“Speech is the most important thing we have. It makes us a person and not a thing. No one should ever have to be a thi

1. “Speech is the most important thing we have. It makes us a person and not a thing. No one should ever have to be a thing.”-Dorene Individual who uses AAC

2. Augmentative Communication-How Do Pediatric Occupational and Physical Therapists Fit In? Molly Shannon, OTR/L, ATP Tammy Pereboom, PT, ATP North Carolina Assistive Technology Program www.ncatp.org

3. NCATP Overview • Federal and state funded Tech Act Program • Free consumer consults if no funding source • Fee based evaluations, trainings • Interagency collaborations • Loan Program • Speech to Speech Dial 711, Overview/handout • Work with all ages and all disabilities in many western NC counties (depends upon age as to which counties, but about 12-22 counties overall)

4. Overview, Introductions • Molly and Tammy’s bios • Course Objectives: definitions, OT/PT roles, AAC, Assessment, Access, Mounting, Devices, Resources • Agenda, Handouts • Two Breaks, Restrooms • Tours of AT center available in breaks, Devices available for hands on • Scott Chapman of Dynavox and Dawn Haynes from Prentke Romich are here, thanks! • Participant Introductions: name, where work, main reason they are here today

5. Why Aren’t OTs and PTs Using AT or Helping with AAC? • Lack of experience and/or confidence • Too little time for additional training • Little access to AT in particular settings • No mentors • Just don’t get it, no buy in yet or “ah-ha” moment or client • Afraid to admit sometimes that we don’t know • Lack of institutional or supervisor support • Lack of resource information • Fear of technology! Batteries to hard drive analogy. • YOU ARE HERE! Thanks for coming!

6. Definitions of OT, PT and AT • AOTA: OT is skilled treatment that helps individuals with disabilities achieve independence in all facets of their lives. It gives people the “skills for living” necessary for independent and satisfying lives. • APTA: PT includes: • Examining individuals with impairment, functional limitation, and disability or other health related conditions in order to determine a diagnosis, prognosis, and intervention. • Alleviating impairment and functional limitation by designing, implementing, and modifying therapeutic interventions. • Preventing injury, impairment, functional limitation, and disability, including the promotion and maintenance of fitness, health, and quality of life in people of all ages. • Engaging in consultation, education, and research.

7. AT Definition from PL 100-407: • AT Device: Any item, piece of equipment or product system whether acquired commercially off-the-shelf, modified, or customized that is used to increase or improve functional capabilities of individuals with disabilities. • AT Service: Any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device.

8. What is Augmentative and Alternative Communication (AAC)? • According to ASHA, augmentative and alternative communication (AAC) is an integrated group of symbols, aids, strategies, and techniques used by individuals to enhance communication. • AAC serves as part of a person’s communication system, supplementing gestural, spoken, and/or written communication abilities.

9. RESNA Certification for ATP • Now is only one certification for professionals and vendors • Used to be ATP and ATS • We do have ATPs from wheelchair companies in Charlotte • Exam, ongoing continuing education, training, ethics, etc. • www.resna.org

10. What Augmentative and Alternative Communication (AAC) Does: • Facilitate language development • Provide a different form of communication, enhancing the student’s present communication system • Increase independence • Facilitate academic development and classroom participation • Offer opportunity for social interaction

11. AAC Does Not: • Inhibit spoken language • Interfere with classroom instruction • Create social barriers

12. AAC may involve: • Low tech techniques, like picture schedules, Picture Exchange Communication Systems (PECS), and communication boards or books. Students touch/point to or look at objects, picture symbols, words, or letters to communicate.

13. High Tech techniques/devices with voice output that provide students with a way to speak intelligibly. These approaches give the student the opportunity to use pictures, words, or letters to produce • a single message, “Please, turn on the fan.”

14. a few messages, “I want a drink.” or “I am hungry.”

15. or many messages, some text based only and some with icon picture support (some with both!).

16. AAC Device Overview • Quick look at some low to high tech devices • No tech ideas: flip, boards • Partner One and other less expensive one message devices: Yes, Virginia there are more options than Big Macs!!! • Tech 8 with ECU • Tech 32 with levels • Dynawrite • Springboard Lite • Dynavox V • Eco 14 • PASS Software for demo, nice option for training! Show Access • Hands on during breaks

17. A Beginning… • I drew it, the letter A. There it was on the floor before me. I looked up. I saw my mother’s face for a moment, tears on her cheeks. I had done it! It had started, the thing that was to give my mind it’s chance of expressing itself. That one letter, scrawled on the floor with a broken bit of yellow chalk gripped between my toes, was my road to a new world, my key to mental freedom. Christy Brown, 1954 My Left Foot, movie and book How can therapists not believe that we are a vital component of AAC delivery?

18. Communication is not only the essence of being human, but also a vital property of life. John A. Piece

19. “Molly or Tammy? Why Did You Stop Being an OT/PT?” WRONG!! • We have never stopped being OTs and PTs. • We are proud to be OTs and PTs!! Some in AT, not so much! • We are therapists that specialize in AT. • AT professionals come from all backgrounds, but OT and PT are logical choices. • We have always done adaptive equipment and AT is just the umbrella term for all of the equipment categories. • As do more AT, become more of a generalist and lines merge with professions.

20. If you want to know what it is like to be unable to speak, there is a way. Go to a party and don’t talk. Play mute. Use your hands if you wish, but don’t use paper and pencil. Paper and Pencil are not always handy for a mute person. Here is what you will find: people talking: talking behind, beside, around, over, under through, and even for you. But never with you. You are ignored until finally you feel like a piece of furniture. • Rick Creech • Individual who uses AAC

21. Categories of AT: Today’s Focus is AAC But Access Overlaps All Areas of Course! • Computer Access • Augmentative communication • Activities of Daily Living • Environmental Controls • Seating, Mobility and Positioning

22. Assessment Assistance: • AT assessment, $6 month for individuals, free 4 wk trial at www.customtyping.com GREAT site. • WATI free AT eval form (37 pages) and other materials online, http://www.wati.org/content/supports/free/pdf/ASNAT4thEditionDec08.pdf 337 page guide to AT, Section 9/10 on seating and positioning. Great forms! • GPAT www.gpat.org FANTASTIC protocols, 14 page one on AAC and OT and PT “areas” are nice • SETT (Student, Environment, Task, Tools) Zabala, hard to find now, but many use. Forms similar in WATI above. • MSIPT (DeCoste 1996) Find still?

23. Checklist for charting 3 observations with 3 different devices M=movement S= site of control I=input method P=position of input T=targeting method MSIPT, handout is an old form, but nice! Assessment form, hard to find anymore

24. http://public.doe.k12.ga.us/DMGetDocument.aspx/AAC%20Evaluation%20Protocol.pdf?p=6CC6799F8C1371F64E4F53D91653586E66B5D054B9D6977ACF2448B2C7785534&Type=Dhttp://public.doe.k12.ga.us/DMGetDocument.aspx/AAC%20Evaluation%20Protocol.pdf?p=6CC6799F8C1371F64E4F53D91653586E66B5D054B9D6977ACF2448B2C7785534&Type=D

25. Suggested Team Roles: No One Person Can Wear All the Hats! • Language/Communication: SLP • Programming of AAC: SLP, AT, parent/consumer, or other with interest! OT/PT? • Curriculum Integration/Literacy: Teacher, AT/OT • Physical Access and Positioning: OT/PT, AT • Linking and Computer: AT or other interested staff, some parents/consumers • Mounting: some would say PT only, but really anybody willing to try!!!

26. OT/PT Role Typical Roles in AT Evaluation: • Functional range of motion • Strength • Sensory • Cognitive, depending upon team • Coordination • Reach • Hand Strength and finger isolation or other isolated access control • Functional skill levels • Posture, changes in position and environments

27. Assumption: Interdisciplinary Assessments • Best to have entire team’s input • Current assessments • Parent and consumer/client info vital • Copies of private or outside evaluations or reports helpful

28. Assessment: A Process, Not An Event Assess to meet today’s needs, then tomorrow’s, and tomorrow’s and tomorrow’s… Beukelman and Mirenda

29. Georgia Department of Education , GPAT: Principles of Assistive Technology Evaluations •Smith (1993) points out that the Goal: Is not Which Device, Rather…. What (The child needs to be able to do) Where (In what environment) Why (For what specific purpose) How (Possible ways to help the child accomplish described tasks in specific environments) Then, which device combined with which services and which individual strategies=FEATURE MATCHING

30. AT Evaluation Considerations • Sensory Skills: hearing, vision acuity, perceptual/discrimination issues • Seating and Positioning: ambulatory issues vs. non-ambulatory • Individual Abilities • Motor and Access, Direct Select vs. Switch vs. Scanning • Receptive and Expressive Communication • Communication Needs • Language Functions • Environments/Partners • Tasks

31. Hierarchy of AT/AAC Access Keyboard Mouse Technology Proportional Joystick Switched Joystick 4 switches 3 switches Single switch scanning 2 switches Single switch Least Restrictive Access Most Restrictive Access

32. Evaluation process, Direct Select? Most preferred method 1. Direct Selection: Determine student’s gross and fine motor abilities as related to accessing a system using direct selection, including • Range of motion • Position changes • Move your object around the area in front of student, assess to the right/left, top/bottom, midline/cross midline • Have them touch, point or pick up items • Fine motor control –how do they touch/point? • Ability to achieve an isolated point, closed fist, hand, arm, etc. • Strength and motor control • 90/90/90 myth!

33. Access Evaluation, cont. • Delays in processing/motor recognition/initiation • Observe/measure how long takes to recognize direction, initiate motor movement and complete motor act • Ability to utilize adapted equipment for direct selection, if unable to access independently • Try handheld pointers, splints, t-bars, headpointers, etc. and repeat range and control observations

34. Direct Selection Access Evaluation, cont. • Determine degree of accuracy student can use to access targets of various sizes • Maximum range and number of targets student can access • Extent to which adaptations can be used to optimize accuracy, efficiency, and range of motion • Determine student’s ability to utilize alternate input devices for adapted direct selection (with AAC or computer based systems) • Mouse, Trackpad, Joystick/trackball, headpointing system

35. Eye Gaze vs. Head Control Access • Prentke Romich devices that are Plus have the Tracker infrared input • Can add on Head Mouse or Smart Nav to any device as access if correct cabling, USB, etc. • Magitek products nice too

36. Head/Mouth Based Access Demos • Head Mouse • Others available • Low tech options to remember is : Mouthstick • QuadJoy? Jouse for access, mouse/sip and puff access

37. Eye Gaze Overview • Dedicated computers or AAC devices now • Products: Eco 14 EcoPoint, EyeMax from Dynavox, Erica, Quick Glance, Tobii, LC Tech • Cost, high but less than used to be! 4K-20 depending upon if buying AAC device or computer • Evaluations cost for true eye gaze systems

38. Demo of Head Based AAC access • ECO • Eye Max?

39. If Cannot Direct Select, Assess for Switch Access • Determine student’s ability to use single switch access (using switch toys, music, w/ SLAT or Powerlink, motivating software with switch interface –no scanning at this point) • Identify activation sites student can use to activate one or more switches • Identify possible switch types • Determine student’s ability to • Activate a switch on command –how quickly, how easily • Release a switch on command –how quickly, how easily • Reactivate a switch –how quickly, how easily • Hold and maintain closure on a switch –how easily • Complete the above listed areas on a variety of activation sites and switch styles

40. Hierarchy of Access Sites: Can Have Multiple Sites for Access Hands Head/voice Arms/elbow Legs/knees Feet

41. Switch Access Evaluation, cont. • Determine student’s ability to use two switches for potential dual switch/step scanning –two sites easily • Determine student’s ability to release and reactivate switch to continue use of communication system • Determine student’s ability to using scanning access for communication system use live voice scanning or partnered visual scanning with single message voice output device • Assess student’s ability to watch a visual cue, process and activate the switch when it is on a designated target (stand behind student if using an infrared pointer -start with one target, move to 2 –designate target, then go to choice 2-4)

42. www.tarheelreader.org

43. Spectrum of Switch Training and Use toys job • Play, Exploration, Leisure • Communication • Movement: Cooper Car, power chairs • Activities of daily living and Environmental control (EADL) • Education, Computer • Pre-vocational and vocational

44. Top Tips for Switch Selection: Movement Issues: naturally occurring, volitional, social and communication issues, motivation is key Positioning and Environmental Concerns: team assessment helps, space constrictions, reflexes, mounting, different locales/times different access? Performance Variables: Target size, Force,Timing, Accuracy, Efficiency, Durability, Safety and Fatigue User Input:Interest and acceptance, Fun for younger users, Increases independence, Comfortable, Ease of use, Reliability, Cost issues Professional or Family Support Pointers: Wait!, consider previous attempts, try it yourself!, ease and reliability of set-up by staff/families

45. 1.Movement Issues • Observe naturally occurring movements • Look for a volitional movement • Don’t let it take away from communication interactions • Social considerations in different settings • Motivating movements will often win out

46. 2. Positioning and Environmental Concerns • Importance of prior team assessment • Reflexes: ATNR, STNR • Space restrictions • Different access site and switches for various settings, times of day • 90/90/90 • Mounting issues

48. 3. Performance Variables • Target size • Force • Timing • Accuracy • Efficiency • Durability • Safety and Fatigue

49. 4. User Input • Interest and acceptance • Fun for younger users • Increases independence • Comfortable • Ease of use • Reliability • Cost issues

50. 5. Professional or Family Support Pointers • Wait, wait, wait for responses • Consider previous successful attempts • Try it yourself to see how it feels • Ease and reliability of set-up for caregivers is key