Category Archives: AAC

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.

Advertisements

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

c

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!

d

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)

 

 

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.

Specialised Services for AAC and Environmental Control: An Update

There have been big changes within the Barnsley Assistive Technology Team over the past three years, we have been steadily recruiting more team members as we expand our services across the Yorkshire and Humber region as part of the staged roll-out of Specialised Services for AAC and Environmental Controls. You can read more about the history of this process on our website.

We are now almost at the end of this process. We currently cover most areas within Yorkshire and Humberside and will be accepting referrals from all CCG’s by the end of the year. Information regarding our care pathway and how we work with local services can be found on our website:

Supporting Local Services

We are keen to work with local services to support them through this transition period and beyond. We have already visited lots of teams to talk about our service and how we can work with each other to support people using AAC and Environmental controls.

We also offer a wide range of free training courses which can be delivered in your local area. Details of our curriculum are also on our website: www.barnsleyhospital.nhs.uk/assistive-technology/services/training-courses/

We are also trying to bring together local services to share and learn from each other. This includes setting up and arranging the Yorkshire and Humber AAC Clinical Excellence Network meeting which has been running for almost a year now. The group meets every four months to discuss a range of Assistive Technology issues and serves as a useful forum for networking and CPD.

Also on our website is a range of resources, including our popular ‘local services resource pack’ which details products and resources which local professionals will find useful: www.barnsleyhospital.nhs.uk/assistive-technology/services/resources-and-information/

NHS England have also recently published guidance about AAC provision from local and specialised services. This is a useful reference for local commissioners and managers when considering AAC provision: www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/03/guid-comms-aac.pdf


We have received lots of positive feedback so far and are enjoying getting to know the professionals across the region supporting AAC and Environmental Controls. If you have any questions about our service or would like to arrange for us to visit your team, please email barnsley.at@nhs.net

To receive further updates and news from the Barnsley Assistive Technology Team, please sign up to our mailing list (we send a message or two per month).

Multi Sensory Keyguide

Working with clients with visual impairments offers challenges within the field of AAC that are unique and can require imaginative solutions to enable the client access to their device.

After supporting  a young child with no functional vision for numerous months, progress  in terms of his ability of navigating through the ‘pages’ of his language package on his communication aid was limited. This child was  accessing  his 45 location Wordpower language package set via a standard key guard and appeared initially to be making good progress in terms of remembering where specific vocab items were located.

As a navigation strategy, the child was supported to place his hand at the top left of his  device and then move down the columns and then from  left to right across the rows. He was able to press a few  cells  before his chosen cell and used the auditory feedback to cue him in as to where he was on the page. However after a period of use of this method  his progress appeared to have plateaued and his targeting  was not getting more accurate.

After discussion with one of our mechanical techniologists a multi sensory keyguide was developed using the department’s new laser cutter. This keyguide was layered – the top layer splits the page into eight sections and then on the bottom layer within each section six shapes (circle, star, square, triangle, diamond, oval) are cut. In this way the child is provided with a sensory code/cue for each cell of the vocabulary package and this should allow himself to orientate himself and more easily learn the use of the system.

Keyguard_annon_sm

Multi sensory keyguide showing layered shapes

Multi sensory Keyguide showing vocabulary

Multi sensory Keyguide showing vocabulary

We are looking forward to reviewing this child and seeing if this multi sensory keyguide has supported his ability to learn his AAC language package more effectively.

Local Service Resource Pack – update

Following the well received publication of our Local Service Resource Pack last year, an updated version has now been produced, including even more information about Augmentative and Alternative Communication, Environmental Control and Computer Access devices, software, hardware and other resources.

The pack is designed as an easy to use resource and is hoped to be particularly useful for supporting those working in local services within the Yorkshire and Humber Region, who may be expected to provide and support clients with using assistive technology that does not come under the remit of the Barnsley Assistive Technology Team. This may include local Speech and Language Therapists, Occupational Therapists, Teachers and Teaching assistants.

The guide includes ideas including communication aids and apps, computer access equipment, simple devices for environmental controls as well as details of assessments, software and other resources that may prove useful.

Local Sercvice Resource Pack

Local Service Resource Pack

The pack is available from our website at  http://www.barnsleyhospital.nhs.uk/assistive-technology/services/resources-and-information/

We hope that the resource will be useful and welcome any feedback, including any other products that you feel it would be useful to include. We hope to continue to update the resource on an ongoing basis.

Some low-tech AAC suggestions

We have been spreading the message about mainstream products that can help people communicate.  These are products that can be useful for people who require augmentative communication, and can be easily sourced by local therapy teams to support individuals they meet. Here we describe two examples:

E-Writers:

Boogie Board E-Writers, for example the Boogie Board, have been a particularly popular suggestion. An e-writer is an LCD board with a stylus for writing messages or drawing pictures. The image can be erased when it is finished with. This is a low-cost, portable low-tech AAC solution which may be preferable to using large amounts of paper.

E-writers are available in a range of sizes and styles, with some models saving your images and transferring them wirelessly to a phone, tablet or computer. They are suitable for clients who are able to use handwriting or drawing to support their spoken communication.

The Pen Torch:

PentorchOne of our clients, a gentleman with MND, explained that as one means of communication he used a stylus to point to an alphabet board. Unfortunately deterioration in his hand function meant that he was finding it increasingly difficult to point the stylus accurately. His conversation partners were often having to guess approximately where on the board he was pointing. This was effortful and time-consuming for all involved.

We suggested that a small pen torch might be helpful to more accurately highlight the letter he wanted without requiring increased hand movement. This piece of kit was easily purchased from the High Street and he found that it made a great difference to his ability to communicate via low-tech AAC. This solution was considered alongside other possible technology (e.g. eyegaze etc). The photo shows it successfully being used in action!

Previously this has been achieved using laser pens (see this great sheet on making one from Margaret Cotts, an Assistive Technology Specialist in the US ), these do carry a small risk in use however.  With the advance in LED technology, pen torches are now so bright that they can work just as well in some situations.  The use of a light seems easier to ‘read’ than pointing, and can be more relaxing/require smaller movements.

More Resources

We have created a Local Services Resource Pack  with lots more detailed information. This pack has been developed as a guide for local professionals and contains one page profiles on AAC (communication) and Environmental Control products and resources.

Have you got some techniques/mainstream products that have worked well for low tech communication support?  Please let us know!