Supporting People who have Complex Communication Needs: Implementing AAC in Day Services

In An Ideal World

When a person who has complex communication needs (CCN) is learning to use a communication device, the support team should ideally be modelling its use all the time. Initial and follow up training should be provided so that all the key people in the person’s life have the practical skills to set up, use and resolve issues with the communication system. The team should be able to find the words they want to say within the communication software, model them with the person who has CCN and have a plan for adding any messages that are missing from the system.

This is the aim but how do we get there?

How do we make this achievable for busy staff in day services who have numerous responsibilities and limited time?

Although it would be wonderful to jump in and do everything all at once, the reality is that it can take time to amass the knowledge and practical skills to support someone who is not only learning to use a communication system, but might also be learning a new symbol set and access method at the same time.

The acquisition of any new skill can be made easier by breaking it down into more achievable chunks. Supporting the use of AAC is no different.

Obtaining operational knowledge of how to set up a communication system is relatively straightforward. When supporting teams, one of my first tasks is to create a “reader’s digest” version of the manual that includes just the main things– buttons and functions, how to turn it on and off, change the volume etc. Assistive technology suppliers and manufacturers have lots of online resources available and YouTube videos are great too. Facebook is invaluable and there are private groups for professionals, users and families of people using specific communication strategies and technologies where you can share information and learn from one another.

The early stage of implementing the use of a new communication system is about building routines – remembering to take the communication system everywhere, charged and ready for use and learning how to position it safely and optimally so it is always available for the person whenever there is a chance to interact with someone. Establishing these habits leads to the development of operational knowledge as the support teams become more and more familiar with the system.

The next step is to apply the intervention strategy known as aided language stimulation. The communication partner models the use of the communication system with the person who has CCN to teach them what the words and symbols mean, where they are programmed and how they can be used in everyday situations. The communication partner speaks as they access messages in the system, and communicates with the person who has CCN by using their own communication system with them. Modelling requires knowledge of how language in the communication system is organised, so staff need options for obtaining this information.

Communication partners can practise with:

  • Laminated screen shots of frequently used pages from the communication system
  • A light tech version of the person’s communication system
  • Scripts that include step by step instructions for finding the message they want to communicate e.g. I want – Activities – Game
  • A trial version of the communication software if it is available to download

Providing daily aided language stimulation can be one of the most challenging aspects of AAC intervention because it requires everyone to change the way they interact with the person who has CCN. It requires everyone to:

  • Recognise opportunities for communication
  • Find the time to respond to them
  • Model communication options
  • Be patient and provide opportunities for the person with CCN to communicate
  • Model possible communication options if necessary, to demonstrate what the person might want to communicate

It is also a time to manage the team’s expectations. Having access to a communication system is one piece of the puzzle but its presence does not generally lead to spontaneous expressive communication in the absence of aided language stimulation.

We must show the person how to use their communication system by using their system with them.

Interaction Logs

I’ve been trialling the use of “Interaction Logs” in day services recently to make it easier for staff to increase the amount of aided language stimulation they provide for people who have CCN.

The Interaction Log is a data record of interactions that occur in a short period of time between staff and the person they are supporting to learn to communicate.

The team selects a time period e.g. 10:30am-11:00am, or an activity, and then writes down the messages that are communicated with the person learning to use AAC during that time.

Interaction Log

Some obvious considerations:

  • Consent must be provided to collect and analyse information
  • The conversation content should not be sensitive or private in nature
  • Ideally someone other than the communication partner should collect the data as it doesn’t make for a natural conversation if the communication partner is writing everything down!

By focusing on a small segment of the day, for example during a cooking activity, staff can gather valuable information about the number, type and frequency of interactions made between the person learning to use a communication system and their communication partner. They can see at a glance if they are modelling lots of messages or if there is room for improvement. It may also become a valuable record of the person’s journey towards independent communication.

Following the interaction, it is crucial that communication partners reflect upon the success of the communication exchange, to see what went well and to brainstorm ideas to enhance future interactions. After collecting information across a number of times / activities on different days, the team will have a deeper understanding of how the person learning AAC uses their system on a daily basis.

Reflecting on the use of Interaction Logs may be an important catalyst for change if it becomes apparent that the person learning to utilise AAC is not being provided opportunities to access, learn and use their communication system.

It is important for families to know how their relative with CCN is being supported to communicate in environments outside the home. Often families want to know:

  • How much is the device being modelled?
  • Do support staff know how to find the message they want to model?
  • Are a range of people interacting with the person and modelling the communication device or is it the same people each time?
  • Are a range of messages being modelled? Are there lots of questions but not many comments or expressions?
  • Is the communication device available when it is needed? Is it kept near the person? Is it charged up? Is it attached to the mount?
  • Are there issues with using the communication device at certain times?

Gaining a deeper understanding of the communication process and the factors that influence the success of exchanges may assist teams to enhance their support and ultimately, better assist the people they work with to communicate.

Above all, communication is about sharing information with other people, so two of the best things we can do to support people with CCN is to think about common interests that we might be able to chat about, and make some time for communicating.

Acknowledgements & Links to More Information

There are many professionals working in the field of AAC whose work has informed my approach and the information contained in this post.

I would like to acknowledge the work of Gayle Porter, speech pathologist, who developed Pragmatic Organisation Dynamic Display Communication books. I recently attended a PODD Training Workshop and I cannot recommend it highly enough! In addition to providing practical knowledge about using PODD communication books, it also included information about implementing AAC, setting up routines, using aided language stimulation and the importance of modelling a range of pragmatic functions. For more information, please visit:

https://cpec.org.au/

Jane Farrall is a speech pathologist who writes an excellent blog about topics that relate to literacy, AAC and assistive technology. She also features guest posts and Mary-Louise Bertram’s “Why We Do Aided Language Stimulation – And You Should Too!” is fantastic!

http://www.janefarrall.com/

“We Speak PODD” is a personal blog on Facebook written by a family who communicates with their children using PODD books and page sets in AAC devices. The family regularly post videos and share how they model language via PODDs to support their children to communicate.

https://www.facebook.com/wespeakpodd/

Kate Ahern’s blog “Teaching Learners with Multiple Special Needs” a great resource. In particular, I love her post “5 reasons to use the high-quality vocabulary already included in your AAC system”.

http://teachinglearnerswithmultipleneeds.blogspot.com.au/

Communicating Without A Shared Language

I’ve recently returned from a trip to Beijing, China and had the unique opportunity to experience communication in the absence of a shared language. Despite the obvious language barrier, I met lots of great people who were keen to chat about my smallest travelling companion (my two year old son). Through the use of pointing, gestures, natural signs and some guesswork, I muddled through with people and was able to interact quite successfully!

Here are some of the things that travelling reinforced for me:

  • Travelling with a toddler is a great conversation starter!
  • You can make an educated guess about the kinds of things people want to know about you when you are visiting another country (e.g. “Where are you from? How long are you visiting?”)
  • Having some visual aids like a map or photos makes communication so much easier. We quickly learnt to favour restaurants with photo-based menus, where we could point out what we wanted to eat and had a reasonable understanding of what we had ordered
  • People seem to really appreciate your effort in attempting to say “please” and “thank you” in another language. My toddler also learnt how to say “Xie xie” for “thank you” and uttering this guaranteed lots of attention!

Taking the Time to Communicate: Using Augmentative and Alternative Communication (AAC)

Before establishing The Communication Toolbox, I spent four years working with the Aids and Equipment Program, Electronic Communication Devices Scheme. In this role I provided Electronic Communication Devices, software and communication apps for people who had difficulty communicating verbally. I also provided the client’s team with some initial training in how to use the device. This training covered the important basics of setting up the device and how to charge it etc but I always wished for more time to spend on my true passion: supporting people to use their device in the long term. This has been the impetus for creating The Communication Toolbox, a private speech pathology practice that assists people with complex communication needs to evaluate and implement Augmentative and Alternative Communication (AAC) options.
 Learning to communicate is a journey that takes time, especially for those learning to communicate without speech. Using AAC may include the use of gestures, pictures and communication boards, as well as more complex systems like Electronic Communication Devices or apps such as Proloquo2Go.
 For those who use communication systems that contain stored pictures, words or phrases, sessions at The Communication Toolbox might include:
  • Creating a map of folders in your communication system that contain all the words you like to use, as well as room for what you might like to say in the future
  • Identifying core vocabulary items that relate to the activities you enjoy, so that you can access the words you need at the appropriate time
  • Storing vocabulary items within your communication system so they can be accessed quickly without requiring too much navigation through folders
  • Programming vocabulary logically so that you can find what you want to say
For most people, the process of learning to communicate via AAC is long-term endeavour and requires motivation, practise and access to communication partners who are skilled in communicating through the chosen AAC method. Ample time should be spent modelling the use of the AAC system before any expectations of using the system should be placed upon the person. It takes time to:
  • Establish trust
  • Develop receptive language skills (e.g. learn new vocabulary and how the words fit into sentences)
  • Develop confidence to communicate (especially if one has not had the opportunity to experience communicative success before)
  • Learn how to use the communication system
  • Learn how and where words are stored in the communication system
I read a fantastic comment the other day on Proloquo2Go’s Facebook page (posted by Jennifer):
“Too often we stop trying AAC if the person doesn’t start using it right away! Typically developing children get 12 months of people talking to them before they’re expected to speak!”
How true! This comment illustrates the importance of perseverance when learning to use AAC.
To access the full conversation thread, please visit http://www.facebook.com/proloquo2go/posts/10150563626711053, posted on March 2, 2012 at 11:57AM.