I chose to apply to the National Institute for Health Research (NIHR) for funding to carry out further research into the perspectives of users of communication aids. In February 2016 Prof Karen Sage relocated from Bristol to a post at Sheffield Hallam University (SHU) Centre for Health and Social Care Research. This provided me with the opportunity to establish a team to help me with my research project from the vibrant health research community in Sheffield and, more specifically, to approach Simon Judge at the Barnsley Assistive Technology Team. Simon agreed to join Prof Karen Sage, Prof Karen Collins (SHU) and Prof Georgina Jones (Leeds Beckett University) in supporting me to develop my research proposal, complete the funding application and, if successful, to supervise me while carrying out the research.

At the end of last year I was awarded NIHR funding. My project aims to develop a greater understanding about why people do and do not use communication aids and how they view success with using them. I plan to carry out a more extensive and specific literature review focusing on user perspectives and outcomes for communication aids. I will then complete a series of interviews with young people and adults who use communication aids at different points across the AAC pathway – from assessment and provision of equipment to the use of communication aids in people’s homes, schools and communities. The ultimate aim of the project is to develop a patient reported outcome measure (PROM). The PROM will be made available for use by NHS services to gather the perspectives of people who use communication aids about the equipment and the support they receive.

The project is one aspect of my PhD training programme (the Clinical Doctoral Research Fellowship, or CDRF) targeted at developing practicing NHS clinicians into academic researchers. This scheme is part of the current drive to improve the use of research evidence within NHS services.

I am really looking forward to working closely with people who use communication aids and their friends, families and carers throughout this project. I am also excited about the opportunity of working closely with the team at Barnsley Assistive Technology whose clinical work and research I have admired for some time. I will be setting up my own blog imminently to keep people informed about the project – but in the meantime, I am contactable via Simon and the team. I am passionate about good communication and I still have a lot to learn about AAC, so please get in touch!

 – Katherine Broomfield, Speech and Language Therapist, Gloucestershire Care Services NHS Trust.

 

 

 

Oral Histories and Legacies

Leaving an oral history or legacy is something that can be important to those with life limiting conditions.  Our team works with people with communication difficulties who rely on AAC systems to communicate and I (Nicola) was curious to investigate what services are available for people with life limiting conditions to leave a legacy for friends and families. I have had client’s that have left letters and planned their funerals using AAC systems that family have found subsequent to their death.  I have also had requests that family copy information that is stored on the systems to remember the person by.  However, I had felt that I was unable to support or guide people to services if they do want to leave something for their friends and family, so I went to find out more.

Legacy Service

My self and our team’s clinical psychologist met with the organiser from a local hospice, who coordinate a team of volunteers who support people with life limiting conditions to create an oral history for friends and family. This service has been running since 2013 when it was set up as part of a research project by the University of Sheffield and Macmillan Cancer Support.

The Macmillan service will support people referred to their service to create an audio recording. They do this in a number of different ways and will be guided by the individual.  They offer an interview, desert island discs, personal histories and memory boxes.  They use a crib sheet, but it is very much what the person wants to talk about and the facilitator just offers encouragement.

To do this, the service uses high quality recording equipment, funded by donations, the microphones on the system are small and frequently the person will forget that they are using them.  Recordings can be done either  on site or at the person’s home.  They need a quiet room and the service will offer emotional support.  The service then uses software called “audacity” to edit the audio together – so that the person does not need to do it in one go.  The service reported finding that the process can be beneficial for the person as a reflective exercise.

The Macmillan service have discussed using video with clients – however feedback so far has been that this would not be positive, including for reasons that the person could see physical changes in themselves. This may change in the future as younger people live their lives through social media.

Once completed, the person signs a consent form for who they want to access the recording. A CD is produced or people can have it in a digital format.  They can also consent to have the recording saved with the University of Sheffield as part of the research project to develop a growing oral social history to help future generations connect with real people from the past.  There is very little other research on the topic of leaving oral histories and legacies by people with life limiting conditions.  The research reported benefits for the participants and the importance of it being their voice.

Legacy using AAC

The service in Sheffield does support people with communication difficulties and have found that this takes more planning.  They did have one person referred to their service who used a communication aid, but following discussions this person did not follow through as she felt that the voice was not hers.

I now feel that I can discuss and offer sign post to services that will enable our clients to complete this, if that is what they want to do. It is a very personal thing and is not for everyone. When possible it should be offered prior to deterioration or loss of speech, but this is not always possible.  The hospice now feels that the local AAC service can support them if they have issues support people who use AAC to access the service.  For client’s using AAC it may be a matter of leaving the information in other ways such as in writing, videos, photographs as well as through their communication aid.  If you work with people using AAC I would urge you to offer and support people to enable them to leave a legacy behind and not be held back by their communication issues.

BBC Accessibility Champions

In August Vicky Johnson and Marcus Friday from our Team were invited to present to the BBC accessibility champions event at BBC Media City in Salford.

BBC Media City, Salford

This day was organised to bring together many BBC accessibility champions. The group included people who design BBC websites and apps to ensure accessibility. The audience consisted of programmers, user experience designers, researchers and testers, business analysts, assistive technology users and accessibility specialists.

The BBC now has approximately 85 accessibility champions which span across many BBC departments, eg TV, radio, sport and children’s. Presentations were given to explain the ways in which the champions ensure that accessibility is considered early in the design process, and that testing is carried out as a website, app or game is developed.

‘Physical’ ICT Accessibility

Vicky and Marcus, from the Barnsley AT team, were invited to speak at the event in order to provide the audience with an insight into how users with severe physical impairments access technology. The focus was on their clients who predominantly have upper limb physical impairments and sometimes have associated visual and cognitive difficulties. An overview of the Barnsley AT Team was provided, along with some powerful case studies of clients using their AT systems to enable computer access, control of the environment, and access to communication.

Three breakout sessions took place in the afternoon and we listened to the Head of Accessibility and Accessibility Specialists provide an insight into the developments in the accessibility of BBC output in recent years. Part of the discussion focused on how to ensure that breadth of BBC output is accessible to those with visual, cognitive or physical difficulties.

Looking to the Future

The day ended with a fun session spent in the Blue Room. The BBC have dream jobs where Technologists are employed whose role is to keep aware of new mainstream developments which may have an application or scope for development of interest to them.

We tried the Amazon voice recognition system called Echo which uses the protocol IFTTT (if this then that) which provides a flexible system, where for example the system recognises your request and you program it to perform any number of actions e.g. control your environment, interact with an app in order to order a taxi or food or action another command programmed in other IFTTT enabled apps. We also had time to try Google Glass and a relatively cheap head worn display called Glasshouse.

It was a privilege to meet some of the people behind the iPlayer TV and radio apps, including the Good Food site. Overall, it was an informative and enjoyable day which has opened up the opportunity for Barnsley AT Team to work further with the BBC.