Alternative and Augmentative Communication AAC EBP Group Extravaganza Presentation 2011

1. Alternative and Augmentative Communication (AAC) EBP GroupExtravaganza Presentation 2011 What is the best practice for the layout/design in augmentative and alternative communication systems for people who have a communication disability ? An update

2. This CAT was completed as a review of the original CAT compiled in 2005 by Speech Pathologists from The Cerebral Palsy Alliance (formerly The Spastic Centre) to appraise the evidence for: Design and layout of communication arrays Whether certain design principles were advantageous for people who have communication disabilities. Background

3. Originally the idea for this CAT was to look into research for PODDs (Pragmatically Organised Dynamic Display) however limited evidence was found to formulate a CAT. Our original question was �How successful is the design of PODDs for individuals with complex communication needs?� In the beginning��

4. Pragmatic � the way that we use language socially Organisation � words and symbols arranged in a systematic way Dynamic Display � changing pages. PODD communication book : the words and symbols organised in a particular way. Devised by Gayle Porter (Speech Pathologist with the Cerebral Palsy Education Centre (CPEC) in Victoria) The aim of a�PODD is to provide vocabulary (larger range): for continuous communication all the time for a range of messages across a range of topics� in multiple environments. They can have different formats, depending on the individual physical, and communication needs of the person i.e., direct access, partner assisted eye gaze, coded access, speech generating device. (http://www.novita.org.au/) What is a PODD?

5. http://www.youtube.com/watch?v=xv-b_GHonJM http://www.youtube.com/watch?v=TOvC9OoygaA&NR=1 Video examples of children using PODDs

6. However limited evidence was found to formulate a CAT regarding PODDS�.

7. We expanded the question to look at the layout / design of AAC in general. Discovered that a CAT had been previously done in 2005 by CPA speech pathologists with a plan to be reviewed in 2007. They concluded�. Insufficient high quality evidence to guide clinicians regarding this question. �Clinicians should be guided by their clinical experience and client and family values�� So our next step�..

8. We decided to review the original CAT. Importance of reviewing the original CAT given the dynamic nature of AAC and how rapidly it changes with new technology. On investigation we found that very little new research has been conducted since the original CAT in 2005 and therefore we were unable to achieve our original objective of reviewing how effective the new AAC systems (high and low tech) are.

9. Layout: topic, place, colour, alphabet, size, dynamic or static Other factors: individual�s age literacy personal preference age of onset of disability motor skills, positioning, accessibility Factors to consider when designing an AAC device

10. Method

11. Level Number Located Case series IV 3 Comparative study III 4 Systematic review I 1 Study Design/ Methodology of articles retrieved

12. Colour Clinicians should incorporate colour in foreground of line drawings when constructing visual displays. Targets that contain only background colour (e.g., Fitzgerald key) but no foreground colour make it slower for younger children to locate the target. When creating AAC displays, results suggest symbols that share colour should be placed together as the speed of location/access increased e.g., Gail Van Tatenhove Use of colour may assist in segmentation of visual scene to highlight contrasts between objects or to highlight detail & as a means of cueing memory. This would suggest that in a natural scene or schema, colour may aid memory however this may not be true for a grid layout. (from CPA CAT) Key findings

13. Example of Gail van Tatenhove�s core vocabulary approach. www.vantatenhove.com

14. Symbol Organisation Adult participants required less time to sequence symbols when they were a shorter distance apart. Symbols that are high frequency combinations should be placed close together on the display.

15. User Preference When people have a choice in selecting preferred AAC systems, this increases their motivation to use the system and thus opportunities to learn communication competence Children value AAC technologies that serve to enhance their self-esteem and social image i.e., integrated systems such as something you can play with as well as a communication system (e.g., iPAD, iPOD). That have a �high smile value� i.e., should be fun. Light J.,& Drager, K. (2007)

16. Age In young children.. generally have a preference for personally relevant schematic layout. (5 ways to group vocabulary - Taxonomic (categories), schematic (event schema), semantic / syntactic, alphabetic, idiosyncratic) ( from CPA CAT) Embedding language concepts within contextual scenes maybe an effective approach for young children learning dynamic display technology

17. Preference and motivation will greatly impact on the outcomes of AAC competence. Colour aids with speed and accuracy of use � (e.g., Minspeak and core vocabulary) Highly used symbols should be grouped together. Clinical bottom line

18. Alternative and Augmentative Communication (AAC) EBP GroupExtravaganza Presentation 2011 Is a high tech AAC system more effective than a low tech AAC system for people with ASD? The adult swallowing EBP Group comprises of both metropolitan and rural members. We teleconference with rural sites at every meeting. There are approximately 41 active and inactive members of the group. The adult swallowing EBP Group comprises of both metropolitan and rural members. We teleconference with rural sites at every meeting. There are approximately 41 active and inactive members of the group.

19. Taking EBP back to the workplace Caseloads being seen � intellectual disabiliies, physical disabilities, ASD, CP, Rett�s Sydrome, Prader Willi, William�s syndrome Difficulties facing � Parent�s perceptions and unaware of limitations � not toy � using for distractions and behavioural motivators Media coverage (e.g. Social acceptance Isolation in community Take into account Fine motor skills Gross motor skills Programming App preferences Current best evidence - List articles found / capped Clinical expertise Varies on client abilities � own performance and preference no set rule � doing better on one system to another Client values Preferences Motivations Community involvement Schooling Media exposure Generalisation Caseloads being seen � intellectual disabiliies, physical disabilities, ASD, CP, Rett�s Sydrome, Prader Willi, William�s syndrome Difficulties facing � Parent�s perceptions and unaware of limitations � not toy � using for distractions and behavioural motivators Media coverage (e.g. Social acceptance Isolation in community Take into account Fine motor skills Gross motor skills Programming App preferences Current best evidence - List articles found / capped Clinical expertise Varies on client abilities � own performance and preference no set rule � doing better on one system to another Client values Preferences Motivations Community involvement Schooling Media exposure Generalisation

20. Why this clinical question? Therapists are finding that a lot of clients with ASD and their families are interested in high tech devices such as Proloquo2go on iPad/iTouch so we wanted to look at the effectiveness of both high and low tech AAC on people with Autism

21. Taking EBP back to the workplace Caseloads being seen � intellectual disabiliies, physical disabilities, ASD, CP, Rett�s Sydrome, Prader Willi, William�s syndrome Difficulties facing our populations / and in general � Parent�s perceptions and unaware of limitations � device is not a toy � often being used as a distractor and to manage behavioural issues Media coverage (e.g. articles being published daily � Ipad is a cure) Social acceptance (e.g more accepted with the latest device to assist communication vs. something else a little more �antiquated� Isolation in community (not having anything to communicate) Take into account through our clinical expertise Fine motor skills Gross motor skills Programming difficulties and experience App preferences Setting in which the device will be used and if it is appropriate or not Varies on client abilities � own performance and preference no set rule � doing better on one system to another Current best evidence - List articles found / capped Client values Preferences Motivations Community involvement Schooling Media exposure Generalisation Understanding of the issue Exposure to different therapies and success had with those before trialling or refusing a specific AAC system Caseloads being seen � intellectual disabiliies, physical disabilities, ASD, CP, Rett�s Sydrome, Prader Willi, William�s syndrome Difficulties facing our populations / and in general � Parent�s perceptions and unaware of limitations � device is not a toy � often being used as a distractor and to manage behavioural issues Media coverage (e.g. articles being published daily � Ipad is a cure) Social acceptance (e.g more accepted with the latest device to assist communication vs. something else a little more �antiquated� Isolation in community (not having anything to communicate) Take into account through our clinical expertise Fine motor skills Gross motor skills Programming difficulties and experience App preferences Setting in which the device will be used and if it is appropriate or not Varies on client abilities � own performance and preference no set rule � doing better on one system to another Current best evidence - List articles found / capped Client values Preferences Motivations Community involvement Schooling Media exposure Generalisation Understanding of the issue Exposure to different therapies and success had with those before trialling or refusing a specific AAC system

22. Steve Jobs called it a magical device. For the parents of autistic children, it actually might be. Experts say the Apple iPad lessens the symptoms of the disorder, helping kids deal with life's sensory overload -- in a sense "curing" the disorder, one parent says. Read more: http://www.foxnews.com/scitech/2011/03/09/can-apple-ipad-cure-autism/#ixzz1fd1ugwHt Steve Jobs called it a magical device. For the parents of autistic children, it actually might be. Experts say the Apple iPad lessens the symptoms of the disorder, helping kids deal with life's sensory overload -- in a sense "curing" the disorder, one parent says.

24. Benefits of Low Tech AAC systems Low cost Easy to use Easy to replicate Easier to use in a number of settings Easier to implement with those new to AAC Easier to implement in acute settings (infection control) More widely recognised and used

25. Disadvantages of Low Tech AAC May have limited vocabulary Communicator needs to get the communication partner�s attention first before sending message Communication partner needs to be able to see the message. For example, seeing visuals in a dimly lit room Communication partner needs to be trained in the use of the low tech AAC, e.g., PECS General public may not recognise AAC as a means of communicating (e.g. community request cards) Can be bulky and cumbersome (e.g. PODD)

26. Benefits of high Tech AAC systems May be able to store a large amount of vocabulary for dynamic display devices Able to get feedback to the user, i.e. says the word/sentence that you have pressed Reduces the communication partner�s burden because the output is spoken language and provides information in a mode that is familiar and non threatening. Allows partners who are non literate to participate in conversation (if device has voice output) Allows communication to happen at a distance Allows predictability More recognised in the �digital age�

27. Disadvantages of High Tech AAC Expensive (although it is getting more affordable now with things like iPads) Takes a lot of time to program Some high tech AAC devices are heavy External factors such as battery life. For example, if battery in High Tech AAC is gone they have no communication method High tech devices are not as durable, e.g., dropping it on ground Can�t be used in all settings (e.g. pool, at the beach)

28. Disadvantages of High Tech AAC Even though the speech is fairly intelligible, it still may be difficult to hear in noisy environments by people with hearing impairments, non-native English speakers or those with reduced receptive language abilities.

29. Taking EBP back to the workplace Caseloads being seen � intellectual disabiliies, physical disabilities, ASD, CP, Rett�s Sydrome, Prader Willi, William�s syndrome Difficulties facing � Parent�s perceptions and unaware of limitations � not toy � using for distractions and behavioural motivators Media coverage (e.g. Social acceptance Isolation in community Take into account Fine motor skills Gross motor skills Programming App preferences Current best evidence - List articles found / capped Clinical expertise Varies on client abilities � own performance and preference no set rule � doing better on one system to another Client values Preferences Motivations Community involvement Schooling Media exposure Generalisation Caseloads being seen � intellectual disabiliies, physical disabilities, ASD, CP, Rett�s Sydrome, Prader Willi, William�s syndrome Difficulties facing � Parent�s perceptions and unaware of limitations � not toy � using for distractions and behavioural motivators Media coverage (e.g. Social acceptance Isolation in community Take into account Fine motor skills Gross motor skills Programming App preferences Current best evidence - List articles found / capped Clinical expertise Varies on client abilities � own performance and preference no set rule � doing better on one system to another Client values Preferences Motivations Community involvement Schooling Media exposure Generalisation

30. Critically Appraised Papers 45 identified articles referenced and sourced. 14 were deemed relevant however only 10 were accessible. 4 articles subsequently CAPped and used for CAT as remaining 8 did not directly relate to question on closer scrutiny of paper As a group we have conducted a fairly complete search for evidence and found 62 potential papers, which has resulted in a total of 6 relevant studies, however only 4 were full articles. As a group we have conducted a fairly complete search for evidence and found 62 potential papers, which has resulted in a total of 6 relevant studies, however only 4 were full articles.

31. Objective: To synthesise research regarding the potential benefits of speech output for persons with ASD Results: Several studies have compared PECS but no mention of speech output made Speech output devices as part of computer assisted treatment packages Packages had potential to teach reading and PA skills for stimulating verbal expression & improving interactions of kids with ASD and their comm partners Speech output from voice output devices (SGD) Contribution of SGD to effectiveness of treatment package unclear Speech output as independent variable Promising results � speech output increased spontaneous utterances but poor design and small sample size Strengths and weaknesses Further research since 2001 Schlosser et al (2001) Aim of the Study To synthesise evidence, research regarding the potential benefits of Speech output for persons with ASD Method 73 published articles reviewed � small number included participants with ASD Studies grouped into 3 Speech output devices as part of computer assisted treatment packages Packages had potential to teach reading and PA skills for stimulating verbal expression & improving interactions of kids with ASD and their comm partners Speech output from voice output devices (SGD) Contribution of SGD to effectiveness of treatment package unclear Speech output as independent variable Promising results � speech output increased spontaneous utterances but poor design and small sample size Aim of the Study To synthesise evidence, research regarding the potential benefits of Speech output for persons with ASD Method 73 published articles reviewed � small number included participants with ASD Studies grouped into 3 Speech output devices as part of computer assisted treatment packages Packages had potential to teach reading and PA skills for stimulating verbal expression & improving interactions of kids with ASD and their comm partners Speech output from voice output devices (SGD) Contribution of SGD to effectiveness of treatment package unclear Speech output as independent variable Promising results � speech output increased spontaneous utterances but poor design and small sample size

32. Clinical bottom line There is a role for speech output devices for people with ASD, however the benefits still remain unclear at this time and more research into specific SGD�s is needed Schlosser et al (2001)

33. Objective: Use of Vantage Speech output device with voice on and off to determine benefits of voice output Results: Overall � non-speech goal did not increase in � participants, however increase by two fold in requesting skills in children with ASD using SGD � participants showed increase in vocal imitation skills using SGD vs. those that were not exposed to use of SGD Strengths and weaknesses 2 fold aim of paper � looking at requesting with high tech devices as well as looking at changes in natural speech production as a result of intervention Detailed information about how each participant met the criteria for the study Difficult methodology to follow Very strict participant criteria needed for study Schlosser et al (2007) Aim of the Study To synthesise evidence, research regarding the potential benefits of Speech output for persons with ASD Method 73 published articles reviewed � small number included participants with ASD Studies grouped into 3 Speech output devices as part of computer assisted treatment packages Packages had potential to teach reading and PA skills for stimulating verbal expression & improving interactions of kids with ASD and their comm partners Speech output from voice output devices (SGD) Contribution of SGD to effectiveness of treatment package unclear Speech output as independent variable Promising results � speech output increased spontaneous utterances but poor design and small sample size Aim of the Study To synthesise evidence, research regarding the potential benefits of Speech output for persons with ASD Method 73 published articles reviewed � small number included participants with ASD Studies grouped into 3 Speech output devices as part of computer assisted treatment packages Packages had potential to teach reading and PA skills for stimulating verbal expression & improving interactions of kids with ASD and their comm partners Speech output from voice output devices (SGD) Contribution of SGD to effectiveness of treatment package unclear Speech output as independent variable Promising results � speech output increased spontaneous utterances but poor design and small sample size

34. Clinical bottom line Could not determine specifically if a high tech AAC system is more effective than a low tech AAC system. However � it is essential to look at the child / adult�s preferences and ensure that these are taken into account when prescribing a specific system Schlosser et al (2007)

35. Objective: Comparison of PECS vs. VOCA system for requesting desired items Results: In baseline no preference of PECS over VOCA vv All participants increase percentage of correct responses using both systems (PECS & VOCA) [86-100%] Reported increase in speed in responding using VOCA 1 of 3 participants preferred use of VOCA, other 2 participants preferred PECS All 3 participants continued to use preferred AAC 6 months post study Strengths and weaknesses Small number of participants VOCA device not specified No comprehensive follow-up No generalisation data collected Sigafoos et al (2006)

36. Clinical bottom line All participants in the study learnt to functionally use PECS and Voice Output communication system with comparable speed and proficiency. Child preference appeared to be driving force in success of administration of communication system Sigafoos et al (2006)

37. Objective To measure and compare effectiveness of peer mediated teaching with and without SGD, and to determine whether changes generalised. Results Peer mediated naturalistic teaching with SGD resulted in more communicative behaviours per minute than peer mediated naturalistic teaching without SGD for 2 of the 3 subjects. All 3 subjects generalised slight increases in communicative behaviours with peers during mealtime interactions. Strengths and weaknesses Only 3 subjects - ? Ability to generalise results. Number of prompts provided by researcher not controlled � may have influenced peers� ability to implement interventions. Affect of factors such as different abilities of peers and different settings Only small number of generalisation probes taken due to time constraints. Trembath et al (2009)  Method: 6 typically developing peers were taught to use peer mediated naturalistic teaching, with and without SGD, during 3 play sessions with 3 classmates with autism in 3 preschools. Generalisation probes were conducted during mealtimes at the preschools. A multiple baseline design was used to assess outcomes of the 2 interventions. Method: 6 typically developing peers were taught to use peer mediated naturalistic teaching, with and without SGD, during 3 play sessions with 3 classmates with autism in 3 preschools. Generalisation probes were conducted during mealtimes at the preschools. A multiple baseline design was used to assess outcomes of the 2 interventions.

38. Trembath et al (2009)

39. Take home message There is no absolute system that would suit every client There are both advantages and disadvantages to both a high and low tech AAC systems and on top of this we also have to take in to account client abilities and preferences as well as financial situation. It is best not to use a single mode of communication but a combination of both high and low tech AAC to ensure its use in a variety of environments with a variety of communication partners

40. In 2012� Meetings will take place at Cerebral Palsy Alliance � Ryde . 3A Smalls Road, Ryde 1st meeting for 2012 � 15th February at 10 am Please contact Natalie Albor�s or Cecilia Rossi nalbores@nsccahs.health.nsw.gov.au cecilia.rossi@facs.nsw.gov.au

41. References Chiang, H & Lin, Y. (2008). Expressive communication of children with autism. Journal of Autism & Developmental Disorders 38(3), 538-45 �Goldstein, H. (2002). Communication intervention for children with autism: a review of treatment efficacy. Journal of Autism and Developmental Disorders, 32(5) Johnston et al. (2003). The use of visual supports in teaching young children with ASD to initiate interactions Augment Altern Commun. 2003 , 19, 86-103 Schlosser, RW. Blischak, DM (2001). Is there a role for Speech Output in Interventions for Person with Autism. Focus on Autism and Other Developmental Disabilities; Fall 2001; 16, 3; 170-178 Schlosser, RW. Sigafoos, J. Luiselli, JK. Angermeier, K. Harasymowyz, U. Schooley, K. & Belfiore, PJ. (2007). Effects of synthetic speech output on requesting and natural speech production in children with autism: A preliminary study. Research in Autism Spectrum Disorders 1(2) 139-163 Sigafoos et al. (2009) A comparison of Picture Exchange and Speech Generating Devices- Acquisition, preference and effects on social interaction Augment Altern Commun. 25(2):99-109. Sigafoos, J. Drasgow, E. (2001). Conditional use of aided and unaided AAC: A review and clinical case demonstration Focus on Autism and Other Developmental Disabilities 16(3) 152-161 Son,SH. Sigafoos, J., O'Reilly M. & Lancioni, GE. (2006). Comparing two types of augmentative and alternative communication systems for children with autism. Pediatric Rehabilitation 9(4) 389-395 Thunberg, G., Ahlsen, E. & Sandberg AD. (2007). Children with autistic spectrum disorders and speech generating devices: communication in different activities at home. Clinical Linguistics and Phonetics 21(6). 457-79 Trembath, D. Balandin, S. Togher, L. & Stancliffe, RJ. (2009). Peer-mediated teaching and augmentative and alternative communication for preschool-aged children with autism. Journal of Intellectual and Developmental Disability 34(2) 173-186