Tag Archives: Thought process

10.22.2014: Supervisory Notes — Resources related to AAC & Aphasia

Notes on clinical supervision, ,

There is considerably more I would like to someday do to collect my thoughts around AAC and persons who have aphasia, but for now I just wanted to document the resources I have used to-date to inform my process with assessment and intervention.

One of my challenges here is that this clinic is typically the “last” stop/hope for folks — more often than not, they’ve  already been through acute care facilities, outpatient rehab, and whatever home care their insurance would pay for.  I am usually consulted (a) when other efforts have proved unproductive and/or (b) there’s no more money.  This frequently means that there may well be a lot of non-functional habits and frustration built up.  As a result, what we do here may be very different than I would do if I was at any of the prior stages (front line/acute care, outpatient, in-home).
That said, my bias is clear:  I am strongly in favor of multimodal intervention for pretty much any/everyone.  I signed and used visual schedules made from Boardmaker symbols with my own children as infants, I used hand signals and visual cues for kids with artic/language and fluency, I write things out and provide visual aids with graduate students seeking a Master’s degree, and I would never never never meet with someone I knew had experienced a brain event and just talk to them and plan for them to just talk to me.    In short, I feel like my own sense of myself as an SLP aligns pretty well by the Beukelman & Mirenda Participation Model which is described in their AAC text.

As it applies specifically to persons with aphasia, there is additional information about the Life Participation Approach to Aphasia:
– ASHA statement: http://www.asha.org/public/speech/disorders/LPAA/
– ASHA Leader article:  http://bit.ly/1wjDQr7
– Supporting Communication for Adults with Acute and Chronic Aphasia (Simmons-Mackie, King, & Beukelman, 2013)

I feel like the AAC Aphasia Screening materials from the University of Nebraska Lincoln, http://aac.unl.edu/screen/screen.html  may be helpful to “aid in determining whether the person with aphasia can benefit from partner dependent or independent alternative communication strategies” (quote from the Purpose description, p. 3).
I have also found the following courses throughwww.speechpathology.com to be enormously helpful:
* #5361 AAC and Aphasia by Sarah Wallace
* #4208 Use of AAC Devices and Strategies for People with Aphasia by Sarah Wallace
– #5157 Steps to Success with Technology for individuals with Aphasia by Denise McCall
– #5742 AAC Medicare/Medicaid Funding and Documentation by Patricia Ourand
* #5138 Selecting Apps for Therapy: A tutorial for SLPs on using an EBP model to assist with choosing intervention tools by Lara Wakefield & Theresa Schaber
* #5186 The PICO Template for Reviewing Speech-Language Therapy Apps: A decision-making tool for SLPs by Lara Wakefield & Theresa Schaber
– #5781 AAC Apps:  Finding the Right One For Your Client by Carole Zangari
* #5518 Denial of Deficits and Aphasia by George Wallace
* #5068 Coping with the impact of Aphasia:  What do Significant Others Need and How Can SLPs Help? by Barbara B. Shadden
* #6079 Helping Clients and Families Attain Their Goals:  A Basic Counseling Function by Audrey Holland — although this is described as being generally about counseling (and it is), the examples are more specific to persons with aphasia.
– #5447 Counseling Around the Edges by Audrey Holland
– #4995 Counseling and Communication Disorders:  Working with Feelings and Emotions by Michael FlahiveThese are roughly in the order that I might rank them in strength/value related to Aphasia, plus the asterisks represent the best within each category.  Many of these are available in a variety of formats although I tended to take the “Text” courses when possible.  There are other Aphasia, Aphasia & AAC, & apps decision-making resources at www.speechpathology.com I just haven’t gotten to them yet.
Finally, the AAC-RERC has a free webcast on AAC for Aphasia: A Review of Visual Scenes Display Project:  http://bit.ly/1nwWn3q and an example funding report:  http://bit.ly/1t5dawn

11.20.14 Update — Supervisory Notes, “Trust the Process” Reflection

Notes on clinical supervision, ,

A couple of thoughts were brewing in my head all at about the same time right before Thanksgiving in 2013.  This was also updated in November 2014.

Event 1:  Dr. McNaughton made a comment at an AAC Faculty meeting that in the SPED department, they use a “CONE” approach — trying to be mindful of the Content of the Next Environment — to review whether or not students are prepared to move forward.  “Prepared” is something of a trigger word for me.  Students have either told me directly or provided in written feedback that they very much appreciate our discussions, my guidance, resources I share, etc.; however, that they worry that they are not prepared for the Real World, for how things actually go in the schools.  I work very hard to align what I teach them through clinical practicum experiences to what they learn in their courses, I hope to model EBP with my supervision just as I hope they will apply it in their clinical careers (and, over time, as they have opportunities to mentor or provide supervision themselves).  So I have struggled with how to reconcile the idea that some students suggest they feel more ‘principled’ than ‘prepared’ when we’re done.  At present, I’ve come to the notion in my own mind that my role is not to prepare them how to DO the work — it’s a mistake to think that’s even possible — but how to THINK THROUGH the work.  Uncertainty is part of the gig:  there will always be an unfamiliar diagnosis, or an unusual presentation of skills/needs, an unexpected confluence of personal and work events.  My goal isn’t to share with them every possible scenario, it’s to hopefully put a foundation of problem solving skills and coping strategies that will support their efforts.

Event 2:  A surprising number of second year grad students have expressed the notion, “I just want to know what you know.”  I have had a surprisingly emotional reaction to that idea — that’s simply not fair.  I didn’t know what I know now when I was where where they are — I’ve worked hard to know what I know now.  I’ve earned it.  Further, I am certain I don’t know everything:  I’m very much committed to being a learner yet myself.

So given these thoughts, I wanted to present an activity to the students I am working with to engage them in an experience.  In a general sense, my goal was oriented around the notion of “Trust the Process.”  To not get to caught up or rushed in knowing it all, to not feel like that is the goal, to not consider uncertainty and the disquiet that comes with it as indicators of failure/weakness.  In addition, since it was in front of the Thanksgiving holiday and at a stressful point of the semester (the stampede to the end), I also wanted it to be very different than the assignments they get in their courses.  The following is the email I sent.

“We are at an interesting place in the semester, and I would expect everyone is feeling a degree of tension about getting from here to the next point.

For everyone I am working with through the clinic, I would like for you to please set aside 15 minutes to BRIEFLY review the following, choose one, and email me a 1-paragraph response.  There are no right/wrong answers.  I want to repeat that:  There is no specific answer I am looking for other than authentic consideration.  Due to me by November 30th.

(1).  In 2011, Alan Kamhi established a Clinical Forum on “Balancing Certainty and Uncertainty in Clinical Practice,” and posed the question, “How certain are you that your clinical decisions and practices are the most optimal ones for your patients?” Although I found the whole forum to be excellent and thought-provoking, attached is a three-page response (also in hard copy in your box):  Finn, P. (2011).  Critical Thinking:  Knowledge and Skills for Evidence Based Practice.  Language Speech, and Hearing Services in the Schools, 42: 69-72.

((2).  This 5:22 minute clip from Between the Folds on https://www.youtube.com/watch?v=OlbneFIcXyU.  I highly recommend the entire documentary if you have access, but for now I’m especially interested in this segment.

(3).  A diagram on OODA.  (Note:  The link here includes text and discussion but I just send the diagram itself as an attachment to the email.)

******

I chose these because they do speak to the value of critical review, of being systematic and engaged in learning/questioning/evaluating specifically as an SLP (the Finn article); because the origami sequence is amazing in Between the Folds and he specifically talks about the process and the tension that exists within it; and the diagram comes from a business website but actually illustrates a flowchart of how to engage EBP.  I chose these because they inspire me, and I was interested in reaching the students in different ways (clinical/research-based; artful; graphic).

The responses have been truly great — I have loved the reflections and conversations we’ve had, and this lent itself very well as a lead into a discussion on actively Engaging in Learning (Lesson Plan available in Resources).

So it’s been a wonderful and exciting learning experience for me, too.   I’ve so enjoyed their perspectives into all of this, and how different it is from the other things they do while in the graduate program or that we have done together with their clinical practicum.   Some of them haven’t gone exactly down the path of “Trust the Process” but that’s okay — there were no right or wrong answers.

End blip.

10.17.13 — Supervisory Notes, Talking about 2nd phase of assessment w/examples

Notes on clinical supervision, , ,

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.