Evaluating the Impact of AAC Interventions in Reducing Hospitalization-related Stress: Challenges and Possibilities

Nurse perspectives on supporting children and youth who use augmentative and alternative communication (AAC) in the pediatric intensive care unit

Many children who require hospitalization in the pediatric intensive care unit (ICU) are unable to or have difficulty communicating through speech, whether because of preexisting or acute conditions. Children who are unable to be heard and understood using only speech benefit from aided augmentative and alternative communication (AAC), including in hospital settings. This qualitative interview study sought to understand the perspectives of nurses on care and support for children who use or would benefit from aided AAC in the pediatric ICU. Participants were six nurses who worked in pediatric intensive care at a tertiary care unit of a children's hospital in the United States. Three main themes were identified related to nurses' views about supporting children's communication: (a) Caring for the Whole Child, (b) Needing Support from Others and Moving between Roles, and (c) Working with Available Resources and Demands. Nurses emphasized the importance of a holistic approach to care, the impact of others' support and knowledge, and a desire for building greater capacity for promoting children's access to effective communication. Findings offer insight that could improve patient-centered care for children with complex communication needs and support for nurses themselves, particularly within the broader context of ICU liberation.

Exploring children's preferences for graphic symbols to represent pain-related words

Children who are hospitalized may sometimes not be able to communicate verbally to self-report their pain or other symptoms due to medical conditions, medical interventions, or communication difficulties. As such, these children may need other means, such as augmentative and alternative communication (AAC) strategies, in this case, graphic symbols, to express their pain-related experiences and receive applicable treatment. Choosing suitable graphic symbols to represent pain-related words contributes to the effective use and implementation of visual support. This study explored the preferences of 6.0-9.11-year-old (years; months) children with typical development regarding graphic symbols to represent pain-related words. These symbols were selected from two commonly used and widespread symbol resources: Picture Communication Symbols (PCS®) and Aragonese Portal of Augmentative and Alternative Communication (ARASAAC) symbols. A descriptive, quantitative study design was employed, including a total of 30 typically developed South African children. Data were collected by means of an electronic questionnaire and analyzed using descriptive and inferential statistics. Probability values were determined and predictions, as well as inferences, were implemented. The results showed that the children preferred ARASAAC symbols to represent most pain-related words (p < 0.001). It is important to consider stakeholders' (in this case, children's) input on their preferences in designing communication support to enable participation during the clinical decision-making process.

Child-health nurses' experiences from using pictorial support with families within child-health services in Sweden

AIM

To gain insight into child-health nurses' experiences of using pictorial support in health visits within child-health services.

METHODS

A qualitative study involving interviews conducted with 17 child-health nurses in Sweden. The interview data were analysed using content analysis.

RESULTS

The nurses experienced that pictorial support could facilitate communication with families and increase opportunities for children to participate in child-health services, although it may come with challenges. This theme can be broken down into three main categories: (1) Pictorial support makes interaction with families clearer and easier and is used in different ways; (2) The design and extensiveness of the pictorial support can create obstacles; and (3) Pictorial support influences children's attitudes towards, and participation in, health visits.

CONCLUSION

Pictorial support is an important and useful tool in child-health nurses' own work and improves their communication with children and caregivers during health visits. It can also increase children's participation and help them express themselves. Communicative tools such as pictorial support are very helpful to healthcare professionals striving to offer child- and family-centred care.

Anxiety among children a year after the onset of the COVID-19 pandemic: a Brazilian cross-sectional online survey

Aim

This study seeks to build upon a prior investigation into the impact of the COVID-19 pandemic and to evaluate the prevalence of anxiety among Brazilian children, along with its associated factors, one year after the commencement of the pandemic.

Design

A cross-sectional study.

Methods

A survey was conducted from April–May 2021 in Brazil. Children aged 6–12 and their guardians from five Brazilian regions were included. The Children’s Anxiety Questionnaire (CAQ; scores 4–12) and Numerical Rating Scale (NRS; scores 0–10) were used to measure anxiety.

Results

Of the 906 children, 53.3% were girls (average age = 8.79 ± 2.05 years). Mothers responded for 87.1% of the children, and 70.9% were from the Southeast region. Based on a CAQ score of ≥9 and an NRS score of ≥8, the anxiety prevalence was 24.9 and 34.9%, respectively. Using logistic regression, a CAQ ≥9 score was associated with older children and children with chronic disease or disability. An NRS score of ≥8 was associated with reduced family income during the pandemic, the person caring for the children, and with children with chronic disease or disability.

Conclusion

These findings suggest the need to implement public health actions aimed at children with chronic diseases and disabilities and their parents to guide them regarding the warning signs and negative emotions. This study contributes to characterizing the evolution of the pandemic in Brazil and provides a basis for comparison with the literature from other countries.

Supporting Children's Communication of Choices During Inpatient Rehabilitation: Effects of a Mobile Training for Health Care Providers

PURPOSE

Children with complex medical and communication needs often experience extensive or frequent hospital stays and rely on augmentative and alternative communication (AAC) strategies to communicate in this environment. Health care providers seldom receive training to effectively communicate with these children, which may lead to limited participation opportunities for the child during inpatient interactions.

METHOD

A pretest-posttest experimental group design was completed to evaluate the effects of a brief mobile training designed to teach providers a procedure to support children with complex communication needs to communicate choices. Each provider participated in two pretest and two posttest interactions with children with complex communication needs during naturally occurring inpatient activities. Providers in the treatment group completed the video training, whereas providers in the control group did not.

RESULTS

Following the training, (a) more providers offered choices to the children during hospital routines, (b) providers implemented the trained procedure with increased accuracy, and (c) the children with complex communication needs consistently communicated their choices when given the opportunity to do so. The providers rated the training as easy to use, effective, and suited to the needs of the inpatient setting.

CONCLUSIONS

This is the first AAC training designed to promote child-provider interactions in inpatient settings that demonstrates results that are efficient, socially valid, and effective in a real-world context. Future work is needed to develop additional brief and focused AAC partner trainings to teach providers to support the participation of children with complex communication needs in health care interactions.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.22029008.

A Scoping Review of Research Evaluating Physiological Information for Individuals With Developmental Disabilities: Augmentative and Alternative Communication Research Considerations

PURPOSE

Today, an ever-increasing number of technological advancements are becoming mainstream. As the availability of technological innovations increases, so do opportunities for evaluating any benefits of those innovations in augmentative and alternative communication (AAC) research for individuals with developmental disabilities. One innovation that has become mainstream is the use of noninvasive wearable technology to provide physiological information (e.g., heart rate, skin conductance). Such information could be valuable in AAC research, but more information about its potential feasibility and utility is needed.

METHOD

A scoping review was conducted to review and report on existing research that has evaluated (a) physiological information as a communication intervention tool for individuals with developmental disabilities and (b) the relationship between physiological information from individuals with developmental disabilities and behavioral and/or environmental information in real time.

RESULTS

Results revealed that, while little communication intervention research has been completed, descriptive research demonstrates that physiological information from individuals with developmental disabilities gathered using wearable technology corresponds meaningfully to observable environmental and behavioral events.

CONCLUSIONS

Future AAC research incorporating wearable technology to gather physiological information is warranted. Such research could evaluate potential benefits such as preempting challenging behavior with communication opportunities, signaling readiness for language learning, indicating AAC feature preferences, and expanding methodological approaches.

Child health care nurses' experiences of language barriers during home visits

OBJECTIVE

The aim of the study was to explore the communication tools that child healthcare nurses can use during home visits to families when language barriers exist.

DESIGN

Qualitative study using data collected from focus group sessions.

SAMPLE

Six semi-structured focus group interviews with twenty nurses in child healthcare services.

MEASUREMENTS

The results were analyzed with a thematic content analysis.

RESULTS

The analysis resulted in two themes: Using pictures as support in the conversation, with subthemes Not using pictures as support, Wanting to know how to use pictures as support, Pictures as support for invitations, Different types of pictures as support, and Alternative means of communication with the subthemes Possibilities of using an interpreter, Obstacles to using an interpreter, Mixed communication.

CONCLUSION

If language barriers are present during home visits, decision-making nurses in Child Health Care (CHC) put families in an unequal position when communicating with them. These results point to a need for more education, guidelines and support regarding alternative and augmentative communication (AAC) tools and structures to assist in overcoming language barriers.

Evaluating pictorial support in person-centred care for children (PicPecc): a protocol for a crossover design study

INTRODUCTION

This study protocol outlines the evaluation of the pictorial support in person-centred care for children (PicPecc). PicPecc is a digital tool used by children aged 5-17 years to self-report symptoms of acute lymphoblastic leukaemia, who undergo high-dose methotrexate treatments. The design of the digital platform follows the principles of universal design using pictorial support to provide accessibility for all children regardless of communication or language challenges and thus facilitating international comparison.

METHODS AND ANALYSIS

Both effect and process evaluations will be conducted. A crossover design will be used to measure the effect/outcome, and a mixed-methods design will be used to measure the process/implementation. The primary outcome in the effect evaluation will be self-reported distress. Secondary outcomes will be stress levels monitored via neuropeptides, neurosteroids and peripheral steroids indicated in plasma blood samples; frequency of in-app estimation of high levels of distress by the children; children's use of analgesic medicine and person centeredness evaluated via the questionnaire Visual CARE Measure. For the process evaluation, qualitative interviews will be carried out with children with cancer, their legal guardians and case-related healthcare professionals. These interviews will address experiences with PicPecc in terms of feasibility and frequency of use from the child's perspective and value to the caseworker. Interview transcripts will be analysed using an interpretive description methodology.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Swedish Ethical Review Authority (reference 2019-02392; 2020-02601; 2020-06226). Children, legal guardians, healthcare professionals, policymaking and research stakeholders will be involved in all stages of the research process according to Medical Research Council's guidelines. Research findings will be presented at international cancer and paediatric conferences and published in scientific journals.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT04433650.

'They get the opportunity to say what is important for them': exploring staff's early perceptions of the implementation of a new communicative approach to patients with aphasia

PURPOSE

This study explored the perceptions of staff members regarding the implementation of a new communicative approach at a multidisciplinary neurorehabilitation centre in Denmark. Communication partner training according to Supported Conversation for Adults with Aphasia (SCA^TM) was combined with augmentative strategies from the KomHIT programme to increase the influence of patients with aphasia on their own rehabilitation process.

METHODS

A qualitative approach was used involving two semi-structured group interviews with multidisciplinary staff in two wards. Three staff members from each ward participated. The recorded interviews were transcribed, and a thematic analysis of the data was conducted.

RESULTS

Three main themes emerged from the analysis. Participants reported increased influence of patients with aphasia on their own rehabilitation process, as well as an increased focus on communication with patients with aphasia. Challenges included time restrictions and dilemmas in goal setting.

CONCLUSIONS

Increasing staff knowledge of communication support and augmentative strategies seemed to improve the influence of patients with aphasia on their own rehabilitation process. Because the results were based on interviews with a small number of staff, they cannot be generalized and require further investigation that should also include interviews with the patients themselves and their families.IMPLICATIONS FOR REHABILITATIONThe combination of partner training with augmentative strategies may increase staff understanding of all individuals' rights to have their communicative needs met.The combination of partner training with augmentative strategies may support the influence of persons with aphasia on their own rehabilitation.Goal setting discrepancies between staff and patients with aphasia can be brought to light by more successful communication.The implementation of a new communicative approach can be challenged by a number of factors, e.g., time restrictions.The implementation process needs to be supported by actions on a higher organisational level.

The Use of Communication Technology to Affect Patient Outcomes in the Intensive Care Unit

Effective two-way patient-provider communication is challenging and is even more difficult when patients are communication vulnerable. The results of being unheard and unacknowledged can contribute to negative feelings and may manifest as symptoms of anxiety and depression. Researchers explored symptoms of anxiety and depression when using a team-developed, patient-centered, and nurse-led intervention called Speak for Myself-Voice (formerly published as Speak for Myself) in five intensive care units at a Magnet status, university-affiliated medical center in East Tennessee. This was an equivalent control group design. The data were analyzed with a mixed-effect analysis of variance (between and within groups) with repeated measures to see if the treatment group changed differently than the control group across time (48 hours). This study report adds information about anxiety and depression in patients who are communication vulnerable and using communication technology.

Children's Anxiety and Factors Related to the COVID-19 Pandemic: An Exploratory Study Using the Children's Anxiety Questionnaire and the Numerical Rating Scale

The repercussions of the COVID-19 pandemic on children's lives deserve attention. This study aimed to assess the prevalence of anxiety among Brazilian children and its associated factors during social distancing during COVID-19. We used a cross-sectional design with an online survey from April to May 2020 in Brazil. We included children aged 6-12 years and their guardians. The Children's Anxiety Questionnaire (CAQ; scores 4-12) and the Numerical Rating Scale (NRS; scores 0-10) were used to measure anxiety. We enrolled 157 girls and 132 boys, with a mean age of 8.84 (±2.05) years; 88.9% of respondents were mothers. Based on CAQ ≥ 9, the prevalence of anxiety was 19.4% (n = 56), and higher among children with parents with essential jobs and those who were social distancing without parents. In logistic regression, the following variables were associated with higher CAQ scores: social distancing without parents; more persons living together in home; and education level of guardians. Based on NRS > 7, the prevalence of anxiety was 21.8% (n = 63); however, no associations with NRS scores were found with the investigated variables. These findings suggest the necessity of implementing public health actions targeting these parents and their children at the population level.

Using Visual Supports to Facilitate Audiological Testing for Children With Autism Spectrum Disorder

Purpose One in 59 children is diagnosed with autism spectrum disorder (ASD). Due to overlapping symptoms between hearing loss and ASD, children who are suspected of having ASD require an audiological evaluation to determine their hearing status for the purpose of differential diagnosis. The purpose of this article is twofold: (a) to increase audiologists' knowledge of ASD by discussing the challenges associated with testing and interpreting clinical data for children with ASD or suspected ASD and (b) to provide visual supports that can be used to facilitate audiological assessment. Method Eight children (ages 4-12 years) were recruited as video model participants. Videos were filmed using scripts that used concise and concrete language while portraying common clinical procedures. Using the video models, corresponding visual schedules were also created. Conclusion Although obtaining reliable hearing data from children with ASD is challenging, incorporating visual supports may facilitate testing. Video models and visual schedules have been created and made freely available for download online under a Creative Commons License (Creative Commons-Attribution-NonCommercial-ShareAlike 4.0 International License). Incorporating visual supports during clinical testing has the potential to reduce the child's and family's stress, as well as to increase the probability of obtaining a reliable and comprehensive audiological evaluation. Future research is warranted to determine the effectiveness and feasibility of implementing these tools in audiology clinics. Supplemental Material https://doi.org/10.23641/asha.10086434.

Implementation of pictorial support for communication with people who have been forced to flee: Experiences from neonatal care

A first attempt was made to introduce picture-based communication at a Swedish neonatal ward to facilitate communication with immigrant patients having fled their country of origin. Six members of staff were interviewed about their experiences using semi-structured dyadic interviews. Their answers were analysed using inductive content analysis, and the results were related to a theoretical framework called Promoting Action on Research Implementation in Health Services. The staff found the pictures to be helpful in communication with refugees. They were motivated to use the pictorial support and experienced a great need for it. Two key prerequisites for successful implementation were identified: receiving training and having a person formally in charge of the implementation process.

Children's Perceptions of Pictures Intended to Measure Anxiety During Hospitalization

Many children experience anxiety during a hospital stay, which can have an adverse impact on their recovery and response to future hospital care. To facilitate assessment of anxiety in young children and children with communicative disabilities, the short S-STAI (short version of the State scale of the State-Trait Anxiety Inventory), has previously been adapted to a visual format. The aims of the present study were (a) to validate the pictures used to represent emotions and the steps of a quantitative scale ('a lot' - 'some' - 'a little'), including to determine whether any of them should be replaced, and (b) to assess different pictures to be used for a qualitative scale ('good/like' - 'in between/so-so' -'bad/dislike') in the same instrument. A total of 103 children aged 5-8 years were asked to choose verbal labels for pictures of facial expressions intended to represent emotions, match those pictures with the emotional categories used in the short S-STAI (Tense/Nervous, Worried/Afraid, Calm/Relaxed, and Happy/Content) and indicate their preferences for pictures intended to represent the steps of a quantitative scale and a qualitative one. The children understood both scales and the differences between positive and negative emotions in the short S-STAI. The older children (aged 7 and 8) significantly more often chose a picture for each step of the scales that was intended to represent that particular step. The article discusses implications for the choice of pictures representing emotional states in the short S-STAI and presents recommended pictures.

Using Picture and Text Schedules to Inform Children: Effects on Distress and Pain during Needle-Related Procedures in Nitrous Oxide Sedation

During hospital visits, children often undergo examinations and treatments that may involve an experience of pain and distress that is also connected to the staff's treatment. The United Nation's Convention on the Rights of Persons with Disability advocates the use of Universal Design. One way of implementing this idea within paediatric nursing is to increase the use of pictorial supports, and the few studies that have been published show promising results. The aim of this study was to do a comparison between two groups of children in regard to the pre- and postconditions of implementing an intervention including staff instruction and the use of pictorial support. The support consisted of a visual schedule with pictures and text, used both preparatory to and during the hospital visit. One hundred children aged 5-15 (50 children during the preinterventional data collection and 50 children postinterventionally) reported pain intensity and distress during needle-related procedures in nitrous oxide sedation. The results showed that the intervention had a positive effect in significantly lowering the level of preprocedural distress. The results showed that the pain intensity was also lowered however not reaching statistical significance. This confirms other positive research results on the use of visual supports within paediatric care, a topic that has to be further studied.