Assessing and Developing Emerging Communication

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Assessing and Developing Emerging Communication

• Thursday 5th June 2008
• Victoria Lundie - SLT (ACT)
• Liz Ackroyd SLT (INRU)

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Contacting 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

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New ACT Website
CS
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Timetable

• 9.00 Registration and Coffee
• 9.30 Introduction
• 9.45 Terminology and Client groups
• 10.45 Tea/Coffee
• 11.00 Assessments
• 12.15 Lunch
• 12.45 Goal Setting
• 1.45 Tea/Coffee
• 2.00 Resources and Practical Approaches.
• 3.00 Summary and Questions?
• 3.30 Close

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The West Midlands AAC Care Pathway

• Brief history
• About the training packages
• The documentation and how it can be used.
• Sourcing the documentation

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The West Midlands AAC Care Pathway
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Learning outcomes

• Delegates will be able to
• Understand the terminology associated with
  emerging communication
• Be familiar with a range of assessments
  available
• communicate more effectively with people with
  PMLD and who are in a minimally conscious state.
• To explore ways to develop and extend
  communication for these groups of people
• To look at ways of recording progress effectively

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• Please introduce yourself and tell us who you
  work with

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Terminology

• Profound and Multiple Learning Difficulties
• Minimally Conscious State
• Vegetative State
• Coma
• Multi Sensory Impairment

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Definition of PMLD

• Complex range of disabilities
• 1 2 of LD population
• Profound and multiple disability referring to
  an individual who requires maximum assistance in
  all aspects of everyday life, in terms of 24 hour
  supervision. The person may have difficulty in
  communication, eating and drinking, continence
  and mobilisation, for example Wake 1997
• Additional needs sensory, physical, emotional /
  behavioural

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Terminology in Low Arousal States

• Sleep/wake cycle
• Wakefulness Brainstem
• Arousal
• Awareness Cortex

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Brain Reflex Levels

• Cortex
• Limbic system
• Diencephalon
• Brain Stem
• Spinal

Complexity
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Recovery Continuum

• Coma
• Vegetative State
• Minimally Conscious State
• Cognitive Impaired State
• Normal

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Coma

• No arousal or awareness
• No eye opening
• Reflexive movements only
• No language comprehension
• No purposeful responses
• Rarely last more than 4 weeks

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Vegetative State (VS)

• Exclusion criteria
• CANNOT be secondary to an active cerebral injury,
  degenerative condition, metabolic disease,
  infections or developmental malformations
• CANNOT be due to the effects of sedative drugs,
  anaesthetic or neuromuscular blocking drugs

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Clinical Features of VS

• Medically stable
• Spontaneous maintenance of blood pressure
• and respiration
• Spontaneous eye-opening
• Sleep-wake cycle
• May present with reflex response to stimulus
• No localisation to pain

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Presenting Features

• No evidence of awareness or perception of the
  environment or own body at any time
• No evidence of
• communicative intent
• comprehension
• meaningful expression
• No repetitive, purposeful response to a variety
  of stimuli

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VS Prognosis

• Longer time in VS the lower the chance of
  recovery
• VS can persist until death or progress to MCS
• 6 months after non-traumatic and 12 months
  traumatic injury chances of recovering awareness
  are extremely low
• Life expectancy decreased secondary to
  compounding medical factors
• (Multi-Society Task Force, 1994)

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Minimally Conscious State (MCS)

• Behavioural repertoire is severely compromised
• Sleep/wake cycles
• Severely limited movements
• Feel pain

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MCS

• Altered awareness
• Limited repertoire of SUSTAINABLE and
  REPRODUCIBLE behaviours demonstrating awareness
• follow simple commands
• yes/no responses regardless of accuracy
• verbalisation/expression
• purposeful behaviour

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Problematic Presentation

• Grasp reflex
• Swallowing
• Chewing and tongue pumping
• Bruxism
• Grunts and groans
• Smiles and frowns
• Relaxation response

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Emerging from MCS

• Functional interactive communication i.e. 6/6
  accurate yes/no responses in 2 consecutive
  sessions
• Functional use of 2 objects in 2 successive
  evaluations
• Can be end point of recovery or temporary plateau
  towards further recovery

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Pre-Intentional Communication

• The behaviour does not have a communicative
  function for the person
• The persons behaviour sends messages to others,
  but these messages are unintentional
• The person is not attempting to elicit a response
  from others.

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Video

• Video Intensive Interaction
• Kevin title 7 chapter 1..developing eye
  contact through awareness of communication
  partner

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Intentional Communication

• The behaviour has a communicative function for
  the person
• The person understands that their behaviour gains
  responses from others and that different
  behaviours elicit different responses
• The person is sending a planned message in order
  to gain a response from others
• Based upon cognitive ability / social experience

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Video

• Intentional communication
• MENCAP video
• Miranda
• Francis

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Coffee Break / Practical 1

• Looking at the positives / negatives, challenges
  / successes of working with this client group
• Work in small groups for 10 minutes then feedback
  to the whole group

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• Feedback from discussion

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Assessment

• What is assessment for this client group?
• Includes looking at persons skills, experience
  and environment
• Structured observation
• Repeated over a period of time variable
  responses
• Formal recording
• Consideration of external factors / environment /
  communication partner
• Detailed and extensive

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Pre-Intentional communication

• Reflexive stage
• Reactive stage
• Proactive stage

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Level 1- Reflexive Level

• Communication partner assigns meanings to a
  limited range of early behaviours, sounds and
  reflexes. These behaviours occur as a result of
  internal and external stimuli
• Communicative partners tend to act instinctively
  to the person's behaviours
• E.g person uses different cries when hungry or in
  pain

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Level 2- Reactive Level

• Social significance is assigned by the
  communication partner to a range of behaviours
• Stimuli include events and people within the
  environment
• The person begins to respond to affective
  messages such as tone of voice or facial
  expression
• E.g. if a persons body stiffens this is
  interpreted as dislike

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Level 3 Proactive Level

• Repertoires of behaviours are now exhibited
• Communication partners become more selective
  about the behaviour they respond to
• The focus of attention shifts from care giving to
  objects and toys
• The person can now take meaning from others
  facial expression and intonation
• E.g. Clients deliberately respond to objects and
  people, and people then assign communicative
  intent to them. E.g. pursing lips and turning
  head is seen to mean dont want

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Communication before SpeechAffective
Communication assessment (ACA)

• Structured observation with co-operation of
  familiar people
• Interpretation of responses to stimuli
• Early Communication Assessment
• Develop communication partners skills and in
  doing so reinforce communicators skills
• Judith Coupe OKane
• Juliet Goldbart (1998)

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ACA

• Stage 1 observation
• A set of stimuli and experiences to which the
  person is already known to respond are identified
  in discussion with familiar people
• Stage 2 identification
• Check for consistency and quality of behaviours,
  looking at strongest behaviours (id stage 1)
• Clusters of responses give more info than single
  responses e.g. facial movement, head movement and
  legs pulled up

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ACA

• Stage 3 intervention
• As potentially communicative responses have been
  identified it becomes easier to help them to
  become effective communicators
• Staff and carers become aware of the person's
  communication and are able to respond in a
  relevant and consistent way
• The learner receives feedback for their own
  actions through them being treated as
  communicative

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ACA

• 7 aspects of interaction examined
• Vocalisation
• Facial expression
• Body proximity
• Eye contact/orientation
• Physical contact
• Imitation
• Turn-taking

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Pre-Verbal Communication Schedule (PVCS).

• Needs to be filled in by someone familiar with
  the client.
• Observation Checklist.
• 27 Sections
• Score sheet indicates areas of strengths and
  needs based on the checklist.
• Kiernan and Reid (1987)

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The Early Communication Assessment ECA

• Six levels of communication
• Lots more detail
• Working towards intentional communication

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Structured observations- cont

• Individualised Sensory Environments (I.S.E.),
  Karen Bunning.
• Assessment from Leamington Rehab hospital
• Regular video assessment

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Wessex Head Injury Matrix (WHIM)

• A 62 item behavioural observation scale designed
  to assess and monitor the recovery of
  communication, cognition and social interaction.
• Bridges the gap between GCS and standard tests of
  cognition, motor skills and dependency.
• Provides a sequential framework and is designed
  to pick up minute changes-provides objective
  evidence of recovery.
• Focuses on what patient does/doesnt do rather
  than clinical diagnostic features.

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Sequences of Behaviours

• Basic responses e.g. arousal prior to
  urination/defecation
• Visual behaviours e.g. looks at person giving
  attention
• Social interaction e.g. shows selective response
  to preferred people
• Attention e.g. is able to ignore distraction
• Orientation e.g. can say what part of the day it
  is
• Memory e.g. knows name of one member of staff

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SMART

• Designed for LAS patients
• Assesses full range of sensory modalities
• Optimal opportunities to respond
• Clear protocol
• 10 assessments over 3 weeks
• Assessment of 20-40 mins
• Assessment and treatment tool
• Involves family and team

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SMART Behavioural Observation Categories

• Reflexive responses automatic response
• over which
• patient has no control
• Spontaneous response random non-
• meaningful movements
• that occur without stimulus
• Purposeful response meaningful intentional
• movement

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SMART Sensory Assessment

• 29 techniques
• Multi-modal programme
• Standardization of stimuli for assessment
• Immediately follows Behavioural Observation
  Assessment
• Hierarchical categorization of responses
• Rotation of modalities

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SMART Modalities

• Vision
• Auditory
• Tactile
• Olfactory
• Gustatory
• Motor function
• Communication
• Wakefulness/arousal

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Hierarchical levels

• Level 1 - No response
• Level 2 - Reflex
• Level 3 - Withdrawal
• Level 4 - Localising
• Level 5 - Discriminating

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Levels Using Auditory Modality

• No response no blinking or moving to
  stimulus
• Reflex repetitive blinking startle
  response reflexive facial expression
• Withdrawal blink then habituates
• movement of head/eyes away from
  stimulus
• 4. Localising movement of head/eyes
  towards stimulus

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DifferentiatingFollowing verbal instructions
e.g. Open your eyes Give a slow blink Do
not move Press the switch once Press once for
yes Press twice for no Press for specified
letter
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Categorization of SMART Sensory Responses

• Consistent response
• Occurs in 5 consecutive sessions
• Highest inconsistent response
• Highest response in the modality that occurs in
  1-4 sessions across assessments
• Frequent inconsistent response
• Occurs 5 times but not consecutively

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SMART Levels Related to Diagnosis and Clinical
Features
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SMART Levels Related to Diagnosis and Clinical
Features
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AACtivity Practical 2

• Role play
• Use ACA observation sheet to record
• Stimuli
• Response to stimuli
• Assumptions / interpretations

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Lunch break
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Considerations for Treatment Planning

• Treatment mode
• Type of stimuli
• Order of technique
• Position of stimuli
• Size of stimuli
• Type of prompt
• Volume and pitch
• Duration of response time

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Considerations for Treatment Planning

• Timing of session
• Environment
• Position of patient
• Position of assessor
• Assessor facilitation
• Relative/carer involvement

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Where nextGoal Setting

• SMART goals
• Specific
• Measurable
• Achievable
• Realistic
• Timed
• Link to outcome measure
• Joint target setting is vital
• Use outcomes of assessment / observation
  schedules

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SMART or not?

• Phil will move more.
• Phil will ask for a drink using sign at breakfast
  following verbal prompt.
• Phil will help with the washing up by Christmas.
• Phil will go out to the local shop with his key
  worker every Tuesday.
• Phil will walk to the dining room to drink his
  tea every morning and afternoon within 3 months.

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Where Next

• Goals must reflect small changes
• Requires creativity and inspiration to continue
  to identify activities to move client on.
• Will later discuss some resources to help this.
• Teaching Early Meanings - pre verbal

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Practical 3

• Case study discussion
• In pairs discuss a client you work with referring
  to practical 3 feedback sheet in your pack to
  help guide your discussion
• Feedback

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Creative and Other Resources

• Intensive Interaction
• Scope pack
• Objects of Reference / Sensory Objects
• Use of PowerPoint Tony Jones (Liberator)
• Interactive Story Telling
• Communication Passports
• Sensory regulation
• Using Switches / cause effect activities

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Intensive Interaction
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Scope Manual

• Useful advice / resources and handouts
• Useful contacts references / resources / web
  addresses
• Module 9
• Children and adults with PMLD
• Assessment / information gathering, chart/ form /
  aims objectives section based on
  communication before speech. Suggested
  activities
• Functional
• Importance of facilitators role
• Child adult version, activities and ideas for
  switch progression

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Objects of reference

• These are objects that are used as a means of
  communication
• Originally used with deaf blind individuals
• Now used more widely with people with multiple
  impairments
• Sensory objects of
• reference

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Objects of Reference

• Categories
• Real life objects used in an activity
• Objects not used in an activity
• Objects with a shared feature
• Miniature objects
• Abstract objects
• MMF Meaningful, Motivating and Frequent

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Objects of reference

• Can be used in a number of different ways
• As a bridge to more complex communication systems
• To help understanding of environment
• To help with timetabling or sequencing
• To help people make choices

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Use of Power Point
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My Family
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This is my dog Barnie
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I love going for walk and listening to the birds.
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(No Transcript)
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Interactive Story Telling

• e.g. Odyssey Now Social Cognition through drama
  and literature for people with learning
  Disabilities (Keith Park)

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Communication Passports

• Gives information about how client communicate
  can include pre-intentional communications.
• Needs information from wide range of people.
• More detail included the more useful
• Does not have to only be on paper, can be audio,
  DVD
• time needs to be allowed for carers to
  see/read/hear it.
• http//www.communicationpassports.org.uk/

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Treatment Ideas cont

• Facilitating and harnessing communication
  potential
• Building upon observed responses
• Total Communication Approach
• Written guidelines for interaction, treatment
  etc.
• Establishing a routine sensory regulation

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Sensory Regulation

• What is it?
• How do we do it?
• Who is responsible for it?

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What is Sensory Regulation?

• Described within the International Working Party
  report on Vegetative State (RHND, 1996)
• Patients can quickly become over stimulated by
  the environment
• Optimise the sensory conditions within the
  patients environment
• Importance of regulating noise, visual and
  tactile stimuli

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Switches

• A device for making an electrical connection
  between two contacts.
• Contact switches physical contact required
  (target or held)
• Non-contact switches movement or proximity of
  body parts

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Switches

• Obtain a functional position
• Identify potential sites
• Compare testing of these to establish which is
  most effective
• It is important to carefully observe posture,
  reflex patterns and muscle tone while at rest and
  while performing tasks.

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Switch skills

• Long term goal use switch to access assistive
  technology for communication, environmental
  control, computer access or mobility
• Skills required
• Waiting
• Activating
• Holding
• Releasing
• Waiting
• Reactivating

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Cause and Effect Activities

• Simple computer game providing changing visual
  feedback when switch is activated
• Simple environmental control activity turning
  radio on/off
• Remote control toy
• Personalised PowerPoint display family photos

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Cause and Effect

• Monitor
• Awareness of switch
• Purposefulness of activation
• Response to action after switch press
• ?connect switch press to action
• Repetition of switch presses
• Motivation
• Cessation of switch pressing during
  action/reward/end of sequence
• Responses to visual and auditory actions
• Understanding that switch activation causes
  effect

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Timing and Accuracy - Activities

• Simple computer game press switch at correct
  time to hit a target
• Simple EC device 3 options scanned in turn

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Timing and Accuracy

• Monitor
• Correct timing of switch press
• Number of prompts required
• Switches in response to visual and/or auditory
  cues
• Waits and presses switch at a particular time
• Anticipation

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Switches and Environmental Control

• Used as a motivational tool
• Establishes cause and effect
• Can indicate ability to follow verbal
  instruction, length of time to initiate a
  response and can be used to make a choice

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How do we record share information about
operational / environmental issues..

• Communication passport or dictionary
• The front page in a communication book / board
• A tag etc on wheelchair tray/arm.
• Talking Photo album
• A film

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Communication PassportShow as a Power Point
http//www.communicationpassports.org.uk/ -CALL
centre website
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Questions.