assignment

By Rachael Skinner,Pati King DeBaun

Pati King-DeBaun, M.S. CCC-SLP, is a Speech Language Pathologist/Consultant specializing in assistive technology, Creative Communicating, Park City, UT. She is also the Consulting Director of Communication and Literacy for Standing Tall.

Rachael Skinner holds a Bachelor’s Degree in Conductive Education from the University of Wolverhampton and a Bachelor’s Degree in Biological Science and

Jumpstart AAC For Students with Severe and Multiple

Disabilities

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Teaching from the University of Lancaster. She has worked as a conductor in a variety of locations in the USA and was responsible for establishing a Conductive Education program for March of Dimes Canada in Nova Scotia, Canada. She is currently Director of Programs at Standing Tall Inc., a private Conductive Education and Communication school in Manhattan, NY.

A transformation is going on at the Standing Tall Program, a private school in New York City. Students, parents, teachers, therapists and administrators are all very excited about the new opportunities and learning that are happening. Imagine five students with severe physical impairments, nonspeaking , who have had cognitive skills questioned over and over and have never had the opportunity to use any communication system (high tech or light tech) having conversations, participating in curriculum activities, independently generating 4- to 5-word sentences, publishing a newsletter, writing scripts for plays, emailing, skyping and talking on the phone to parents. Two years ago that was not the case.

This brainstorm project came from Elizabeth Dellureficio, a Board Member of Standing Tall and parent. At the time, it was primarily a conductive education program that focused on the motor development of their students. Frustrated and worried about the lack of communication, lack of success in acquiring high-tech systems and the increasing age of their students (9-14), the Board decided to create a supplemental program, called the Communican Program, that would focus on developing communication and literacy skills for the students. Pati King-DeBaun, M.S. CCC-SLP, was hired as a consulting Director of the Communican Program and worked closely with Rachael Skinner, the Director of Standing Tall. Pati’s vision was simple – everyone can communicate and will communicate. Giving students who had never had a communication system a complete comprehensive communication system seemed like a "leap of faith" says Rachael Skinner, Director and key instructor of the Communican Program. The Light Tech Communication Book (from Creative Communicating), which consists of approximately 75 pages that address conversation (social skills), spelling, core phrases (literacy skills) and core word lists ( language skills), was used. Pati’s approach was a little unconventional and daunting. "Everyone is going to learn how to use the system at the same time – teachers, students, paraprofessionals and therapists. You just have to believe." said Pati.

Background and Philosophies

Research data presented by Kearns, et.al in 2001, involving over 13,000 students nationwide

who participated in alternate assessments (students with the most significant disabilities) indicate that up to 40 percent of such students are not using symbolic communication, There is no statistically significant movement toward symbolic communication across the grade band, from elementary to high school, in most states surveyed, and 50 percent or less of students who should have AAC in place actually have AAC in place. (The term AAC in this article refers to symbol-supported learning, not just high-end devices.) This is a critical concern for many students who need support with communication. Systematic instruction must be present in order for students to learn how to communicate, regardless of what the perceived cognitive abilities are.

Language is often presented at a micro level rather than at a macro level. There is a misunderstanding about what communication is and what language is. Children communicate very early through cries, turn taking and babbling. Even within in the first few months, infants learn the power of communication through their behavior. Communication is the exchange of thoughts, messages or information by speech, visuals, signals, writing or behavior that is not standard and is interpreted by the listener. Language is a standardized set of rules that both the listener and speaker understand. You have to know Spanish to speak Spanish, French to speak French, English to speak English, etc.

The belief that all children do communicate and will if they are given an opportunity is critical for students who have severe and multiple disabilities.

The approach we used is called the Integrated Model of Communication. If AAC instruction is taught with a language-first approach, then skills are taught in isolation, teaching comprehension ("show me" and "touch the" type of activities) and moving on to communicating with single words, putting words together, etc. In some situations, the concept of communication or teaching the skill of communicating is not taught and literacy comes last, as language skills are proven. Learning in isolation fragments communication and, often, one or more component of communication is underserved. Many students who fall into this learning situation never receive the opportunities to show their skills or communicate their skills and thus continue to be mislabeled and underserved. An integrated communication model that focuses on balancing the three major areas of instruction – literacy, social (conversation) and linguistic (language) skills for successful communication – is the foundation of this program.

Who are the students?

All of the students in the Communican Program have severe physical disabilities and are nonspeaking. The target classroom had students ages 9 through 14. Cognition for all students has always been questioned because of the students’ access issues. At the start of the program, none of the students had a communication system (that they were using). No students in the program had ever been approved for an AAC system. Time and time again, students were not approved by the District AAC team because they were unable to prove their skills. Students had access to Picture Communication Symbols for learning activities, however, the symbols would be randomly presented and used at the discretion of the teachers. Students primarily used Yes and No responses for communication.

However, in the initial observations, many of the students did not have a clear yes and no, and interpretation of the yes and no was left up to the facilitator. Access was also an issue; reliance on the use of hands was overemphasized so almost all of the children had no independent access to computers and technology. The most consistent form of communication that was used regularly was a Step-by-Step Communicator that was used primarily for messages from home to school and students still needed assistance in using the Step-by-Steps. The students were initially given the Augmentative and Alternative Communication Profile (Tracy Kovach, 2009). In the majority of the sections on the test, students scored a 0, with the exception of cognitive understanding. It should be noted, however, that students were unable to show skills in many of the areas because they had no reliable access.

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The class participating using the CLAP book with their teacher.

A Best Yes

First, all of the students in the classroom needed a "best yes" to navigate the communication system. Assisted scanning was used with all students as their primary method of communicating with the books.

When using assisted scanning, the communication partner says each choice out loud for the student and the student is asked to look and listen to their choices. Initially, students were first presented with all their choices on a page and then asked to make a choice, so they knew their choices before selecting. The student’s best yes was used to communicate "That’s the one I want." The partner would speak for the student, in class, as if it were the child speaking. Through guidance, students were taught how to navigate the communication system. This was critical as the books themselves were considered a stepping stone to a higher tech communication system. All elements in the book could be reached from the start page. It was important that the student’s "best yes" came directly from them. It could not be something that was given to them by a teacher or communication partner. It had to be the most natural and simple response for them to produce. In the past, the students capable of producing a movement or sound to indicate YES did so, but were also required to have a NO. Those students who did not automatically come up with their own movement or sound were assigned one by facilitators.

We wanted the "best yes" to be the easiest movement that the student could produce. We did not want the physical effort of producing a "best yes" to interfere with the

cognitive skill of responding. More importantly, we wanted the choice to come from the student. We wanted the students to take responsibility for their response and to feel ownership of it. Giving the students control over their own expressive output made a huge difference in the level of participation and the amount of communication we began to see.

The othercrucialaspect that was introduced, or rather removed from theoriginalprogram, was the need for a negative response. Non-response became the NO and thestudentsonly needed to be able to produce a YES. This simplification meant that the students could think less about the physical or vocal complications of responding and focus more on what their response was.

Through guidance, students were taught how to navigate the communication system. This was critical as the books themselves were considered a stepping stone to a higher tech communication system. All elements in the book could be reached from the start or home page and could navigate to other areas of the book.

Facilitation

Rather than having extensive workshops, in a typical trainer session, the lead teacher, Rachael, received scripted lessons on how to introduce the book and use it and specifics on how to communicate with the students. The scripted lessons for communication and later literacy and language lessons came from Teach Me AAC (Creative Communicating). The program is an online interactive course for children using AAC and their instructors. Additionally, one time per month for a week, Pati visited the class and did hands-on coaching and mentor teaching. Collaborative effort was essential to the project’s success. A continuous cycle of planning, implementation, reflection and planning again helped all staff, paraprofessionals and teachers modify and make adjustments.

Scripting

Scripting and instructional lessonscentered around the The Light Tech Communication Book, now called the CLAP Book (Conversation, Literacy, Access and Participation). The best method for providing instruction to staff was through scripted lessons and activities that were used in the Teach Me AAC class.) The classroom teacher had no experience teaching AAC and the paraprofessional staff had no experience using a system as extensive as The CLAP Book. Using a scripting and coaching method streamlined the visits so focus could be on the students and time in the classroom could be used to coach staff, as necessary, within real learning activities.

Student communicating with the CLAP book

In the first eight weeks, a conversation-first approach was taken where the students/lessons were primarily focused on the "conversation" or social portion of the communication book. Aided Language Stimulation techniques (Sevcik & Romski,1986; Goossens’, Crain, & Elder, 1992; Namy (2001); Namy, Campbell & Tomasello, 2004; Barton, Sevcik & Romski, 2006) were infused into the scripts and used to model communication. The purpose of the lessons was to teach the power of communication to the students, teach the teaching and paraprofessional staff how to use the books from presentation to navigation and teach the students how to navigate the books. During this period of time, it was critical that teachers followed the script. After that, teachers seemed to learn the teaching language and could veer from the scripts. Scripts were used again when new academic lessons, such as language, literacy and curriculum activities were introduced.

The scripts demonstrate to teachers how to respond to the students’ output in the same way they would respond to any student who wascommunicatingwith them. They also show teachers how to stopcuingtheir students and leading them in specific directions. This can be hard to do at first, and there’s always the worry that therewill befailure. However, due to the structured nature of the scripts and the lessons, there is no failure. Using the "best yes" meant that the students were able tocommunicatewith much more ease and so they did. As their confidence grows and as they learn that people are responding to them, they begin to think even more about what they arecommunicatingand by the time the curriculum is well underway, we are seeing more independent interaction and more successful and accurate interactions than ever before.

Access

In this classroom, none of the students could use their hands functionally, and alternative access methods were being pursued, such as switch access and eye pointing, when we started. Judy Lariviere, M.Ed., OTR/L, was brought into to work with Pati to assess access for each student. In what they called the "Switch Makeover," Pati and Judy spent two intensive days looking at the best access, positioning, etc. so that students could begin to functionally use a switch to access the computer for language- and literacy-based activities and begin to develop some consistent switch skills. Once the access site was discovered, the students used their switch to say "yes" when participating in activities.

Outcomes

As students’ access skills improved, we began using the Light Tech Communication within Speaking Dynamaically Pro (Dynavox/Mayer Johnson) on classroom laptops. As trials with systems began, we simply imported the pages into the system of the devices – Communicator Software ( Tobi), ECHO (PRC software) and Dynavox. We found that the transition from the light-tech book to the electonic book was incredible. Students knew how to navigate and were familiar with the communication pages within the system. Almost immediately, students were able to communicate unique thoughts, participate in conversations and use core sentence starters to communicate unique ideas. Three out of four of the students in the initial classroom were approved for AAC devices and one student was pending due to an illness. These approvals were based on the success they had with their trials and using the electronic portion of the books with devices. It should be mentioned however, that although students all had an electronic version of the light- tech book on either a dedicated AAC device or a laptop, we still continued to used the light-tech book, CLAP .

The results of post-testing using The Augmentative Communication Profile (Kovack, 2009) were impressive; all students scored at a level 3, being able to generate two- to five-word sentences, independently navigate through the system, initiate conversations, express unique thoughts and ideas, consistently have three- to four-part conversations, communicate emotions and feelings and participate in beginning literacy activities, such as spelling simple words, developing a sight word vocabulary, partner reading books and participate in generative writing activities.

Student using the CLAP book on her new AAC device

One student began using eye pointing midway through the first year. Her progress was staggering when she trialed an eye pointing device. On the second day into the use of a trial eye pointing system, she was able to carry on phone conversations with her teacher and mother, having timely interactions, initiating conversation, conversational turns, asking questions, responding appropriately to the questions and expressing emotion, all within in a three-minute time period. Another student, using single switch scanning on her first trial with the electronic version of the book, was able to tell us that she was frustrated and mad because she did not get to go swimming and all the other kids got to go. Nobody had explained to her what was going on. She was persistent in telling us how she felt and demanding an explanation, even though we tried to guide her in a different direction. Numerous accounts of these little moments began to happen on a regular basis and trickle in from parent and paraprofessional testimonials.

Students progressed in all areas and, as the program has grown, so have both their literacy and language skills. Students are successfully emailing to families, writing scripts for class plays, publishing a monthly newsletter and writing in journals. Students continue to progress in the area of generative language. Below is a sample email conversation between between a mom and a student. This email exchange was 18 months into the program.

Key: underlined text -generative language independent (in parenthesis) – Modeled Italic- using system phrases independent

On Feb 27, 2012 at 11:35AM, Nika D wrote:

Hi Mom, I had (on) black pants I want talk Aunt Phyllis. I want Aunt Phyllis read. I am fast, slow, quiet loud. My nose hurts. Stomach OK. I love you.

Mom responding >Hi Nika I love you too!!!! I hope your nose feels less stuffy soon. I am glad your tummy is feeling OK today. Should we call Aunt Phyllis later? I know she misses you so much. I really love getting emails from you. It makes me happy to read them. Love, Mommy

Nika responding < Mom I want a hug. Talk to you later. Nika

The Communican Program Today at Standing Tall

The students of the original target classroom continue to grow and learn, participating in more academic-based work and literacy work. Students are now showing their individual strengths and weakness so the teachers can better individualize their instruction. Another Communican class has formed at Standing Tall using the model and continues to show equal progress as the first class. This coming year, younger students, kindergarten age, have entered the program and we are very excited to again be able to contribute to their communication growth and watch their communication blossom.

Discussion

The idea of focusing on the macro aspects of communication first, "conversation/social" rather than language instruction (words/grammar), proved to benefit the students

within the Communican program at Standing Tall. The ability to participate in social conversation affected not only the students’ perception of themselves as effective communicators, it affected the willingness of communication partners (paraprofessionals, teachers, family) to engage AAC communicators in conversation. Once the partners believed that the students were truly communicating, it became the tipping point for an explosion of communication interactions and opportunities. The students were empowered to learn and communicate more because of their new-found success.

Students were more likely to participate in more challenging tasks, such as developing literacy and language skills. As the researchers Ritcher, Ball, Buekelman, Laser & Ullman (2003) have found, successful social interactions hinge largely upon the attitudes and perceptions that communication partners hold of one another. Similar studies (Beck, Bock, Thompson, & Kosuwan, 2002; Beck, Fritz, Keller, & Dennis, 2000) have focused on peer interaction with AAC partners with similar results . If AAC is to be implemented successfully, the techniques and devices must be accepted by both the individual requiring the supports and those who will serve as communication partners. We have found that creating an environment where individuals who use AAC are able to succeed, especially in social situations, enhances their overall learning. Once students began communicating unique ideas and thoughts, the staff became excited and more motivated to communicate with the students.

Parents become more interested and more willing to come to school and observe and then wanting to communicate with students at home. As students began to view themselves as successful communicators, their willingness to communicate more and learn more starts to grow at an exponential rate. More cognitively challenging tasks, such as literacy and curriculum activities, become more exciting and fun for the students. Having the right tools in place (light- or high-tech), having the instructional strategies to support those tools, focusing on the conversational interactions first and then balancing the instruction to specifically teach literacy and language skills have proved critical in this situation. As a result of implementing these elements, everyone begins to believe that the students can and will communicate and then it becomes a reality.

Resources

Teach Me AAC : Online Interactive Instruction for Students and Teachers. www.creative communicating.com

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CLAP Book Conversation , Literacy, Access and Participation www.creativecommunicating.com

Augmentative & Alternative Communication Profile ( Tracy Kovach, 2009) Linguisystems. Step by Step Communicator, AbleNet

To view videos and learn more about the Communican classroom visit the http://teachmeaac.blogspot.com/ Teaching AAC: Reports from the Classroom

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