AAC Strategies for Adolescents as They Transition Through Adulthood

In this webinar, Patricia Ourand, MS, CCC-SLP, current President of Associated Speech & Language Services, Inc., discussed person-centered approaches to interventions that support successful communication across environments and over time, communicative competence, levels of literacy, social validity and communication partners. PPT slides are found below.




- [Voiceover] What I'd like to do is welcome all of you to our Center on Technology and Disability webinar adolescence through adulthood while communicating. I'm Russ Holland. I'm the president of Adirondack AccessAbility and we very pleased to be partners in The Center on Technology and Disability and I'll be hosting the session for today. My main duty and host stand is to introduce a colleague Pat Ourand. Pat and I had the good fortune to serve on the CSUN Advisory Committee for a number of years together and it gave me a chance to get to know her and I've also been involved with a number of presentations that she's done. I can tell you you're in for a pretty, pretty treat today.

In addition to that she has a Master's degree in Speech Pathology from Loyola College in Baltimore. Master's degree in Technology for Special Ed and Rehab from Johns Hopkins and she's president of Associated Speech and Language Services Incorporated, a practice specializing in augmentative and alternative communication. Over the years as I've mentioned she's presented locally and nationally on a lot of different topics related to augmentative communication. She has extensive experience working directly with individuals with significant cognitive, linguistic, sensory or motor disabilities necessitating technology access and she's done a good bit of writing on these topics as well. She's an adjunct faculty member at Johns Hopkins University, School of Education, Department of Special Ed. She's licensed with a speech-language pathologist in the state of Maryland, a certified member of the Speech-Language and Hearing Association and Past-President of the United Society for Augmentative and Alternative Communication USSAAC. And with all that Pat, I'm thrilled that you are able to do this for us today and I'll turn it over to you to get started.

- [Voiceover] Well, thanks Russ and thanks everybody who is here this afternoon. Those are kind words that you said Russ and I hope that I keep you an honest man. As you said, the topic that we will be discussing this afternoon is adolescence through adulthood while communicating. And when you think about that, one of the things I thought was really worth noting and hopefully I will bring that out in some of the videos and the anecdote information that we talk about this afternoon. Very often what we're talking about is individuals who have congenital disabilities, no, not very often but always. They're either going to be an individual who has congenital disability, a disability from birth or an individual with an acquired disability. And that means a lot as we go through this session this afternoon, we talk about how to identify optimal strategies and techniques for communicating across the lifespan. It's really gonna be important to note for example, is language intact? So we are going to listen for a second, watch and listen, a short video clip. And this is a gentleman who has an acquired disability as an adult and it's Lou Gehrig disease, Amyotrophic lateral sclerosis. And I just want you to listen to Collin a little bit and talk about what communication means to him as a person who had intact language and speech up into his adult years. So and I wonder if you wouldn't mind pulling that up for us. And while we're getting that pulled up, I'd just like to say to anyone in the audience, please feel free to raise your hand and I will call your name or to make a comment.

- [Voiceover] This is a talk that was presented by Collin on October 18, 2006 at the Oregon Health and Science University. We wish to thank Melanie Freidman and her colleagues for video recording this presentation so that it can be offered as a webcast. Now, here's Collin with NAAC user's perspective.

- [Voiceover] Thank you, Dr. Freidman. Thank you for inviting me to your lunch and meeting. Since this is a luncheon meeting, I trust you will forgive me if I eat as well. I was very pleased to be invited to speak to you today. I spent the most interesting 10 years of my career working closely with scientists and engineers on product development in the medical electronics and software in us and I thank each of you has the opportunity to contribute greatly to the quality of life of people with disabilities.

- [Voiceover] I would like to go on to that cancer.

- [Voiceover] At Hewlett-Packard Company, one of the cohort company values was that products had to make a contribution to their users, to their field of endeavor or to the communities in which they are used. I will come back to this idea of contribution later.

- [Voiceover] Slide four.

- [Voiceover] I am going to spend the next 45 minutes or so talking about myself. By assist I have noticed amyotrophic lateral sclerosis--

- [Voiceover] We'll do another two seconds.

- [Voiceover] The impact of electronic communication, critical environments for testing my needs and your potential to contribute. If you think--

- [Voiceover] So as we listen to Collin, some of the things that and I actually will ask if some folks will tell me, what did you see going on there as an individual communicating? Anybody went out? Sorry, there's an echo going on, I didn't hear that. Anybody wanna make comments on how they were viewing Collin as he was communicating because every time I see this and you can imagine I've seen it dozens and dozens of times. I'm still amazed at how communicative he was. So anybody that would like to write something in the... He was lecturing. Mm-hmm, exactly. And so he was using and in order to get his points across, he was using, absolutely allowed him to participate more, he was using pragmatic skills, you notice how he was nodding his head, he was looking out to the audience. He was using gestures. He's using multiple technologies. If you heard right before we turned it off that it said slide four and so he had this auditory reminder to change the slide.

He was using a mouse. He was using a mouse to change the slides. He was using his electronic speech to speak to us. He was just using a whole host of things and what we need to keep in mind is that Collin was an individual who came to using AAC with strong language skills that were intact. We do know that other individuals are going to have language skills that are not as intact or not intact at all either because they never developed language skills or they lost that language skill through. Something like an acquired brain injury like a traumatic brain injury, a stroke. Any other number of primary so there's all kinds of things that are acquired that can limit an individual's language skills post acquiring that diagnosis. And then there are some individuals and some of the folks you'll see in the videos via lessons today that I have, they are still developing language and so that's really important for us to know.

So how do people communicate? We all communicate. What you communicate as a 14 year old is very different than what you communicate when you're a 24 year old and that is even different from what you're gonna communicate when you're a 44 year old. But communication is central to human life and we all communicate. And optimal communication is what we all strive for. It's what I strive for here in our presentation. So when we use AAC, I wanna ask a question. So we're gonna do a poll, just a real quick poll. The answer is gonna be yes or no. Is communicating medical needs the primary goal of AAC and if you would just click yes or no.

Do you believe that communicating medical needs is the primary goal of AAC? I didn't say it's the only goal but the primary goal. So far... Okay there are about 20 people. So there we go. So about right now 85% of the people say no, communicating medical needs are not the primary goal and 15% say that yes in fact communicating medical needs is the primary goal. And I think one of the things to keep in mind is there are how many of us here in this discussion today, all of us come from a different perspective and so that certainly is why we don't have 100% of yes or no. When we talk about the goals of AAC, I'm gonna talk about them very generally and then we'll get into some more specific things that talks about what we just did in our poll. So when you talk about AAC no matter what your age is, all right, it could be temporary. So if somebody has had say an injury to their vocal folds, if somebody is intubated they may need AAC strategies or techniques for an hour, a day, a week, a month. Other people, long term needs of communication and for other folks and let's see some of those today as well. That AAC, the goal of the AAC in their world, the AAC strategy is to facilitate the development or redevelopment of natural spoken communication. Those are the major areas.

Some additional goals are not just medical and it used to be for those of us who had been in the field for more than two decades that med speak, that's what we used to call it. And if you were to get something to an insurance company whether it's a private insurance company or a public insurance company, health insurance, it was med speak that's only counted. You needed to be able to talk to your doctor but now we've widen the lens. We understand that there are so many stakeholders involved, there are so many communication partners and so the ability to communicate self-care needs, emotional status, that you're happy about something, that you're frustrated by something. The ability to engage in social communicative interaction with familiar communication partners such as friends and family and that interaction can be maybe singing happy birthday over the telephone to your best friend or your grandson or whatever.

Another goal of AAC is to carry out communicative interactions in the community. So with unfamiliar partners whether that's at the playground, whether that's on the athletic field, whether it's at the bank, whether it's at a restaurant, whatever it is we need to be able to communicate and that depends on who the individual is. The way that we attempt to make this process somewhat systematic is to use a selection process that we go through. Here on the screen we talk about kind of what that continuum looks like and we'll go through different pieces of this continuum but you have to know who the individual is. We have to really know what the individual needs to be able to communicate and the needs assessment. So for example, if somebody is in the seventh grade, what they're writing or saying is very different from somebody who's in say graduate school or someone who is in their orientation period of their first job or someone... It depends on where the individual is in his or her life with regard to what their needs are and so that assessment has to be redone often as environments change and needs change. Look at the individual strengths and limitations and once again if it's a stable situation that they're dealing with. Those strengths and limitations may remain stable. In some cases individuals improve in certain areas and in other situations individuals lose skills and it is what it is, that's all there is to it. We'll look at access method.

So it's a person like we saw with Collin, he was using direct selection. Somebody else might be using eye gaze, another person might be using a switch. Somebody else might be using Morse code. I mean we have all kinds of ways that we can access technology. Wanna do a feature match at some point and that is looking at what features not, what features the technology has but more importantly what features of technology the AAC does the individual need. At that next point is to try and mock-up what we think the individual needs and try it out then we can do a final system analysis with purchase and then follow-up. This process if you will, if you would imagine just a large table, a large empty table and as we go through this systematic selection process and as we gain information, anywhere in this process and anyone on the team that has something to provide the individual, their caregivers, whoever else is on the team, a speech path, an occupational therapist, a nurse, a social worker, you name it. Anybody can be on the team.

Any information that is obtained during the selection process is thrown on a scribial table. This table is eventually going to be the puzzle that is the AAC device and all these little tidbits of information that we throw on this table, we're gonna eventually put it all together but the thing is this puzzle didn't come on a box with a picture so we don't know what we're putting together until the end. And that's based on everything we find throughout the systematic selection process. And I have to repeat it has to be done time and again based on where person is in their development and in their needs and that sort of thing. So we'll briefly go through some of these steps and please, anybody else that has questions, please put them in to the chat box and Russ will make sure that we get those addressed. The initial interview is just basic demographic information, background information, interview to caregiver, observe the individual.

There are all kinds of ways that we garner information. The needs assessment, we'll be looking at what kind of partners the individual is communicating with. So the kid is in the seventh grade, eighth grade, ninth grade, who are their communication partners? It's the parents and their siblings and their family but it's also their peers, it's their educators. Is it individuals in the neighborhood and community? What environments are they gonna be communicating in? Is it just at home, is it just from bed? Is it on the school bus? Is it in the school? Is it in the cafeteria, on the playground? What environment, is it at work? Is it out at dinner? What kinds of messages you could be communicated and so if you're in college, if you're in high school, college, graduate school, whatever, you can be relying on simple sentences to communicate the sorts of things that you need to do in this environment.

So what types of messages and what notes does an individual need in order to communicate and part of that is you can do it face to face. You're gonna be doing it over FaceTime or Skype. You're going to be using online access. Are you going to be producing something written because written communication is an important aspect of communication when we talk about AAC and particularly as a person goes through their life into adulthood. And so look at all of those needs and once again where all this information under this proverbial table that I talked about. Next here is we really look at the strengths and limitations of the individual. That's not a negative thing. None of us have every strength they own and we are, there are limitations.

I have no hand coordination, I have a whole host of limitations and we all have strengths and limitations and we're gonna look at those in four specific areas: cognition, language, motor skills and sensory skills. I generally just list them in alphabetical order in my report. That's just because how I am. It doesn't matter how you address these four areas, they just all have to be addressed. And so we will look at some examples of video and I want you each time we're looking at videos to be thinking about this slide when you see going on cognitively. What kind of linguistic skills do you see going on? What's going on motorically and what kinds of sensory things are going on whether it's auditory, tactile, visual, whatever it may be. And all of this is really important in the process as we go through working with individuals and as their needs change. So here we go. We start with what is the widget thing going to have on it? Is it going to have pictures on it? Is it going to have text on it? I don't care what the answer is. The answer is whatever the individual needs. We're gonna go to a video now and we're gonna look at an individual who in the first video is using icons and let me tell you while we're setting up this video. I had just delivered this to Chip earlier in the day about two or three in the afternoon and this is a few hours later and this is a video that his dad took.

- [Voiceover] Chip, can you tell me the time for dinner? Can you tell me time, can you clear it? Clear it. Chip, tell me time for dinner. Chip, tell me. Can you say time for dinner? There you go, good clear.

- [Chip] Time for.

- [Voiceover] For what? Do it.

- [Chip] Dinner.

- [Voiceover] Yeah. You like that?

- [Voiceover] Very nice and so that is Chip using an icon based system so I'm gonna go back one slide and if you look on the left-hand side this is not the exact screen that Chip was working from but that's the idea. Now we're gonna go and see the second slide and his dad will explain, his dad will set it up for us exactly what is happening here.

- [Voiceover] This is just five minutes later and I've added him to the alphabet page and asked him to tell me time for dinner by spelling it out. You had seen how excited he was when he made it out. You got it? Yeah, it did say time. Time what?

- [Chip] For. Time for dinner.

- [Voiceover] Yeah. Good boy, Chip. Yeah. Good boy, Chip.

- [Voiceover] So when we look at those four areas that I showed a few minutes ago, we'll just briefly talk about those again with regarding to the two videos that you just saw. Once again, feel free to enter any information into the chat room. So when we talk about cognitive, linguistic skills with regard to Chip, his dad knows him inside and out. Chip was about 18 years, 19 years old at that time, maybe 20, 21 and his dad knew that based on his level of cognition in language that not only did he need validation things like yes, he did say time. That was also driving some verbal prompting. He did that in the first video. Time for, yeah, it did say time for, time for what? Do it then it says, dinner and goes yeah, you like dinner, that kind of stuff. The dad was prompting him motorically, you saw it was going on there that he was able to isolate a finger and point to, if there was a keyboard you saw that was an old PDA architecture, Personal Digital Assistant. So you can imagine that the alphabet was on that that's at least 26 characters and a period to make it talk or a speech case so there was a lot going on there and you saw that he was able to adjust from the pictures, icons with text to text.

And so with regard to sensory, auditory, visual, it was a small screen, he was able to work with that. He was able to hear what it said. He was able to hear what his dad was saying. It was loud enough so his dad could hear what he was saying. All of those sorts of things are taken into consideration. Here's another example when you look at somebody's cognitive, linguistic, sensory, and motor skills. This is an example of a Picture WordPower from Nancy Inman and I don't even know what device this is on but you can see that the system that uses a color coding. It uses words but they all have icons on them, so with icons with text. There's also a keyboard, along with the keyboard there are some word prediction. You see A, M, work. There are a whole list of things going on here and so in this case we've merged the two. We're using co-words, as well as letters, as well as word prediction and different individuals utilize these different scenarios and so we have to look at what's important for each person. The bottom line is that in the big picture as in the Webster said, it kind of sets us up really well here. It says, "If all my possessions were taken from me "with one exception, I would choose to keep the power "of communication, for with it "I would soon regain all the rest."

- [Voiceover] Along those mindset, Ken has made the comment that the challenge still seems to be interactive communication at conversational speeds which I'm guessing is where you're going anyway.

- [Voiceover] And Ken you're exactly right. Ken said, "Hey, that was a prepared speech, wasn't it?" Yes, it was a prepared speech but he had the timing down. I have been in meetings with Collin where he waited and then he made his comment just the way all of us would on a meeting and then he was able to respond to any questions that were posed. And Ken is ahead of us on this. Ken is about 10, 15 slides, 25 ahead of us. We're talking about communicative competence. All right and so that sometimes needs to be redeveloped or sometimes you need to do that feature matching. What technology can keep up with me so that I can remain conversational? In Collin's case he was using a keyboard with great enhancement strategy such as abbreviation expansion and word prediction or word completion you wanna call it. So the good and the bad news is that it's not easy because we're all individual and Don Johnston said that the best, he said, "We are all individual, "our communication is our own fingerprint." So as, specific as your fingerprint is used so are your communication is. Now, this is an unusual slide here but I use this as my access into this discussion.

There is a book called The Diving Bell and the Butterfly and I don't know if anybody else has seen the book and movie. I haven't been able to really watch the movie the whole way through but I read the book bunch of times. This is by a gentleman who was an editor of a French magazine, the Elle magazine and sustained a massive brainstem level stroke. And so he actually wrote this book The Diving Bell and The Butterfly using spelling only. Now interestingly enough he chose for his communication technique not to use technology. He chose to use a letter board and his communication partner who happened to be his caregiver would write everything down as he used his eyes to go to a letter board. The caregiver would write everything down, that's exactly how they wrote this book. But he talks about letters of the alphabet so clearly and as a writer I guess it makes more sense that he can do it, so I'm gonna use his words.

There was a chapter in this book called The Alphabet and these are his words. "I'm fond of my alphabet letters. "At night when it is a little too dark "and the only sign of life is the small red spot "in the center of the TV screen, "vowels and consonants dance from it." He says, "Hand in hand letters cross the room, "whirl around the bed, sweep past the window, "wriggle across the wall, swoop to the door "and return to begin again." And then he tells a, you see that line there, "E S A R I N T U L O M D P "C F B" line two "V H G J "Q Z Y X K W". He says, "The jumbled appearance of my chorus line stems "not from chance but from cunning calculation. "More than an alphabet, it is a hit parade "in which each letter is placed according "to its frequency of use in the French language." So I emphasize that because those of us that use English will look at that and say that is the most unusual configuration of letters but as he said, he says, "This is why E dances proudly out in front "while W labors to hold on to last place.

"B resents being pushed back next to V "and haughty J which begins so many sentences in French "is amazed to find itself so near the rear of the pack. "Roly-poly G is annoyed to have to trade places with H, "while T and U, the tender components of tu, "rejoice that they have not been separated. "All this reshuffling has a purpose. "To make it easier for those who wish to communicate "with me," and that's the bottom line. And believe me when he wrote this, he didn't know that a speech pathologist would be using it to discuss how we design augmentative communication across the life span and just in general but I think he says it so well. So we have so many different ways that we can lay things out on our screen or whatever it is that we're using. You saw icon based. We saw icon what that icon screen a few, let me go back at that one because I wanna look at this. This is something we don't look at all that often or we don't consider all that often but it is the alphabet arranged statistically from the center out.

So this is on the left-hand side the keyboard that you see is statistically arranged from the center going out and so you could see A, E, I, L, O, certainly vowels are right there in the middle. The space bar is right there in the middle, it's double size because the space comes after every word and in English the average word is five to six characters in length and so you're gonna have a space after every average five to six letters. Your two letters like Z and X, and Q and J are furthest away from the center. The whole point here is if somebody is using a single point whether it's a finger that's isolated, whether it's a head stick that functions, whether it's using eye gaze. You can see that you hope to increase the rate by keeping the letters that you use most often closest to your pointing system, your finger, whatever it happens to be. And so that inherently increases the rate.

You look at the layout of the Picture WordPower, which is color coded from the left to right. We have pronouns, pre-verbs, verbs then we have prepositions. We have other attributes. All of that is laid out so that individuals can communicate optimally and as Ken said to be conversational in nature. Additional and as Jean-Dominique Bauby says so that he can communicate now that you can communicate with him. Here we have a T9 layout on the left-hand side which we really can't use on our laptop and tablets anymore forever because that technology is owned by the phone companies but we've all used it in our cellphone. And I didn't even have to backup that marker now I have this keyboard right here. Once again the example of the frequency of occurrence from the center out. And so the question is, what do we do and what do we for a 14 year old versus what we do for a 40 year old versus what we do for a 60 year old. It all depends once again on the individual. I'm gonna show, we're gonna look at meet Norlan now. Norlan at this time was about nine or 10 years of age and we'll talk on the other side about Norlan but I just want you to watch the video and on the other side maybe put something on the chat box about what you thought was going on there.

- [Voiceover] That's right. The boy--

- [Voiceover] Norlan is the instruction given? Okay.

- [Voiceover] Now let's record the sentence. Drag the correct preposition to the sentence. On. That's right. The cat it sitting on the car. Now, let's record the sentence.

- [Voiceover] It's all right, you can do it this way.

- [Voiceover] The cat is sitting on the car.

- [Voiceover] All right, let's record. Let's record.

- [Voiceover] The cat is sitting on the car.

- [Voiceover] Stop. Let's record.

- [Voiceover] The cat is sitting on the car. Sitting on the car.

- [Voiceover] So, I don't know if anybody else has some things to write in the chat box. When I think about the cognitive, linguistic, sensory, and motor skills, I think we see a lot going on there. The purpose of this activity, this was actually therapeutic in nature. So realize that sometimes you need is AAC short term, long term for the facilitation of natural speech. This was really for the facilitation of language development because at this point in time Norlan had a Vantage which you see over to the right. He would never speak in complete sentences. He would always give me one word responses and he was going into the fifth grade and he thought of start using complete sentences. And so he would do anything for an iPad. So I used apps on the iPad that were for the creation of complete sentences and then he had to put that sentence into the Vantage which would give him experience in creating complete sentences and then he was all excited because he could use speech in Vantage to record into the iPad and then have the iPad speak back what Vantage has said. And so he was incorporating level technology because that's what he needed at that time and age because those were cool to him.

His next technology he took, the software that is on that Vantage and got a mini iPad because he is so motivated to use iPads. And so all of that when I talked about needs assessment, he had this Vantage and it worked but because he was a nine and 10 year old, he wanted an iPad, he wanted tablet technology. And I think we're seeing that come forward. This is a statement from John Dewey in a document titled Democracy and Education written in 1916. A society which is mobile, which is full of channels for the distribution of a change occurring anywhere, must see to it that its members are educated to personal initiative and adaptability. Otherwise they will be overwhelmed by the changes in which they are caught and whose significance or connections they do not perceive. We have to make sure that we are up to date if you will on what it is that individuals need or want for communication purposes and I do think that we're seeing mobile technology takeover AAC strategies.

It's a whole host of reasons. It's much more portable, somewhat intuitive because we're using it in some of the environments. You go in to the rising store and you type in your first name and what you're there for and it gets put up on the waiting list for the screen. There are so many other places where you check yourself out in the grocery that's using a touch tablet. The schools are transferable, very adaptable when the technology tends to be very simple and they're very affordable, they're very accessible. This happened to be from a group that we're talking about mobile technology in special education and that group was a PT and a OT and a speech language from the Appleton Area School District and that's back in 2011 but I think it's really important as we talk about AAC across the environment.

So you saw Norlan. Norlan was communicating in a therapy room. You saw Chip. Chip was communicating with his dad attable. We're gonna talk more about communication partners. I went forward a little bit too fast there but we need to talk about communication partners. And so what I did is I reached out to some folks that have been using AAC for years and years and years. I just asked them to give me some insight for this presentation and I put one of those, the results from one of those individuals into this. India Ochs is a woman who works. This is from a Facebook page. She works at the U.S., for the federal government. She studied Law at Syracuse University and she lives here in Annapolis, Maryland .

When I asked India and this is a picture of India with Cal Ripken as we are in Baltimore and her baby, Jack, at the time. She says, part of it really is who the person is either you have self-confidence. In her case, she said that I have or you don't. If you don't, you can learn to have success but I don't think it's the same. I was also understanding people which goes back to self-confidence. So she was really saying that we need to be empowered with confidence. I knew early on that people only choose me because they lack self-confidence. That doesn't mean I wasn't vulnerable and she said I'd be getting into a fight at times but she went on and said, and there's her little son, Jack. She said, also I always had older friends including adults and having adults respect you at any age makes a huge difference, would ask questions and most people were expecting you not to answer. From the beginning this is what I think the critical case is. This is India but it's nonverbal. She says from the beginning I knew to play with my audience and she said, and I think that helped me get the things I wanted. Not only what you say to them but how you communicate, so whatever, what it is for the other person with how I talk to people.

So what India is saying to us here is she was considering who her communication partners were. So when she communicated, was she communicating to someone at work? Was she communicating to professor at law school or a peer? Was she communicating in the environment with Cal Ripken? Was she communicating with her young son, Jack or with his teachers and his after school program? She would always consider the communication partner and that's so important when we talk about augmentative and alternative communication and that communication partners change as we go through life. So the partner of a 15 year old is very different than a communication partner for a 50 year old. And so Jeff Higginbotham, Howard Shane, and Kevin Caves and others wrote that "Partners benefit from communication output "that fits within their attention, their memory, "their social interaction abilities." So I'll give you a little scenario of India communicating.

As we are driving through downtown, we're driving through D.C. We've gone to lunch and we're driving through D.C. and India prefers to write a lot of her communication. She doesn't use technology all that often for speaking and so she writes and she has absolutely nasty clearable, horrible handwriting and she can scribble so fast because she has so much to say. And so I'm driving and India's having a conversation with me. So we're driving and eventually starts getting dark and so now I'm having to look to my right in the passenger seat, trying to read her scribble as I'm driving through Washington, D.C. and the sun is going down. I finally say to her "India, look, "as your communication partner here, I can't read "what you're writing, what you're scribbling "when the sun is going down." She needed to take in to consideration me and what we were doing, I was driving while trying to read her notes. So you got to think of all kinds of scenarios and each individual is different. And so we have a variety of communication partners. We're gonna talk about who some of those are.

The group has grown consistently over the recent decade. These parties are not only family members and caregivers. There are a host of whole other individuals who are part of our communication partners. And so some of the things we need to do are make sure, and I think Collin did that well. We saw Chip with his dad. His dad knew what he was saying. His dad knew ahead of time but we have a lot of anecdotal information that says that we really have to have the communication partners buying if you will for initial ongoing successful integration of the devices and techniques and strategy. And others remind us that every member of the family is important and we're affected by the introduction of or the updating of a device into the life of a family member. So we have to consider the individual themselves as well as who their communication partners are and really recognize the experience of families and individuals in the community as well as the needs, the stakeholders.

So Sarah Blackstone and her colleagues wrote about the Circle of Communication Partners and essentially those communication partners were life partners at the very center but the very center is the individual who is using the speech generating device or the AAC device but we have life partners, we have close friends and relatives. As you move out there are acquaintances, paid workers and unfamiliar partners. There are few of the family members then and/or close friends and relatives and there are workers and unfamiliar communication partners. And so those circles are large and we have to learn to communicate in those environment and we do know that... So research has shown us that as our social interaction increase, the degree of social inclusion expands so that individuals are not feeling a sense of isolation or loneliness because they have more and more opportunity, to build ties and interaction. We knew that individual has complex communication needs or the high risk for having restricted social networks and so we have to keep that whole social networking in consideration at various points in our life. We're gonna work at a, speaking of communication partners, we're gonna watch a brief video of Jean and who her communication partners are. And so it's just about a minute or so but I want you to know there's all the different interactions here.

- [Voiceover] Pat while you're queuing that up, Ken, noted that writing recognition has come a long way in the last few years, perhaps talking about your partner in the car--

- [Voiceover] Right.

- [Voiceover] Understand writing, at least you might have made it so you didn't have to be looking at her writings.

- [Voiceover] Exactly, Ken that's a good point as well as gestural recognition. When we talk about individuals that have such significant motor disruptions, we're now finding and the researches is really getting better on gestural recognition but you're also right with writing information of text. Thank you so much. Now we're gonna queue up Jean. Anybody?

- [Voiceover] All right Jean, you got your car.

- [Voiceover] Car.

- [Voiceover] Yeah, what are you gonna do with your car?

- [Voiceover] Drive.

- [Voiceover] Yes, absolutely but have you practiced driving yet?

- No.

- [Voiceover] Well who is gonna help you practice driving?

- Vicky.

- [Voiceover] Yeah, anybody else?

- Um...

- [Voiceover] Nolan, this is the wrong video.

- [Voiceover] That's my clean video.

- [Voiceover] Right, there's one other Jean video and we're gonna use this one a little bit later on and I can certainly interact it. Do you see the one that I was caught

- [Voiceover] Oh, that's the one, okay.

- [Voiceover] Yeah. So everybody in the audience, if you just wait for one second. You're gonna see a real difference between Jean and we're gonna talk about that in a few minutes, the Jean that you see in the video that Nolan is pulling up right now.

- [Voiceover] Go.

- [Voiceover] I'm so proud of you.

- I'm so proud of you.

- [Voiceover] Good job.

- Good job. Good job.

- [Voiceover] Good job.

- [Jean] Help us park.

- [Voiceover] I need to talk.

- [Jean] I don't know, need to talk.

- [Voiceover] I need to talk.

- [Jean] Talk.

- [Voiceover] Talk about Harley.

- Talk.

- [Jean] Talk and.

- About.

- [Jean] About Harley. Harley.

- [Voiceover] School.

- [Jean] School.

- [Voiceover] Softball.

- [Jean] Softball.

- [Voiceover] Cheer.

- [Jean] Cheer.

- [Teacher] Fee.

- [Jean] Feed.

- [Teacher] Fee.

- [Jean] Feed.

- [Teacher] Fee.

- [Jean] Fee.

- [Teacher] Fee.

- [Jean] Fee.

- [Voiceover] Fie.

- [Teacher] Fie.

- [Jean] Fie.

- [Teacher] Fie.

- [Jean] Fie. Fie.

- [Voiceover] Foe.

- [Teacher] Foe. Foe.

- [Jean] Foe.

- [Teacher] Foe.

- [Jean] Foe.

- [Voiceover] Foo.

- [Teacher] Foo.

- [Jean] Foo.

- [Teacher] Foo.

- [Jean] Foo.

- [Teacher] Foo.

- [Jean] Foo.

- [Teacher] Great, okay. You just--

- [Teacher] Fie. Fie.

- [Voiceover] Foe.

- [Teacher] Foe. Foe.

- [Jean] Foe.

- [Teacher] Foe.

- [Jean] Foe.

- [Teacher] Foo.

- [Jean] Foo.

- [Teacher] Foo.

- [Jean] Foo.

- [Teacher] Foo.

- [Jean] Foo.

- [Teacher] Great, okay.

- [Voiceover] So as we looked at that video, we see that the communication partner that Jean needed to take into consideration where she was a mom, so she had two daughters, Carly and Katelyn. She was Steve's wife. She was Louis' friend. She had a lot of friends in the community. We see in this first video, I mean this video that we just watched. The first one that we pulled up, I'm gonna show you again whether you see how improved Jean's speech was and that's what we're gonna talk about, how she became more competent. Because right here she's working on consonant vowel sounds, she's working on imitating an immediate model where she would prompt herself using the device and then try to repeat it. What we were talking towards with Jean and with Norlan and with Chip was essentially communicative competence and that's originally designed by Janice Light back in 1989. As an individual's ability to communicate functionally with communication partners across the day and across all of their natural environments and that's really important what's natural.

A natural environment for me is very different than the natural environment for my sisters which are very different than the natural environments for my neighbors. So communicative competence is defined as linguistic competence or linguistic skills, operational skills or competence, social skills competence, strategic skills and competence. So linguistic skills and competence, we saw Jean and we saw some very limited linguistic skills. We saw India and the writing that she did and she has some very strong linguistic competence and she's a very successful human rights attorney. She's also a past-president of USSAAC and she got all kinds of things. Look at operational competence.

We saw Chip and he knew how to work the screen. He knew how to work with there were icons on it. He or whether there were letters on it, how to turn the volume up, how to turn the device on and off, how to move. You saw operational competence with Norlan when he was working two separate devices. He knows how to control now Vantage but the iPad. Social competence or social skills competence, I think we saw that with Collin and strategic skills, strategic competence. I'll give an example, Norlan one day was leaving my office and his mother said, "Tell Pat where we're going "when we leave," in my office in downtown Baltimore. And he looks at her and then he gets a smile on his face and starts running through his Vantage and what he had done is they were going sailing to downtown sailing center and he didn't know, he didn't have sailing in his Vantage. So he went to sit, he went to nouns, sailboat and then he went to his backspace and took off B-O-A-T and then he added I-N-G from the trim. He was using Picture WordPower at the time. So he was able to say sailing because he strategically knew how to get to that word. He could have spelled it with word prediction, there's all kinds of things he could have done.

So when we talk about breaking out these, we'll run through this but essentially what are the receptive and expressive language those of the individual and their native language. But not only of the individual of his or her communication partners and that competence is the ability to learn and use symbols or letters or words or drawings, whatever it is that an individual can communicate meaning. Our linguistic skills or competence or an individual's ability to learn in the composition, in the language of the AAC if you will, whether it's Picture WordPower or whether it's another icon set or whether it's a keyboard, statistically arranged keyboard versus the qwerty keyboard versus an ABC keyboard and these operational skills are important for electronic and non electronic devices and we have to keep that in mind. Social skills refers to the pragmatic aspects of communication which are critical in all forms of communication.

So we saw Norlan, what he wanted to do is he wanted to change up the order in which he did things. And so he put his finger up and he turns around and he laughs, and he smiles and laugh because he was like saying to me "I know, I didn't do it "the way that we normally do it," and I just need to give him validation there, yeah, it's okay. You can do it this way. And so those are some social skills that he incorporated into that communication that we had which happen to be in a therapeutic environment. Strategic skills, those compensatory techniques or strategies that are employed by an individual to, I'll say, guarantee effective communication interaction. I don't know that we can ever guarantee anything. But some of these strategies may include mechanisms to introduce a communication partner to an AAC strategy or to avoid or repair a communication breakdown. There are all kinds of strategic competencies that we need to include and some of these need to come through therapy.

So an individual gets the widget, the communication device depending on what their needs are and what their skill set is. We need to work with that individual and so very often we're going to have to also do some AAC treatment or therapy. But I wanna ask now, I wanna do a poll question and ask those of us that are here today. Which is the most important environment to practice and use your skill to communicative competence? Would you say it's in the therapy setting, it's in the home or it's in the community and if we could pull up that poll and a handful of us and can respond to that. Okay, so we have the poll right there underneath the slide. So, which is the most important good, environment to practice and use skills of communicative competence? Therapy setting, home, community? This is perfect. All right, now I want everyone to look at that poll and if you would do a mirror image of it and then look at the next slide. So you guys hit the nail on the head.

So when we talk about social validation, therapy is at the top of the list and that's what you all said. In the home is more but out in the community is where you really develop and increase develop, really use your competency to communicate. So you guys really did hit that nail in the head. I mean use Jean as an example of this whole social validation. Although I did say that when Chip was talking with his dad, his dad was in the home but his dad was giving a whole lot of really good stuff with him. His dad was like I said have been... Chip said, "Time for," and his dad said, "Time for, time for what?" He said, "Come on Chip, do it." And then Chip says, "Dinner." He goes, "Yeah, you like dinner." And the next time when he was doing it with the keyboard, he said, "Yeah, it did say time," after Chip had typed up T-I-M-E. And so this whole concept for validations from other or how we develop our skills, it's how all of us developed our skills whenever we start to developing speech and language. Gonna use the case study of Jean in our last couple of minutes that we have here and you saw Jean talking with her daughter and with, she has been with Louis her friend. And then about a year later after therapy, we started noticing some things.

Now, we notice that whenever she would block or not be able to say a word with her husband, he would give her a linguistic prompt where he would say the initial sound or a phonemic prompt. We were noticing that they were fading that Jean starts spontaneously produce wonderful word questions and comments with her own natural speech and some examples that Steve gave me where dinner, like when he came home, she would say "Dinner" like do you want dinner now? She would say "What now?" I asked her a question. Who went out for dinner on the other night? She said, "Me, Carly and Steve." And then who knows what question she was answering. She said, "Yes, he wears it." So those are examples where she had a communication device.

In addition to the electronic communication device she also used writing on a paper and she also spell things out in the air on occasion. All of this was helping to develop her natural speech. Then a few months later Steve reported that Jean was using 60 plus words for items around the house and that friends would take her to the grocery store and expect her to order items. In fact, we did that as a homework if you will in therapy. I said, "When you guys go to the grocery store, "Steve, this week, make Jean say "everything that she's putting in the cart." And they came back the next week and they were like "Well we didn't get everything in the grocery "that first time but she started doing this thing." He reported that while they were driving, Jean would say stop, left, right and so she was really interacting in and playing her role as the wife while they were driving, while she was a friend. And then we continued on and we got more data. And we looked at Jean in May of 2009 where she was independently saying things 20% of the time. She was using her device 20% of the time and she was relying on phonemic cues when her communication partners 40% of the time. And then 11 months later she was communicating independently 67% of the time. She was using her device to prompt her 23% of the time and she was no longer relying on phonemic cues. And the way we got some of this data, she was using picture cards as open ended questions at home and was only requiring minimal prompting. So now what we will look at the video of Jean and I want you to look at her communicative competence and how she's learned to use her device across communication partners across environments and so this is gonna be a little different than the first five video.

- [Voiceover] All right Jean, you got your car.

- Car.

- [Voiceover] Yeah, what are you gonna do with your car?

- Drive.

- [Voiceover] Yes, absolutely but have you practiced driving yet?

- No.

- [Voiceover] who is gonna help you practice driving?

- Vicky.

- [Voiceover] Yeah, anybody else?

- Beth.

- You got it started.

- [Voiceover] Your husband.

- Steve.

- [Voiceover] Very good, Vicky and Steve are gonna help you drive.

- Drive.

- [Voiceover] What kind of car did you get? Do you remember?

- Dazda.

- [Voiceover] Mazda, did you get the Mazda 3 or the Mazda 6?

- Six.

- [Voiceover] Very cool. What color is the car?

- You can do this. We practiced this with colors of shirts. What color is your shirt? Is that orange?

- No.

- Blue?

- No. Red.

- [Voiceover] Very good. You got a red Mazda 6.

- Six.

- [Voicoever] Very good. Is it manual or automatic transmission?

- Yeah.

- [Voicoever] Which one? It's not manual?

- No.

- [Voicoever] It's automatic?

- Yeah.

- [Voicoever] Can you say automatic?

- Automatic.

- [Voicoever] Beautiful, very good. So where do you wanna drive in your new car?

- Drive.

- [Voicoever] Yeah, where?

- I don't know, downtown.

- [Voicoever] Yeah, do you wanna have the radio on?

- Yeah.

- [Voicoever] Singing?

- Yes.

- [Voicoever] You're gonna go spend?

- Money.

- [Voicoever] Where?

- [Voiceover] And so I'm prompting her with a model.

- At the?

- Mall.

- [Voicoever] Very good. Are you gonna shop or eat at the mall?

- [Voiceover] She's using gestures, she's smiling.

- Shop.

- [Voiceover] Shop, very good.

- And, okay...

- [Voiceover] So we can stop that video here just because we're running out of time but I hope that this last video illustrated that Jean was using a variety of strategy so that she communicated not only with her friend Louis. Her husband Steve was sitting to her right out of the view position. I was in the room. We were really just having conversation for adults, having conversation but she also had to be with Carly when she was cheer leading. She was as I said with friends in the community. That was very different. This is an acquired disability in her mid-40s and you can see that it took a while to get her communicative whether it was using a combination of her device with writing, with gestures and from natural speech goals.

And so each person is different. There's no question, that's what the word individual means. We have to consider on the individual. Not only but we have to primarily consider the individual and their communication partners and their needs when we're looking at strategies. And as I said in that process then we do follow-up because when you're communicating, as I said, a 17 year old that's not like communicating like a 35 year old and so but they constantly keep this up. I really wanna thank everybody for coming to this session this afternoon. I appreciate the interactions. I appreciate the comments. I appreciate that you did the polls and did it so well. Anyone can feel free to contact me via e-mail which is up here on the screen or call my cell if you want, I always have it on. And have a nice day. Thank you so much. Thanks Russ for the opportunity.

- [Voiceover] Pat, you have them just a couple of comments that I just collaborated what you were just stating the need to practice in every setting in which the individuals can use the AAC.

- [Voiceover] Perfect.

- [Voiceover] And that it's gonna depend completely on various client's needs.

- [Voiceover] Isn't that wonderful. If you guys get, yeah, that's all exactly right. That's great. Well thanks everybody for coming.

- [Voiceover] Just to note Ana-Maria has put a link in the chat box. We'd really appreciate it if you take the time to go to that survey and just let us know whether this webinar met your needs or how we might improve them in the future. We take those comments real seriously because we're always trying to do better and to make things more relevant to the folks that are participating. So I'll add my thanks to Pat, to you all for coming. And to you Pat, thanks an awful lot for putting this together and sharing it with us today.

- [Voiceover] Absolutely. All right everybody, have a great day.