It does not have to be everything:

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It does not have to be everything Trying to
balance communication and access.
Helen Millward Occupational Therapist Chris
Sherlock Speech and Language Therapist Access to
Communication and Technology CM 2008
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Introduction to Access to Communication and
Technology (ACT)

• Helpline 0121 472 0754 Website
  www.actwmids.nhs.uk
• Email format Firstname.Secondname_at_sbpct.nhs.uk
• Main phone number 0121 627 8235
• Address ACT, WMRC, 91 Oak Tree Lane, Selly Oak,
  Birmingham. B29 6JA
• Regional NHS Tertiary Assistive Technology
  Service all ages and conditions Mission
  statement
• To work with patients / clients and their local
  teams to assess for and provide techniques and
  technologies which optimise the potential for
  communication and control.
• Staff OT, SLT, Clinical Scientists, Workshop
  Team, Administrators about 30 people.
• Other teams in UK are similar but each is unique
• NB WM AAC Care pathway version 3

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Introduction to ACT
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Learning outcomes

• After attending this presentation participants
  will have considered
• Some pros and cons of 3 systems of vocabulary
  organisation
• Narrative based
• Phrase based
• Linguistically organised single words
• The impact of access methods and access effort on
  the choices made about vocabulary storage when
  using VOCAs
• Communication functions choices/priorities for
  different AAC users.
• Some choices to be made about digitised and
  synthesized speech

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Why we are discussing this topic?

• As a team and with local colleagues we have moved
  away from off the shelf vocabulary packages
  towards bespoke narrative based packages.
• The more effortful the access for the client the
  more we have moved towards bespoke programming
• The communication functions for which these
  clients use their AAC has also dictated the
  paths we have taken.
• Characteristically these clients
• Are sociable people
• Have mild to moderate LD and are not literate or
  minimally so
• Are out of school/in later school years (post 16)
• Communicate in a number of different environments
  and have a number of different strategies.
• Have families who skilfully and richly interpret
  their non verbal and spoken communication.

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Main theoretical points

• Achieving a Balance between AAC and non
  verbal/residual speech in someones
  communication emphasis on augmenting existing
  communication in clients who are in the
  expressive language group for AAC
• Vocab storage/ organisation methods what are
  they good for?
• Language based
• Narrative based (telling ones own self
  defining stories)
• Phrase based
• Taxonomic V Schematic issues
• Vocabulary for Social closeness
• Access effort
• Synthesized and digitised speech

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Expressive language group

• Expressive language group these are individuals
  whose language comprehension may be good, but due
  to physical impairment they are not able to
  produce verbal speech. Included in this group
  might be people with cerebral palsy. These
  individuals will need AAC as a permanent means of
  expression, to be used in all situations.
  Although they may understand spoken language,
  they will require AAC input as a model to assist
  them to learn how to use their system.
• Martinsen, H von Tetzchner, S (1996)

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Achieving a Balance effort and message (1)

• Clients are able to get many of their wants and
  needs across using their residual communication
  skills with their familiar communication
  partners. Even though we would describe them as
  being in the expressive language group.
• Using these residual communication methods is
  less effortful than using a voice output
  communication aid.
• Using residual communication methods can put more
  of the responsibility for the communication onto
  the communication partner.
• BUT

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Achieving a Balance effort and message (2)

• The communication of narrative
• Which is motivating
• Reusable but needs recalling and choosing
• This is where the effort to retrieve the story
  from the AAC system becomes more worthwhile to
  the person and the effort for the communication
  partner can be reduced.
• Having a system that is weighted towards larger
  narrative chunks for clients can potentially be
  the best focus for their AAC system.

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Vocab storage/ organisation methods

• Mainly Dynamic screen VOCAs
• (also include medium and low tech AAC)
• Making some slightly artificial distinctions. A
  lot of cross over now
• Can still put aspects of Minspeak based AAC into
  the picture.

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Vocab storage/ organisation methods

• Language based pages based on a left to right
  sentence building structure single word or short
  phrase/selection. Related pages with topic based
  words and parts of speech e.g. Little words,
  verbs, describing words. Personalisation space
  available E.g. Gateway (mainly taxonomic)
• Pros very flexible for novel utterances, useful
  for those with stronger language skills,
  meta-linguistic skills and navigational skills.
  Finding high content single words/short phrases.
• Cons laborious for building complex/structured
  output. Very limited for intonation even with
  digitised speech. Can lack space for longer
  personalized output or this is buried.

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Vocab storage/ organisation methods

• Narrative based Pages based on longer utterances
  that tell or build to tell personal stories and
  might/should include phrases to be used to engage
  a communication partner. E.g. aspects of
  INTERAACT pages by DynaVox.
• Concept of re-useable communication (Waller and
  Newell 1997)
• Pros expresses the personality, interests and
  memories of the person easily, shares
  communication that is self defining and more
  closely to real time. Big output pay off for
  selection of a few items.
• Cons needs designing and creating with careful
  structuring and lots of updating, less novel or
  flexible output. Reduced range of interactions
  possible.

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Vocab storage/ organisation methods

• Phrase based pages of a schematic style that
  relate to communication within and about a topic,
  situation or event. Spoken output is
  characteristically phrase and sentence based.
  Typically adaptations of basic off the shelf
  page sets.
• Pros some flexibility and novel output possible.
  Relatively easy to structure. More output per
  selection(s).
• Cons Lots of pages needed to cover a wide range
  of situations, needs updating and developing.
  Reduced flexibility. Less suitable for
  synthesized speech?

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Vocab storage/ organisation methods

• Taxonomic organization refers to a hierarchical
  system of categories that are related to one
  another by means of class inclusion.
  Foodgtpizzagtthin crust
• Schematic Organization includes items related to
  scenes or event scripts that are based on
  functional organising principles. Circle time
  teacher/time table/sing/show/

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Vocabulary for Social closeness

• Light (1998) identified that a key function of
  communication was for social closeness and that
  this could be achieved through the sharing of
  narrative.
• For example
• Narrative about the life of patients in acute/ICU
  settings has been shown to help staff caring for
  people to see them more holistically
• The communication passport/life book process
  supports the communication of the AAC user in a
  range of ways including memory, sharing stories
  and broadening the perceptions of communication
  partners about the person.

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Vocabulary for Social closeness

• Aims to Establish and maintain and or develop
  personal relationships
• By focussing on the interpersonal relationship
• May be lengthy but might be somewhat predictable
  or have a wide scope
• Rate may not be important
• There will be some tolerance for communication
  break down
• Usually 2 people or only a small group
• The communicator does not have to be independent.
• Communication partners are often familiar with
  each other.

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Access effort

• It is recognised that using a voice out put
  communication aid is slower than using a voice.
• The speed of vocabulary retrieval can be slowed
  even more if an individual has additional
  requirements accessing it such as
• Use of alternative access method like switches or
  joystick requiring the additional learning to
  understand the process of selecting the
  vocabulary as well as the effort to get to that
  vocabulary.
• Effort required to maintain general trunk
  stability to allow for movement to directly
  access a device with a functional level of
  accuracy.

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Access effort

• Experience suggests that there is also a greater
  impact on cognitive load if there is an
  additional access method or if the individual is
  having to concentrate on maintaining their
  position.
• For some individuals this can impact on their
  motivation for using a communication aid and this
  motivation can be impaired if they have limited
  response to the output they retrieve.

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Synthesized and digitised speech

• Speech from VOCAs is retrieved and generated
  either by synthesis
• or
• digitised speech recording and playback.
• VOCAs with synthesized speech usually also store
  some digitised speech but not V.V.
• For narrative and longer voice out put each
  system has its strengths and weaknesses

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Strengths and weaknesses

• E.g.
• Digitised speech gives a more natural flow and
  emphasize emotions such as humour and perhaps
  indicate communicative intent better through
  intonation.
• Synthesized speech make take less long to load
  when selected than Digitized speech
• In aids where photos are being used the memory
  load on a purely digitised speech dynamic screen
  device can be significant, and may slow the aid
  down.

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Case study 1 Wendy

• Woman, 22 years with Athetoid CP and
  mild-moderate learning difficulties. No
  intelligible speech.
• Sociable and with a very supportive family
• Attending Local independent day centre
• Participates in holidays/club with PHAB
• Respite overnights
• Might move to independent living.
• Access method 2 switch using a slide switch. Very
  effortful.

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Case study 1 W

• Using a communication aid first from aged 8
• Majority of school time using a range of formal
  off the shelf language based vocab packages
  which she could use to build short sentences in
  structured settings but usually used in a single
  high content word approach to contextualize
  message.
• Single familiar and motivating word recognition
  for reading
• First letter generation for spelling familiar
  words.

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Case study 1 W

• Communication with family etc able to make wants
  and needs known with non verbal communication and
  shared knowledge and some no tech AAC approaches
  for choices.
• W wanted an aid that would allow her to
  participate in discussion about college outings
  and tell stories about her nephew.

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Case study 1 W

• Development of bespoke communication package

A vocabulary package was developed and has
continued to be updated to maintain the
usefulness of the programming. It consists of 40
location pages with quick phrases on the first
two rows, link pages on the bottom 3 rows.
Synthesized speech.
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Case study 1 W

• Link buttons go to a page which are set up with
  more specific vocabulary of a schematic and or
  narrative type.
• The narrative stories are set up with the
  potential for turn taking
• and developing expansion of the story.
• Big pay off for single selection in terms of
  length of voice output.
• There is a link button on the majority of pages
  with access to sentence building vocabulary and
  the potential to build novel messages. This is
  rarely used.

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Case study 1 W

• W is using this style of vocabulary to a greater
  extent than previous systems.
• She is using it at college and recent effort has
  been put in to encourage her to use it when she
  goes into respite care.
• W is able to get high reward vocabulary from
  limited number of key activations.
• It has required a high level of support to keep
  the vocabulary up to date and current.

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Case study 1 W

• Challenges/pros and cons
• Creating the programme to begin with is time
  consuming and involves lots of work on
  Vocabulary.
• Problems recently when output did not match what
  was needed and longer output could not be stopped
  by W.
• Keeping it up to date.
• Still very effortful to access and this affects
  practice
• The Computer access linked in with email access
  has encouraged Ws use of the vocabulary to put
  into emails.
• System needs to be supplemented by use of Low
  tech for quicker messages e.g. about basic needs.
  
• Communication partners are crucial.

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Case study 2 Reena

• R is 9. She currently has a MT4 with Gateway 60
  on it.
• R has cerebral palsy of an athetoid type with
  marked dystonic movements of her right arm which
  she chooses to have stabilised on the arm of her
  chair by tethering.
• R demonstrates understanding/comprehension at
  above 5 information carrying words.
• R directly accesses her MT4.
• she is able to stabilise her index finger of her
  left hand.
• Respite care overnights at school
• Brownies at school
• Family have many animals and live in the country.

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Case study 2 R

• Communication
• Has Gateway 60 package
• Communicates with her family mainly using non
  verbal communication single words, able to
  communicate his wants and needs in this way with
  rich interpretation and shared knowledge.
• R is able to participate in discussion using her
  VOCA mainly using single high content words and
  rich interpretation from experienced
  communication partner.
• I.e. expression does not match comprehension
  Multi-factorial reasons for this.
• Rs local school team have personalised her
  programming with pages of schematic and
  pragmatically based longer utterance Vocabulary.
• R is asking for more of the same particularly
  jokes and phrases.

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Case study 2 R

• Challenges/pros and cons
• Maintaining programming including longer
  utterances
• Motivating her to use more of the language based
  package
• Supporting her to develop his language skills
  with the aid

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Discussion

• Common themes
• Clients who can not programme for themselves
• Still a big effort to produce utterances that
  have power and are motivating
• Level of non augmented communication that the
  person has in some situations
• Wanting to have communication for social
  closeness humour and sharing stories about their
  lives
• Level of effort to prepare the bespoke
  programming
• Local level maintenance and development of
  current narrative based vocabulary

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Discussion it is late.BUT!

• It appears that a significant theme of CM 2008 is
  around narrative in Augmentative and Alternative
  Communication.
• Are there any overall messages emerging from
  this?
• Should most AAC for Expressive language AAC users
  with increased access effort/decreased access
  efficiency be of a narrative type?
• What are the experiences of the group?
• What are the messages we should give to
  manufacturers?

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Conclusions

• A system does not have to be everything for
  clients
• Concentrating on narrative for many clients is
  motivating
• It is a lot of work for everyone but this is
  Augmentative and Alternative Communication.
• There have to be alternatives for other
  communication e.g. low tech/no tech/speech
• Issues of access can influence how much choose to
  go down the route of narrative/ chunk type
  programming
• Thank you and a safe journey home

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References

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  Augmentative and Alternative Communication
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