Creating Communication Opportunities for Students with Complex Needs

Screen Shot 2018-09-19 at 12.34.35 PMIn August, I had the distinct (and more than slightly scary) opportunity to participate in my first podcast.  The topic was “Creating Communication Opportunities for Students with Complex Needs,” and the interviewer was Char Boshart, SLP extraordinaire and creator of Speech Dynamics , where Char shares her endless wealth of knowledge on all aspects of articulation and school-based therapy (more on her later).  The podcast was made for SpeechTherapyPD.com and will be aired at 7 PM on October 4, after which I will be live to answer your questions.  My jitters were understandable, given it was the first time I was interviewed and recorded, but I was quickly put at ease by Char, who, among many other talents, is an excellent interviewer.  I am also fortunate to call her my friend and mentor, having established a connection through workshops and the web over the years.

So, how did it go?  Well, I guess, given this was my first time, it went rather well. For one thing, all of the technology worked, so that was a huge relief!  It was weird, I must say, sitting at my dining room table with a laptop, headset, and elaborate microphone on a stand (thanks to my son, a professional musician). But we eased through all that to get to the discussion at hand:  how to get students who have significant communication impairments to communicate more.  I have done 3-day team trainings on this very topic, so you can imagine that I had to jettison a lot of information to fit into the 50-minute format.  There is so much excellent information out there regarding presuming competence, aided language input (modeling), considerations for AAC system and vocabulary selection, expanding messages using core and fringe vocabulary, and ways to measure the efficacy of an AAC system, that I figured the podcast listeners didn’t need to hear me spout more of the same.

Instead, my focus was on how to change adult behavior and intervention strategies to increase a student’s participation in and communication during daily routines.  I chose this focus because I find that adult behavior can be the #1 barrier to communication for our students with complex learning needs.  This barrier manifests itself in a number of ways:  low expectations of the student’s abilities;  a focus on what a student can’t do, rather than finding ways to enable him so he CAN do;  a lack of training with instructional assistants;  instruction that follows the traditional teacher-led agenda, rather than taking the lead from and building on the students’ interests;  a lack of routines that have a clear beginning, familiar steps, and a clear ending;  a mismatch between the adult’s spoken message and body language, facial expression, and tone of voice, and a lack of awareness of how important these nonverbal cues are to a student; characteristics of adult behavior that have the unintended consequence of creating passivity and learned helplessness (or, at times, aggression); failure to recognize behavior as communication;   and — one of the most important, in my view — inconsistent or absent use of pausing with a prompt hierarchy.  Pausing is a challenge for most adults, even well-trained SLPs, and we often do not give the students time to process, formulate a response, and then deliver that response in a way that is understood by others.  The use of a prompt hierarchy with pausing keeps adults aware of how much assistance they are providing by moving from a least-to-most progression of prompting, which, in turn, promotes an increase in student independence. As mentioned in the podcast, videotaping and then viewing the interactions of adults and students can be extremely powerful in raising awareness in adults of their interactional style.

For those adults who are resistant, for one reason or another, to a student’s use of an AAC system (yes, there are adults like that; I see them all the time, and that is a BIG barrier), I recommend an assignment I gave my graduate students when I taught in the special education departments of two colleges:  be absolutely silent for 24 hours.  You can tell people ahead of time that you will be doing this.  You can wear a tag that says “I can’t talk today.”  You can use any other means to communicate (text, paper/pencil, sign/gesture), but you cannot talk.  It’s important that the 24 hours include typical activities of daily living — work, social activities, errands in the community.  Without exception, my grad students were profoundly shocked by their own experiences and the behaviors of family, friends, colleagues, and community members during this experiment.  And, without exception, I’m sure that each of these grad students changed their perceptions as to the importance of AAC and the need to break down barriers to its use, largely through making changes in adult behavior and expectations.

Throughout the podcast, which seemed to pass by so quickly, I tried to provide real-life examples and suggested two books with a powerful message for anyone who interacts with children or adults who have severely limited expressive communication:  “My Stroke of Insight” and “Ghost Boy,” both previously mentioned in previous posts and in my post, “The Therapy Voice.”  I also touched on the importance of scripting routines to be sure that (1) communication opportunities are built into each daily routine, including transitions, and (2) that routines are done consistently, no matter which team member is involved.  Other important points I hope got through, albeit briefly:  how to move beyond choice-making to include all functions of communication and the importance of visual supports for receptive and expressive communication.

What I didn’t have time to share are some amazing resources for ways to build and expand communication in routines and how to help all team members to become more effective facilitators of expressive communication.  Below are some of the resources that I encourage you to explore and share with your team (hint: a great way to spend your next PD day!).   You’ll notice that PrAACticalAAC is referenced often — an incredible wealth of information that I’m barely touching on here!

Autism Classroom Resources:  Functions of Communication and How to Expand

Autism Teaching Strategies:  Free social skills materials

Autism Teaching Strategies:  Visual supports to build appropriate non-verbal behaviors

PrAACticalAAC:  Using Video to Teach Vocabulary

PrAACticalAAC:  Scaffolding language

PrAACticalAAC:  S’MORES and Partner-Assisted Input

PrAACticalAAC:  Be the FUN in FUNctional Communication (goals and spreadsheets)

PrAACticalAAC:  Selecting and teaching new words

PrAACticalAAC:  Creating communication opportunities for the older learner

PrAACticalAAC:  Autism and AAC:  5 Things I Wish I Had Known

PrAACticalAAC:  Supporting Reluctant Communicators

PrAACticalAAC:  Using Aided Language Input to Build Communication Opportunities (scripting)

PRC AAC Language Lab:  yearly subscription, plus free resources, Language Stages and goals for teachers and SLPs, activities for parents

Kidz Learn Language Blogspot:  games with core words, summer activities and much more

AAC Intervention Tips of the Month from Caroline Musselwhite

Saltillo’s Chat Corner:  ideas for Saltillo speech-generating devices, but that also can be used by any AAC system

Keep Talking by Call Scotland:  a 70+ page book that you can download -free! – full of ideas on how to increase communication throughout the day

News-2-You and Unique Learning System:  lots of ways to build communication around these subscription-based materials

Using Video to increase communication:

 

Increasing communication with peers:

Thank you for all you do to support the communication needs of our complex students!  I hope you enjoy the podcast on Oct 4 and will look forward to talking with you at its conclusion.  Please visit SpeechTherapyPD.com for more information.  Stay tuned to this blog for upcoming posts on the amazing resources offered by Char Boshart and the use of LessonPix for visual supports.

Advertisements

Why try AAC? He’s verbal!

Every year I receive parent-initiated referrals for AAC consideration, but when I consult with the school-based team I’m told “He’s verbal. We understand everything he says.”  In probing further, it is revealed that the student’s utterances are very short (1-3 words) and are only to request a few highly preferred items. So while intelligibility is good, expressive language is very limited.  Would providing a form of AAC help to increase the quantity and quality of the student’s expression?  That’s really what the parents are asking us to explore. In addition, I want to know if changes in the environment and adult interaction style will prompt improvement in the student’s communication skills.

tally_marks-five-bar_gate-svgThe first step is to get a solid measurement of the student’s spoken language.  For this purpose, I created a simple form that can be used to gather baseline data.  In the first column, the data collector makes a tally mark each time the student speaks, entering that mark under “initiated” or “response/prompted.” The data collector then rates each utterance as “intelligible” or “not intelligible” and “meaningful” or “not meaningful.”  The data collector can write some examples of the student’s spoken messages on the back of the form, along with any anecdotal information that might be helpful in analyzing the effectiveness of the student’s verbal communication.  My Intelligibility Tally form is available as a free download at the Materials Exchange on Speaking of Speech.com.

The second step is to look at the communication mode(s) the student uses and the environment in which he communicates.  Are there many and varied opportunities for communication (see my post about using “colorful language”), or are opportunities limited to stimulus/response interactions, such as making choices?  Does the team employ a consistent least-to-most prompt hierarchy with adequate pausing to allow for initiation and response? When given opportunities to communicate, does the student have the means to do so, or are supports needed so the student can communicate effectively?  Those supports can take the form of programming messages into a speech generating device, providing sentence strips or other visual representation of language, teaching needed words or signs, adult modeling of expressive interactions, and multiple opportunities to practice in a functional context.

To help teams become more aware of the need to provide both the opportunity and the means of communication, I created an Activity Analysis form, also available as a free download at the Materials Exchange on Speaking of Speech.com.   This form enables teachers and SLPs to look at each activity in the school day in terms of communication partners, mode and functions of communication, the expected messages the student may convey in each situation, and whether or not the student has access to and the ability to use the needed messages.  It can be quite illuminating when the team thinks through a daily routine and realizes that either there are no opportunities for communication, or that those opportunities are very limited in number and function. I encourage the teacher and SLP to use this analysis as a jumping off point for collaboration to raise expectations of the student, increase opportunities for communication, broaden the functions of communication, widen the student’s circle of communication partners, and develop the supports the student needs to be a more effective communicator.  Scripting activities and posting reminders to the team about prompting and pausing can be very helpful when implementing changes to activities and adult behavior.

When adjustments are made to the daily activities based on the Activity Analysis, teams should use the Intelligibility Tally again to see if there has been an uptick in self-initiated, intelligible, meaningful verbal output.  If sufficient improvement is noted in the student’s verbal communication, the team (including parents) may realize that changes in routine, the dynamic of adults’ interactions and expectations, and/or the training and implementation of supports already in place are key to increasing the student’s expressive communication skills.  If these changes aren’t sufficient, various forms of AAC can be tried and measured systematically, providing a comparison of aided and unaided communication. Even with ample opportunities to communicate, it is quite possible that, although verbal and intelligible, the student cannot access the words he needs without some form of visual or auditory support which AAC can provide.

 

“No Useful Moves Detected”

SolitaireTo keep my mind sharp in those rare moments of down time (never at school, I assure you!), I like to play Solitaire on my iPad.  Maybe it’s the need to organize things that attracts me to the game, or maybe it is the quickness of the outcome;  win or lose, a game never takes more than 3 minutes, often much less than that, and that’s often all the down time I have!

As I play, I pay attention to the cards.  If I hit a wall, I may “undo” my moves until I get to a place where I can make a different choice.  I may simply replay the game, remembering where I went wrong and seeing if playing a different card yields a different outcome.  If nothing works and I get the dreaded “No useful moves detected” message, I try to figure out which cards remain hidden, as they are the key to the game’s solution.  And oh, what momentary and silly delight, when I beat my best time or number of moves!

In many ways, I view therapy in the same way.  Students come into my room with the cards they were dealt, some more disorganized than others.  As we go through therapy, be it artic or language, I proceed in a methodical manner, always watching for the outcome of each move.  It is truly joyful when a student’s system becomes organized, especially when this happens in the fewest sessions possible.  It is truly frustrating when we hit a wall in therapy.  That’s when I need to step back an analyze the situation to determine what “cards” need to be uncovered for the student to become successful.

  • Did I give enough background knowledge and training in the desired skill, or did I jump to therapy techniques and materials without a solid foundation of understanding?  This occurred with several students in Learning Support who were having difficulty with auditory comprehension and couldn’t reliably answer “wh” questions about story details after hearing a story of 3-5 sentences.  Practicing this each week wasn’t having much positive effect, so I backed up, designed a graphic organizer, and asked them to note the “wh” info from a single sentence.  Holy smokes!  That was the problem!  They weren’t able to organize and relate the information to the “who, what, when, where, why” at the sentence level.  Once we practiced this in therapy (and I shared this strategy with their special education teacher), the students gained proficiency at the sentence level, and THEN we could move on to one, then two, paragraphs with more complex graphic organizers.  The same goes for parts of speech, grammar forms, and various aspects of vocabulary:  sometimes we need to start back at the beginning in order to move the students ahead. “Never assume!” is my mantra.
  • Have I provided sufficient auditory, verbal, visual, and tactile instruction?  Maybe I  skipped over critical steps.  Do we need to revisit the “speech helpers” lesson and manner/place/voicing for target sounds? Is more time needed on auditory discrimination? Would going back to the sound/syllable level help them move on to more successful productions at the word and phrase levels?  Should we bring back the mirror and flashlight, VowelViz or other visual apps, the “speech gizmo” or other tactile cues, or search for other strategies to build on?  Standing up and/or squeezing a stress ball to increase muscle tension; lying over the bed in the nurse’s office to let gravity pull that tongue back; using PVC “speech phones” to increase auditory feedback; recording and playing back video to improve self-awareness; using mouth puppets, posters, drawings, and gestures to cue desired targets and movements;  making Silly Putty tongues:  all of these ideas came from Internet and therapy book resources or were born from an “aha” moment when what we were doing simply wasn’t working.
  • Am I giving sufficient descriptive feedback?  It’s not enough to tell students they made the sound or answered the question correctly.  We need to tell them what they did to get to that correct production or response; this will ensure the student’s foundation is solid and the chances of repeated and more advanced successes are high.
  • Have I given the student ownership of his or her therapy process and outcomes?  Do the students have clear understanding of their goals? Do they know what successfully meeting the goals will look like?  Do they know where they presently stand on that path to success?  Do they understand the importance of practicing and applying their skills?  I start each year with a review of each student’s IEP goals and write them in their speech folder in terms they can understand.  I review each quarter’s progress on a graph to show growth, which is very motivating to the students.  I actively engage the students in data collection and other self-monitoring strategies, and encourage them to make connections between therapy goals, their activities and interests, and their curriculum.

Just like in a game of Solitaire, if the present game plan isn’t leading anywhere, and you sense that “no useful moves are detected,” it’s time to reshuffle the deck and start again.  Only in that way will the student’s system become organized and then you’ll know “You’ve  Won!”

Maximizing Responses and Repetitions

A challenge we all face when working with groups is eliciting the maximum number of responses or repetitions from each student.  Here are some ideas you might want to try:

“Gimme 5, then 3 More” for Artic Drill:   When playing a quick and simple game, like the Stick Game (mentioned in previous post) or Feed the Kitty, each student has to say his/her stimulus word 5 times, then the whole group repeats it 3 times in unison.  This allows me to hear the first student solo, so I can make corrections as needed, then gets the other kids “in gear,” keeping their attention and keeping them involved, even when it isn’t their turn, and giving them extra repetitions, too. (Click image to learn more about Feed the Kitty.)
Roll the Die for Artic:  Using a real die or one on my iPad (Make Dice or Game Tools), students say their target word according to the number they roll.  Since this may not yield too many repetitions per roll, you can use 2 dice, have the students add them together (math standard!), then say the target word that many times, or say that many words from their word list.

Drop It In for Phonological Awareness:  I’ve been doing this for years for phonological awareness tasks.  Each student has a laminated card divided into 2 or 3 sections, with a small medicine cup on each, kindly supplied by the school nurse. (Note: I often put up barriers between the students so that I’m sure their responses are their own). The 2-section side is for speech sound discrimination.  I mark the target sound on one section, a circle/slash or sad face on the other.  Students drop a chip or small theme eraser into one of the cups, indicating they heard the sound or they didn’t.  The 3-section side has a train engine, box car, and caboose, and is used for discrimination of the position of the target sound. Again, students drop the chip into the cup to signal their answer.  In this way, all the students are making a purposeful choice with each trial, and it’s easy for me to see and collect data on responses.

Alternate Response Modes for Language:  Some of these ideas come from my friend and uber-presenter, Linda Seth.  A master at getting kids involved, Linda is a strong proponent of having all kids respond to every question.  This can be accomplished in a variety of ways:

Write it, Show it:  Laminate a white piece of card stock and give students wipe-off markers.  Students write their answer on the card, hold it to their chest, then show them on command.  The SLP, teacher, or TA can quickly take data;  the SLP can give the correct answer and correct any error responses in a general way, without singling out and embarrassing anyone.

Thumbs Up/Thumbs Down:  Each student gets a pair of cards depicting thumbs up/thumbs down.  The SLP phrases all questions as yes/no;  students hold their cards close to the chest, then reveal their response on command.

Multiple Choice:  Similar to Thumbs Up/Thumbs Down, students are given 4 cards each (either numbered 1-4, lettered A-D, or color coded).  An answer code can be posted;  for example, if working on identifying parts of speech, 1=noun, 2=verb, 3=adjective, 4=adverb.  Again, the students hold all cards close to their chest, then reveal their answer on command.

The aforementioned ideas are great for small groups, but also work very well in classrooms.  For a crazy fun alternate response method for individuals and small groups, check out the use of “Speech Lights” from Jenna Rayburn’s Speech Room News Blog.  Can’t wait to get to the dollar store for some of these lights!

How do you maximize responses and repetitions?  Please share your ideas by posting a comment below!

Session Notes Made Simple!

One of the most positive aspects of the Internet is the ability to learn from the experience of others.  And one of the nicest things about all the blogging SLPs out there is the generous spirit which drives them all to share so many wonderful ideas.  I truly appreciate the collegial nature of the SLPs who participate in the message boards of my site,www.speakingofspeech.com, and those who maintain blogs and websites related to our field.  A good example is Ruth Morgan, the SLP who maintains the blog, Chapel Hill Snippets.  Ruth shares lots of creative therapy ideas, materials, and tech tutorials on her blog.  It was the tutorial about using the iPad and Google Docs for data recording that really caught my eye.  You can find her tutorial here: http://chapelhillsnippets.blogspot.com/2011/06/idata-with-ipad-tutorial-for-therapists.html, along with a second article on how to transfer Google Docs to the iPad.

With a few modifications from Ruth’s example, I was able to use these instructions to create an elegant way to record individual session notes that:

  • * will allow input and access from my iPad or my laptop
  • * will record attendance and number the therapy sessions
  • * will provide an “at a glance” view of which goals we’ve worked on in any given time period
  • * will allow for quick graphing of data on any IEP goal
  • * will include areas for listing materials used, making notes on the session, and tracking completion of homework
  • * can be emailed and printed
  • * will make progress reporting SOO much quicker and easier
  • * will be complete, detailed, and legible (unlike my handwritten log book which only I can decipher)
  • * automatically updates the student doc on the iPad when changes are made on the laptop.

Using these new Google Doc forms for recording my daily session notes and writing progress reports will be a MAJOR improvement over the logbook in a binder that I have used for the past 18 years!  My first rainy-day project of the summer?  To create Google Doc forms for each of my students so they are ready to be used on the first day of the new school year!  Whoever thought one could be inspired by data recording?  Thanks, Ruth!

UPDATE 3/31/15:  Because my employer will not allow Google Docs (now Google Drive) for session notes, due to concerns of web security and confidentiality, I now use Excel on my laptop.  The format looks just like the format Ruth describes in her tutorial, but because it is not web-based, it is accepted by my employer.  I have used Google Docs, then Excel, for 4 years and absolutely love this way of keeping session notes for each student.  My notes are far more detailed and legible than my old hand-scrawled notes.  I can see at a glance which skills I have worked on and which need to be addressed for each student.  Writing present levels and progress reports is so much quicker and more accurate.