Speech-Language Pathologists’ Perceptions of Implementing Communication Intervention with Students with Multiple and Severe Disabilities

Use of an intelligent tutoring system for a curriculum on augmentative and alternative communication: Feasibility for implementation

BACKGROUND

Over 8 million children with disabilities live in Africa and are candidates for augmentative and alternative communication (AAC), yet formal training for team members, such as speech-language therapists and special education teachers, is extremely limited. Only one university on the continent provides postgraduate degrees in AAC, and other institutions provide only short modules at an undergraduate level. The need for an introductory training course on AAC that is accessible by university students continent-wide was identified. An online programme, namely an intelligent tutoring system (ITS), was identified as a possible option to facilitate interactive learning without the need for synchronous teaching. The use of an ITS is shown to be effective in developing knowledge and clinical reasoning in the health and rehabilitation fields. However, it has not yet been applied to student teaching in the field of AAC.

AIM

To determine both the feasibility of an ITS to implement an AAC curriculum for students in four African countries, and the usability and effectiveness of such a system as a mechanism for learning about AAC.

METHOD & PROCEDURES

The study included two components: the development of a valid AAC curriculum; and using the ITS to test the effectiveness of implementation in a pre- and post-test design with 98 speech-language therapy and special education students from five universities.

OUTCOMES & RESULTS

Statistically significant differences were obtained between pre- and post-test assessments. Students perceived the learning experience as practical, with rich content.

CONCLUSIONS & IMPLICATIONS

The findings suggest that the ITS-based AAC curriculum was positively perceived by the students and potentially offers an effective means of providing supplementary AAC training to students, although modifications to the system are still required.

WHAT THIS PAPER ADDS

What is already known on the subject Professionals typically lack formal training in AAC. In Africa, this presents a serious challenge as there are over 8 million children who are candidates for AAC. A need for an introductory training course on AAC, which can be accessed by university students continent-wide, was identified. What this paper adds to existing knowledge An AAC curriculum was developed and integrated into an ITS, an online programme allowing interactive learning through asynchronous teaching. Students from four African countries completed the AAC ITS curriculum. The curriculum was positively received by the students and statistically significant changes in knowledge were identified. What are the practical and clinical implications of this work? This feasibility study shows that the use of an ITS is an effective means of providing AAC training to university students in these African countries. The results provide a valuable contribution toward ensuring the equitable distribution of AAC training opportunities in the African context. This will have a significant positive impact on those who are candidates for AAC.

A new intervention to prevent social isolation in people with complex communication needs

While implementing communication interventions, practitioners follow diverse theoretical models. Different conceptual orientations influence the way professionals embrace the subject of communication and its disorders. This research project explores the co-creation and validation of a new model and intervention program to analyze and improve communication between persons with Complex Communication Needs and their caregivers. The methodology incorporated a comprehensive narrative review, as foundation for the new model and intervention proposal. Succeeding this stage, the team implemented an online Delphi Panel to improve and validate these results, involving 17 international renowned experts. Following the Appropriateness Method, 25 indications were subject to scrutiny and rated as appropriate with minimal values of disagreement among the evaluators. Qualitative feedback was used to improve the research products. Quality assurance measures were taken to ensure quality and transparency of the results. A new conceptual framework of atypical interpersonal communication and intervention program result from the investigation. The new model is inspired by the Transactional model and principles of Dialogism. The intervention consists of consultations with caregivers, using video analysis and a dialogical methodology to enhance communication. The next research phase is to pilot-test the intervention program with clinicians supporting persons with disability at risk of social isolation.

Leveraging Communication Partner Speech to Automate Augmented Input for Children on the Autism Spectrum Who Are Minimally Verbal: Prototype Development and Preliminary Efficacy Investigation

PURPOSE

Augmentative and alternative communication (AAC) technology innovation is urgently needed to improve outcomes for children on the autism spectrum who are minimally verbal. One potential technology innovation is applying artificial intelligence (AI) to automate strategies such as augmented input to increase language learning opportunities while mitigating communication partner time and learning barriers. Innovation in AAC research and design methodology is also needed to empirically explore this and other applications of AI to AAC. The purpose of this report was to describe (a) the development of an AAC prototype using a design methodology new to AAC research and (b) a preliminary investigation of the efficacy of this potential new AAC capability.

METHOD

The prototype was developed using a Wizard-of-Oz prototyping approach that allows for initial exploration of a new technology capability without the time and effort required for full-scale development. The preliminary investigation with three children on the autism spectrum who were minimally verbal used an adapted alternating treatment design to compare the effects of a Wizard-of-Oz prototype that provided automated augmented input (i.e., pairing color photos with speech) to a standard topic display (i.e., a grid display with line drawings) on visual attention, linguistic participation, and (for one participant) word learning during a circle activity.

RESULTS

Preliminary investigation results were variable, but overall participants increased visual attention and linguistic participation when using the prototype.

CONCLUSIONS

Wizard-of-Oz prototyping could be a valuable approach to spur much needed innovation in AAC. Further research into efficacy, reliability, validity, and attitudes is required to more comprehensively evaluate the use of AI to automate augmented input in AAC.

Augmentative and alternative communication with children with severe/profound intellectual and multiple disabilities: speech language pathologists' clinical practices and reasoning

PURPOSE

Augmentative and alternative communication (AAC) is recommended to be included in communication interventions directed at children/youth with severe/profound intellectual and multiple disabilities (S/PIMD). Even so, the evidence base for AAC practices with children with S/PIMD is limited. Also, little is known about how frequently AAC is implemented with this target group, which AAC tools and methods are applied, and the related clinical reasoning of speech-language pathologists (SLPs). This study aimed to explore SLPs' beliefs, clinical reasoning and practices in relation to AAC implementation with children/youth with S/PIMD.

MATERIALS AND METHODS

In this sequential, mixed-methods study, 90 SLPs working with children with disabilities within habilitation services in Sweden participated in an online survey. The survey answers were statistically analysed. Subsequently, focus group data were collected from seven SLPs and analysed using thematic analysis.

RESULTS AND CONCLUSIONS

Despite AAC being highly prioritized, SLPs found it challenging and complex to implement with this target group. A wide variety of AAC methods and tools were considered and implemented. Clinical decision-making was a balancing act between competing considerations and was mainly guided by the SLPs' individual, clinical experiences. The resources, engagement and wishes of the social network surrounding the child were considered crucial for clinical decision-making on AAC. Implications for research and practice are discussed.Implications for rehabilitationSpeech-language pathologists (SLPs) seemingly find a wide variety of Augmentative and Alternative Communication (AAC), ranging from unaided methods to assistive technology of various complexity, to be potentially suitable for children/youth with severe/profound intellectual and multiple disabilities (S/PIMD).The motivation and preferences of the social network surrounding the child with S/PIMD seem to influence SLPs' clinical decision-making on AAC to a high degree. Sometimes this may be considered an even more important factor than the abilities of the child.SLPs' clinical decision-making on AAC for children/youth is guided by their individual, clinical experience to a high degree.An increase in family oriented AAC intervention research targeting individuals with S/PIMD could potentially strengthen the association between research and the current, experience-based clinical practice.

Exploring Classroom Factors and Augmentative and Alternative Communication Use in Qualitative Interviews

PURPOSE

This qualitative study explores classroom contextual factors influencing augmentative and alternative communication (AAC) use in early childhood classrooms.

METHOD

Semistructured interviews were conducted with six special education teachers, 13 speech-language pathologists (SLPs), and one SLP assistant. Interviews were analyzed inductively in a systematic, multistep coding process using the constant comparative method with member checking.

RESULTS

Seven themes were identified that affected AAC use in the classroom. Each theme was organized into three categories: individual-, classroom-, or school-level factors. Three themes were categorized as individual-level factors: Students' AAC systems are unavailable, professionals face challenges obtaining AAC knowledge and skills, and students' disruptive behaviors reduce access to AAC. One theme was a classroom-level factor: Classroom demands prevent AAC use. Finally, three themes were considered school-level factors: The culture of AAC influences AAC acceptance, team collaboration is essential for successful implementation, and teams need administrative support to deliver AAC interventions effectively. Conclusions: Teachers and SLPs felt that collaborative teams with AAC expertise, a school culture that endorsed AAC, and solid administrative support accelerated AAC adoption by normalizing AAC use in the classroom. Due to classroom demands, they struggled to use strategies such as aided AAC modeling and responsiveness during group instruction. Finally, participants emphasized that while it was necessary to customize AAC systems for each student, this individualization makes it harder for staff to learn each system and integrate them into classroom activities.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23681718.

Reported Barriers to Augmentative and Alternative Communication Service Delivery and Learning Preferences Among Speech-Language Pathologists

PURPOSE

Speech-language pathologists (SLPs) report extensive barriers to delivering augmentative and alternative communication (AAC) services, including the knowledge and skills necessary for AAC service delivery. Although nearly all graduate programs report the inclusion of preservice training for SLPs to provide AAC services, existing research on SLPs' characteristics of AAC service provision does not reflect these changes. This study aimed to identify current AAC service delivery characteristics, barriers, and learning preferences reported by SLPs.

METHOD

A survey invitation was distributed to SLPs with American Speech-Language-Hearing Association (ASHA) Certificate of Clinical Competence through social media and the ASHA Community discussion groups.

RESULTS

Participants were 530 SLPs who predominantly identified as general practice SLPs. Participants reported 1%-25% of their weekly patient caseload has AAC needs for communication or receives AAC intervention. SLPs reported feeling at least "knowledgeable" in more than half of the targeted competency areas. The reported primary barriers to AAC service provision are knowledge, caseload, and time. Preferences for topic, format, and frequency and duration for AAC-related continuing education were highly variable among SLPs.

CONCLUSIONS

SLPs' barriers to AAC service delivery are consistent with research from the last 15 years, revealing a lack of systematic, organizational, and informational mechanisms to support SLPs as vital members of the AAC team. Those involved in post-service instruction and training must consider the training needs of SLPs with varying competence and their experience with AAC modalities, clinical practice backgrounds, and learning preferences. AAC-related training and continuing education must reflect SLP's daily practice, learning needs, and preferences.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23503809.

Augmentative and Alternative Communication in the Classroom: Teacher Practices and Experiences

PURPOSE

This study explored the practices and experiences of teachers who teach students using augmentative and alternative communication (AAC), more specifically, speech-generating devices (SGDs).

METHOD

Nine teachers (one general education, eight special education) from four countries participated in semistructured interviews. A generic qualitative approach was taken to inductively code interview transcripts and establish descriptive themes.

RESULTS

Three themes emerged from the data. The teaching experience theme captured teachers' feelings, role, collaboration with others, knowledge and learning around AAC, and challenges teaching students who use SGDs. The teaching practices theme included curricula that teachers use, instructional planning, materials and adaptations, instructional strategies, and methods for student evaluation and progress monitoring. Finally, the overarching views and practices theme captured teachers' beliefs and interpretation of the educational system for students using SGDs, as well as teachers' overarching views on communication and approach to AAC implementation.

CONCLUSIONS

In sharing their perspectives and practices, teachers highlighted a number of constructs that speech-language pathologists could consider when responding to and supporting teacher and student needs. The findings of this study have implications for facilitating collaborative relationships and supporting the use of AAC in schools. Discussion on how educational placement can influence teacher experiences and student outcomes is also integrated into the context of this study.

'We were just kind of handed it and then it was smoke bombed by everyone': How do external stakeholders contribute to parent rejection and the abandonment of AAC systems?

BACKGROUND

There are multiple stakeholders involved in the introduction of augmentative and alternative communication (AAC) systems to children with complex communication needs. Stakeholders such as speech-language pathologists (SLPs) and teachers who are external to the family unit play a key role in planning and implementing interventions. If this intervention is unsuccessful, it can result in parent rejection or abandonment of the AAC system. However, no studies explore the contribution of external stakeholders to AAC rejection and abandonment from the perspective of parents who have experienced such unsuccessful interventions.

AIMS

To explore parents' perceptions of how external stakeholders may contribute to the rejection or abandonment of an AAC system.

METHODS & PROCEDURES

Data were collected as a part of a larger study that explored parent experiences of AAC rejection and abandonment. Within this study, semi-structured interviews were completed with 12 parents who had rejected or abandoned an AAC system introduced to their child with complex communication needs. Data related to external stakeholder contributions were extracted from the interview transcripts, and a thematic analysis was conducted.

OUTCOMES & RESULTS

Analysis revealed four themes that captured the role of external stakeholders in the rejection and abandonment of AAC systems: (1) parents were influenced by the attitudes and experience of professionals; (2) parents did not feel supported by SLPs; (3) communication between stakeholders was not effective; and (4) parents had difficulties using AAC without a supportive community.

CONCLUSIONS & IMPLICATIONS

This study highlights the importance of family-centred service delivery when introducing an AAC system to the parent of a child with complex communication needs. SLPs may support parent acceptance of AAC systems by using family-centred practices such as listening to parents, acknowledging their expertise and finding compromises.

Key word signing: Parents' experiences of an unaided form of augmentative and alternative communication (Lámh)

Parents' experiences of using Lámh, a key word signing approach used in Ireland, were captured through in-depth face-to-face interviews with parents of children with a range of intellectual disabilities. It emerged that Lámh provides child users with one of the rudiments of inclusion, that is, a means of engaging with others. A number of factors can potentially influence the engagement achieved, namely ongoing family commitment to the sustainment of Lámh, available communication partners, accessibility, appropriate Lámh training, speech and language therapy support and the existence of a Lámh signing environment external to the home. The child's family, education and community need to commit to Lámh in order to support a child user become an active member of their community.

An online community of practice to improve intervention for individuals with complex communication needs

Collaboration and information sharing are essential in the fast moving world of augmentative and alternative communication (AAC). This paper describes communities of practice, justifies their need in AAC, and introduces the Communication Matrix Community of Practice (CMCoP)-an online community of practice for professionals and family members supporting individuals at the earliest stages of communication development. Stakeholders share the goal of advancing language and communication intervention for individuals with complex communication needs. Features of the CMCoP include a community forum for discussing and sharing information; collections of posts by professionals and nonprofessionals on various topics; an events calendar of AAC-related activities relevant to stakeholders; and a shared science section offering portraits of the communication skills of various populations with severe communication disorders. The utility of these and other CMCoP features in supporting the implementation of AAC assessment and intervention strategies is discussed.

A systematic review of the barriers and facilitators to the provision and use of low-tech and unaided AAC systems for people with complex communication needs and their families

PURPOSE

Speech-language pathologists may introduce augmentative or alternative communication (AAC) systems to people who are unable to use speech for everyday communication. Despite the benefits of AAC systems, they are significantly underutilized by the people with complex communication needs. The current review aimed to synthesize the barriers and facilitators to the provision and use of low-tech and unaided AAC systems.  Materials and methods: Relevant literature was identified via a systematic search strategy. Included articles (n = 43) were evaluated using the Critical Appraisal Skills Programme. Qualitative framework analysis was then completed with reference to the International Classification of Functioning, Disability, and Health (ICF).  Results and conclusion: Most barriers and facilitators were coded as contextual factors within the ICF. Of most prominence were environmental factors, including attitudes of and supports provided by professionals, family members, and the society at large. Themes were also identified which related to the personal factors, including the user's own attitude, socioeconomic status, and culture. Beyond these contextual factors, the remaining codes related to body functions such as cognition and movement. There are numerous barriers to the provision and use of low-tech and unaided AAC systems, which may contribute to the inadequate use of these systems by people with complex communication needs. Suggestions for reducing these barriers are presented with regards to the person with complex communication needs, their family, and the professionals involved in their care. Implications for Rehabilitation AAC systems can reduce participation restrictions for people with complex communication needs. The provision and use of AAC systems is influenced by environmental factors, personal factors, and features of a person's body function. SLPs may need to collaborate with a large multidisciplinary team to successfully introduce AAC systems. SLP, teaching, and nursing students require theoretical and practical experience in AAC throughout their training to enable the provision and use of these systems.

Exploring Expressive Communication Skills in a Cross-Sectional Sample of Children and Young Adults With Angelman Syndrome

PURPOSE

This study explores data on expressive communication skills of 300 individuals aged 0.0-21.11 years with Angelman syndrome (AS). These data provide a composite portrait of communication skills in a large sample of children and young adults with this rare disorder, specifying new detailed information about expressive communication.

METHOD

The database associated with the Communication Matrix assessment (Rowland, 2004, 2011; Rowland & Fried-Oken, 2010) was mined for data regarding individuals with AS. We extracted data on the reasons for communicating, level of communication achieved, and use of various expressive communication modes to convey 24 specific messages. The performance of children and young adults in 5 age groups in the cross-sectional sample were contrasted.

RESULTS

Results confirmed earlier studies showing that few individuals with AS use natural speech. However, in addition to using presymbolic modes, many children used alternative symbolic modes such as picture symbols, object symbols, and manual signs. Assessment scores increased slightly with age, F(4, 295) = 2.416, p = .049.

CONCLUSIONS

Aggregating data on a large sample of individuals with AS provides a reference point for practitioners and family members and a basis for future investigations.

Gaze-controlled communication technology for children with severe multiple disabilities: Parents and professionals' perception of gains, obstacles, and prerequisites

The aim of this study was to explore parents' and professionals' thoughts of how a gaze-controlled computer can be beneficial to children with severe multiple disabilities. All systems were provided primarily for symbol-based communication, but were also used for other purposes such as play, leisure and school activities. A further aim was to investigate factors affecting usability, specifically for communication. The study used a qualitative approach, involving content analysis of semistructured interviews with the children's key persons (N = 11). The analysis yielded three categories and twelve subcategories. There were gains for the children in terms of empowerment, social interaction, learning opportunities and efficient computer use. Inaccessibility, liability issues and technical failure were seen as obstacles, while the prerequisites included time, collaboration, stimulating content, know-how and opportunities. To sum up, this study suggests that gaze-controlled technology can provide children who have multiple disabilities involving severe motor dysfunction and communicative and cognitive problems with new opportunities to communicate, interact and perform activities independently, as long as conditions are right.

Teachers' perceptions of implementation of aided AAC to support expressive communication in South African special schools: a pilot investigation

Although the provision of assistive technology for students with disabilities has been mandated in South African education policy documents, limited data are available on the implementation of aided augmentative and alternative communication (AAC) in classrooms. This pilot investigation used a concurrent mixed-methods survey design to determine the extent to which aided AAC was implemented to foster students' expressive communication in preschool to Grade 3 classrooms in special schools from six urban school districts in the Gauteng (the smallest, most affluent and most densely populated of the nine South African provinces), and also obtained teachers' perceptions of this process. A total of 26 teachers who taught students who used aided AAC for expression participated. Although there is evidence of provision and also implementation of aided AAC in classrooms, various limitations still exist. Teachers identified an array of factors that influenced the implementation of aided AAC, including those related to themselves, the classroom context, the characteristics of aided AAC, students using AAC, and other stakeholders. These factors are discussed in the light of international literature as well as the local context, and are used as a basis to suggest a research agenda for AAC in the South African education system.

Triangulated Proxy Reporting: a technique for improving how communication partners come to know people with severe cognitive impairment

PURPOSE

This paper explains and demonstrates the pilot application of Triangulated Proxy Reporting (TPR); a practical technique for enhancing communication around people who have severe cognitive impairment (SCI).

METHODS AND RESULTS

An introduction explains SCI and how this impacts on communication; and consequently on quality of care and quality of life. This is followed by an explanation of TPR and its origins in triangulation research techniques. An illustrative vignette explicates its utility and value in a group home for a resident with profound multiple disabilities. The Discussion and Conclusion sections propose the wider application of TPR for different cohorts of people with SCIs, their communication partners and service providers.

CONCLUSIONS

TPR presents as a practical technique for enhancing communication interactions with people who have SCI. The paper demonstrates the potential of the technique for improving engagement amongst those with profound multiple disabilities, severe acquired brain injury and advanced dementia and their partners in and across different care settings. Implications for Rehabilitation Triangulated Proxy Reporting (TPR) shows potential to improve communications between people with severe cognitive impairments and their communication partners. TPR can lead to improved quality of care and quality of life for people with profound multiple disabilities, very advanced dementia and severe acquired brain injury, who otherwise are very difficult to support. TPR is a relatively simple and inexpensive technique that service providers can incorporate into practice to improving communications between clients with severe cognitive impairments, their carers and other support professionals.

The Communication Supports Inventory-Children & Youth (CSI-CY), a new instrument based on the ICF-CY

PURPOSE

Two studies are presented that evaluated the Communication Supports Inventory-Children & Youth (CSI-CY), an instrument designed to facilitate the development of communication-related educational goals for students with complex communication needs (CCN). The CSI-CY incorporates a code set based on the ICF-CY. The studies were designed to determine the effect of using the CSI-CY on IEP goals for students with CCN and to evaluate consumer satisfaction.

METHOD

In Study 1, sixty-one educators and speech-language pathologists were randomly assigned to either (a) provide a student's current IEP (control group) or (b) complete the CSI-CY prior to preparing a student's next IEP and to submit the new IEP (experimental group). Study 2 was a field test to generate consumer satisfaction data.

RESULTS

Study 1 showed that IEP goals submitted by participants in the experimental group referenced CSI-CY-related content significantly more frequently than did those submitted by control participants. Study 2 revealed high satisfaction with the instrument.

CONCLUSIONS

The code set basis of the CSI-CY extends the common language of the ICF-CY to practical educational use for children with CCN across diagnostic groups. The CSI-CY is well regarded as an instrument to inform the content of communication goals related to CCN. Implications for Rehabilitation The CSI-CY will guide rehabilitation professionals to develop goals for children with complex communication impairments. The CSI-CY is a new instrument that is based on the ICF-CY for documentation of communication goals.

Eina! Ouch! Eish! Professionals' Perceptions of How Children with Cerebral Palsy Communicate About Pain in South African School Settings: Implications for the use of AAC

Most children with severe cerebral palsy experience daily pain that affects their school performance. School professionals need to assess pain in these children, who may also have communication difficulties, in order to pay attention to the pain and support the children's continued participation in school. In this study, South African school professionals' perceptions of how they observed pain in children with cerebral palsy, how they questioned them about it and how the children communicated their pain back to them were investigated. Thirty-eight school professionals participated in five focus groups. Their statements were categorized using qualitative content analysis. From the results it became clear that professionals observed children's pain communication through their bodily expressions, behavioral changes, and verbal and non-verbal messages. Augmentative and alternative communication (AAC) methods were rarely used. The necessity of considering pain-related vocabulary in a multilingual South African context, and of advocating for the use of AAC strategies to enable children with cerebral palsy to communicate their pain was highlighted in this study.

Communication intervention in Rett syndrome: a survey of speech language pathologists in Swedish health services

PURPOSE

To investigate communication intervention that speech language pathologists (SLPs) provide to people with Rett syndrome.

METHODS

A web-based survey targeting all Swedish SLPs working with people currently receiving support from habilitation services.

RESULTS

The SLPs reportedly followed recommended practice in the following aspects: (1) Information on communicative function was collected from several sources, including observation in well-known settings and reports from the client s social network, (2) Multimodal communication was promoted and, (3) Responsive partner strategies were largely targeted in the intervention. However, few instruments or standard procedures were used and partner instruction was given informally. Most SLPs used communication aids in the intervention and their general impression of using communication aids was positive. Further, augmentative and alternative communication (AAC) was estimated to increase and clarify communicative contributions from the person.

CONCLUSIONS

Communication aids were reported to have a positive influence on communicative functions. Swedish SLP services followed best practice in several aspects, but there are areas with potential for development. Tools and best practice guidelines are needed to support SLPs in the AAC process for clients with Rett syndrome. [Box: see text].