In the clinical practicum instruction I provide for assessments of individuals with complex communication disorders, we apply a multiple-phase process: (1) information gathering through record review, interview, surveys/checklists, and observation with familiar partners in familiar surroundings (by video if distance prohibits on-site visits), (2) direct observation at the campus clinic via structured “naturalistic” opportunities to review current communication (receptive, expressive, and pragmatic language; means of communication; purposes of communication; sensory and/or motor, seating and positioning considerations; literacy; partner-interactions, etc.), (3) direct observation at the campus clinic via structured “naturalistic” opportunities for what strategies and supports may effect meaningful change in the individual’s communication opportunities and effectiveness, and according to what features (e.g., size, symbol representation, organization, etc.); and (4) a review of findings. There is considerable overlap among the phases and it requires multiple sessions to complete. I find that students have a sense of the principles involved and frequently have practiced these ideologies through case study example projects for courses. But having a real person to think about and face, a team to work within, a family or school to report to, and, most importantly, the genuine hope to truly help an individual, all add a profound stress on how to think all of this through. After talking with students, the following is an email I send to review the principles we discussed. This example is for a preteen young woman with complex sensory and motor needs in addition to no verbal communication and mixed reports about minimal language (e.g., both making choices to convey wants and answering yes/no questions are in question).
“We’ve talked about how the assessment plan for our first session here on campus needs to reflect what unanswered questions you feel you need to directly observe, and what strategies/supports you would like to consider for review (no tech, low tech, high tech). Much like plans for intervention, this should include your objective (what you want to learn), rationale (why/how what you learn will inform next steps), the activity or structured event, whatever materials are needed to complete activity, means of communication, and data collection. Different from intervention at the clinic, I also need to know who is doing what.
When we met at the very beginning, we said that we needed to start from what we know now and hypotheses based on our observations and what the literature/research base would inform as relevant for her age/experience. We want to consider our objectives for how we are going to learn what we need to know, and then develop activities that will allow us opportunities to gather information. When we talked earlier, I wanted to expand on that piece with some examples but I know it can be difficult to remember everything. My apologies for the long email but I hope this can be a reference of my thought process and how it leads to specific questions/objectives.
For example:
Rationale: Based on interview and parent completion of surveys/checklists, determine CLIENT’s receptive and expressive vocabulary. Observations and parental report indicate that CLIENT has an extremely limited vocabulary. No tech: Siegel and Cress’ (2002) Communication Signal Inventory from Exemplary Practices for Beginning Communicators (p. 36-38) to determine what behaviors/patterns/signals familiar partners successfully cue into. Multimodal (no tech, low tech, high tech): The PSU research on early intervention with beginning communicators (with young children) and early research with older individuals who are at beginning levels of communication suggest in-context support of vocabulary and benefits of social sequences (aka, joint action routines). The UW AugComm Continuum of Communication Independence discusses a need for a clear and reliable signal for acceptance and rejection as foundational for building yes/no.
Accordingly, assessment questions/objectives may include (but are not limited to):
(1). Provide structured opportunities for observation of CLIENT’s receptive vocabulary, expressive behaviors/signals/signs.
(2). Provide structured opportunities for observation and assessment of supports/interventions to expand her vocabulary with symbolic means.
(a). Given instruction and coaching on partner assisted scanning consistent with Linda Burkhardt’s research; please particularly note information re: Rett Syndrome since that has been suggested as the closest comparable profile): what is parental reaction; based on observations, what is sense of vision/motor obstacles; observable behaviors of reaction from CLIENT?; observable indicators of potential?; if yes, journals/data collection to be sent home for specific targets?
(b). Given instruction and coaching on principles of intervention outlined by Light & Drager research, adapted for older individuals who are beginning communicators: what is parental reaction; observable behaviors of reaction from CLIENT?; observable indicators of potential?; if yes, journals/data collection to be sent home for specific targets? Will require provision of some materials (e.g., printed symbols/photographs; recommendations for apps).
At present, CLIENT has extremely limited means of communication and it is not clear what types of references will be most beneficial/effective for her.
(3). Provide structured opportunities for observation and assessment of symbolic representation: signs/gestures, actual objects, photographs of discrete items, photographs of scenes/contexts; picture symbols; text; photographs, picture symbols, or text which have been modified for high contrast, etc. What would we need to know about vocabulary/concepts that she currently understands in order to be able to set this up; or, in the absence of that information, what kinds of teaching/structure would we need to put in place for a valid assessment? What are observable behaviors of reaction from CLIENT? Are there distinctions in engagement (interacting at all, without specifying whether or not was ‘correct’), versus accuracy (seeking a specific answer)? What are observable behaviors to indicate processing for # of options presented: one at a time w/partner assisted scanning? choice of 2? more? Presentation in vertical versus horizontal? Size of symbol?
(4). Provide structured opportunities for observation and assessment of organization (e.g., categorical, event, PODD): given a review of options, what is parental reaction? What are observable indicators of ease of use for partner to augment input and make means of expression available? Accuracy? What can we provide for home trial — for example, a simple book of references based around her reported key partners, interests, activities (categorical); a book based around concepts organized for her daily routine (event based); a book based around conversational sequences common for her life events and/or teens (PODD).
Those are just examples, but please refer to the materials I have provided for what Beukelman & Mirenda considers the key areas for assessment, the information and references compiled by the National Joint Committee for the Communication Needs of Persons with Severe Disabilities; and the published materials such as the Communication Matrix; Functional Communication Profile, Revised; TECEL; Social Networks; and AAC Profile (among others) as means of structuring or focusing our efforts. Again, always start with your objective (what do you wish to learn), and we can build activities around that.”
It’s a long process and has been argued that may not well match what can be accomplished outside of a University clinic environment. I hear that argument, and know that there is valid concern on whether my approach authentically prepares clinicians for different environments. That said, I feel that it is my mandate to align my practices as closely as possible with what is taught in the courses as best practice — that to do otherwise perpetuates poor practices elsewhere. So I strive to be an example, sounding board, model, coach, etc. towards that goal and hope that students will adapt and advocate over time to the circumstances they face to raise the expectations and practices elsewhere.
End blip.