10.13.13 — Talking about speech relative to AAC/Multimodal communication

Notes on clinical supervision, , , , ,

A recent online discussion on the ASHA Special Interest Group for AAC (SIG 12), got me thinking about the various resources that have fed into my collective sense of how to relate to the question:  “Will speech be [negatively] impacted by AAC?”  The following is my attempt to have some sense of organization to the range of materials which contribute to my own thought process when having this conversation with families or school teams.  For the sake of ease/time/effort (always in limited supply), much of this is cut and pasted from other places — which sometimes results in odd formatting and abrupt font mixes.  My apologies for that.

(1) Dr. Light and Dr. Drager at Penn State did extensive research on Early Intervention with kids as young as six months old who had developmental disabilities such as autism, cerebral palsy, Down Syndrome and others.  Their work is profiled at their Early Intervention website with comprehensive discussions and video clips of the principles of intervention which fully incorporated the range of no tech (e.g., intonation, vocalizations, speech, gestures, sign language), low tech (e.g., print materials such as photos, picture symbols, communication boards and books), and high tech computer technologies.  The FAQ page on the site goes into some discussion about the question of benefits of AAC and implications on talking, and specifically references an intensive review of the literature  which found no evidence of negative impact:

–> Millar, D., Light, J., & Schlosser, R. (2006). The impact of augmentative and alternative communication intervention on the speech production of individuals with developmental disabilities: A research review. Journal of Speech Language Hearing Research, 49, 248-264.

I have sometimes found that using these video clips or those from the Literacy Intervention website  can help illustrate that speech is always modeled, supported, and reinforced.  Using case studies like these can sometimes add an objectivity or emotional distance from the conversation:  I can talk about my thought process around the individual(s) profiled and how decision-making and/or priorities might be considered without it being quite as personal.  In particular, the Success Story of Sandra on the Literacy website illustrates beautifully (and heartbreakingly) what access to multimodal instruction in literacy has meant to her as she speaks in her own words about being underestimated much of her life to that point.  Her profile further explains that she uses speech, gestures and a communication book to communicate as well as a computer with speech output.

(2)  The next two are from books or journals written for SLPs, so they may be pretty dense reading to someone less familiar with the jargon.

– Hustad, Morehouse, and Gutmann (2002).  “AAC Strategies for Enhancing the Usefulness of Natural Speech in Children with Severe Intelligibility Challenges.”  From _Exemplary Practices for Beginning Communicators:  Implications for AAC_.   This book chapter is dedicated to discussion of what kinds of multimodal or AAC supports may be put into place for individuals with compromised speech either some (in which case, clarification strategies may be predominantly appropriate), or all of the time.
— King, Hengst, and DeThorne (2013).  “Severe Speech Sound Disorders: An Integrated Multimodal Intervention”  Lang Speech Hear Serv Sch 2013;44;195-210:  This presents research which had evidence that incorporating multimodal communication (options in addition to or in support of talking), IMPROVED speech as well as demonstrated gains with communication overall.
A slightly more parent-friendly “print” reference includes:
— Closing the Gap put together a report on Evidence-based AAC interventions for individuals with autism spectrum disorders in April 2013.  In particular, it includes a  sample AAC Implementation Plan — it is a table that reviews the kinds of opportunities that may be available across the school day, and the variety of additional supports that may be put into place/made available to support effective communication opportunities.  It really resonated for me across a wide variety of individuals because I think often one of the challenges school teams have is identifying situations and what kinds of supports will be meaningful and can be reasonably adapted.  The SETT model is a framework for reviewing opportunities like this; it stands for:  Student, Environment, Task, Tool, and represents the kinds of questions we should ask when trying to identify what the learner’s skills/needs are, what are the demands/obstacles (and, therefore, adaptations) in the Environment, what does the learner need to be modeled/taught/practice in order to do, and what are the strategies and supports which will help him/her learn and achieve.  I really like the Closing the Gap sample review because it shows that there are a wide variety of methods/tools (including speech or speech approximations) that may be appropriate for a particular situation.   Closing the Gap does have a Facebook presence, and promoted the report last April (I don’t know if this will work, but here’s the link to that — https://www.facebook.com/permalink.php?story_fbid=530197533685800&id=137354302970127)
The report is available here, from their archives of last April: http://www.closingthegap.com/solutions/articles/2013-04-01
They have a 2-day free trial, but overall they have a lot of great information.
(3) Taking a slightly different perspective perhaps directed more around Strategic Competence (Light, 1989):  reviewing that we all have different strategies for the people and situation, and that we need to consider Family Quality of Life (Saito & Turnbull, 2007; Granland, BjÖrck-ÅKesson, Wilder, & Ylvén, 2008), within our process of recommendations (if the intervention has too great demand on the stress, resources, etc. of the family, outcomes suggest it is not likely to be sustainable).  The UW AugCom web review of the Continuum of Communication Independence may lend insight into the value of effective expressive symbolic communication across environments — so at home, with familiar partners, a person may be entirely independent and effective with speech only even when there are challenges to intelligibility; and using minimally demanding strategies may be the best decision for the family health as a whole.  However, as service providers and educators our goal is also to work towards competence and strategies broadly with everyone everywhere (especially relative to full access to education and social relationships with peers in the schools).  Again, this has to be framed within a context of what is achievable.   I also LOVE LOVE LOVE the additional modules they have at the left margin.
(4) There is also an increasingly robust body of research in favor of augmented input or Aided Language Modeling (ALM).  Examples also include (but certainly are not limited to):
– Drager, Postal, Carrolus, Castellano, Gagliano,  & Glynn (2006).  The effect of Aided Language Modeling on Symbol Comprehension and Production in 2 Preschoolers with Autism.  American Journal of Speech-Language Pathology Vol.15 112-125 May 2006. doi:10.1044/1058-0360(2006/012)
– Dada & Alant (2009).  The Effect of Aided Language Stimulation on Vocabulary Acquisition in Children with Little or No Functional Speech.  American Journal of Speech-Language Pathology Vol.18 50-64 February 2009. doi:10.1044/1058-0360(2008/07-0018)
But truly there is a lot that can be found in this area — some specific to particular methodologies, such as with the work by Porter & Cafiero relative to PODD.  The website/Facebook/Pinterest presence at PrAACticalAAC also has numerous articles and references.

(5) Last, but absolutely not least, there may be a huge, huge value in first-person accounts from other parents.

Rob Rummel-Hudson, dad to Schuyler, writes the blog “Fighting Monsters with Rubber Swords”, as well as articles for Support for Special Needs and he has a presence on Facebook.  Rob is unflinchingly honest about his emotions around Schuyler’s challenges, the value of AAC in her life, and how both he and Schuyler continue to fervently wish for a day when she will be able to “speak like her friends” even as they recently made the decision in her IEP to discontinue that as a target in favor of focusing on her fluency with multimodal communication.  Rob is deeply eloquent in his discussions of family life, interacting with schools, and I rarely leave his writings without feeling deeply moved.

In April of 2013, Dana Nieder published “An Open Letter to the Parent of a Child with Speech Delays” on her family blog, “Uncommon Sense” about their family’s experience loving and supporting her daughter, Maya, and coming to terms with decisions around AAC.  She is honest about the process — the importance of feature matching, the impact on family life — and provides resources parent-to-parent for others to reflect on what may be best in their own lives.

I imagine there are first-person accounts from the other side of parents/families out there who made the decision to focus entirely on speech, successfully…but I do not know of those.  My ~guess~ is that these may be associated with specific interventions (and substantial investments financially, and in practice/focus both in and out of therapy).  I don’t want to fall prey to a Bias of Fairness and assume that there always is an equally relevant, balanced other side to the argument — I think sometimes that the effort in seeking one out is a distraction from what could be authentic and functional change and/or feeds false hopes .   But neither do I mean to be closed minded and beyond surprise — so I certainly acknowledge that there may be profiles/characteristics/indicators which could be of value to families and SLPs trying to make this judgment call of how to best allocate limited time, energy, and resources.

For now, for me:  speech is always anchored solidly within a deep belief around Multimodal.  From there, it is a process of the evidence, the family values, response to intervention, functional outcomes, and prognosis.

End blip.