Ellen Leonard , M.D, Meredith Potts, MA, CCC-SLP, CP-LAMP, CP-TLP Laura Deming, MS, RN-CS, PNP, CNS, CCM, CLCP Septemb

1. Advances in Technology to Support Children with Communication Disorders Ellen Leonard , M.D, Meredith Potts, MA, CCC-SLP, CP-LAMP, CP-TLP Laura Deming, MS, RN-CS, PNP, CNS, CCM, CLCP September 2011

2. Welcome

3. Objectives 1. Identify the types of diagnoses which would likely benefit with augmentative communication . 2. Identify various types of augmentative communication and discuss the appropriate use augmentative communication for children. 3. Explain appropriate recommendations for augmentative communication training for the child and family and discuss pricing /costs for the recommendations. 4. Discuss the implementation and evaluation of a high-tech device for a child/children. 5. Explore various high tech augmentative communication programs and devices. 6. Discuss the pros and cons of various types of augmentative communication.

5. Diagnoses and AAC

6. Conditions that cause communication disorders • Stroke • TBI • Neurological insult • CP • Unknown origin • CAS (childhood apraxia of speech) • Sensory Integration Disorder • ASD (autism spectrum disorders) • MR • Oral Motor Dysfunction/Dysarthria

7. Beau’s first experience with his device… Age 2 ½ years

8. Prevalence • 1 in 10 children have communication disorder • 60% of children with ASD have CAS • 80% of children in Texas with ASD graduate high school with NO functional method of communication • Amer Journal of Speech-Language Pathology vol 16, p 359-67, Nov 2007

9. Types of Pediatric Cases • Examples of children who need and/or use AAC • Jenny has mental retardation, and she has limited speech that is very hard to understand. She mainly uses gestures, such as eye gaze and pointing, to communicate, and she also occasionally uses a picture communication book. • Tony has severe apraxia of speech, and his speech is very difficult to understand. He pantomimes elaborately and sometimes gathers objects from around the room to help get his point across. • Marcus has autism and uses schedule boards containing line drawings and photographs to help him transition from one activity to another. • Maria has multiple disabilities and responds to very few stimuli. Her main forms of communication are by looking toward desired objects and by crying.

10. Coding

11. CPT Codes • 92605: Evaluation for prescription of non-speech generating AAC device. • 92606: Therapeutic service(s) for use of non-speech generating device, including programming and modification. • 92607: Evaluation for prescription of SGD, face to face with patient, first hour. • 92608: Evaluation for prescription of SGD: each additional 30 minutes of billing . • 92609: Therapy services for use of an SGD, including programming and modifications.

12. HCPCS Codes • E2500- Speech generating device, digitized speech, using pre-recorded messages, less than or equal to 8 minutes recording time, multiple access methods. $410.61E2502- Speech generating device, digitized speech, using pre-recorded messages, greater than 8 minutes recording time but less than or equal to 20 minutes, multiple access methods. $1255.59 • E 2504 - Speech generating device, digitized speech, prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes, multiple access methods. $1656.29 • E 2506- Speech generating device, digitized, prerecorded messages, greater than 40 minutes, multiple access methods. $2428.61 • E 2508-Speech generating device, synthesized, message formulation, direct physical contact with SGD, message formulation by spelling. $3755.44 • E 2510-speech generating device, synthesized, message formulation, multiple access methods, message formation technique is spelling. $7106.66 • E2511-synthesized, message formulation, program for personal computer or PDA, spelling and other methods. • E2512-mounting system, individually priced • E2599-accessory, individually priced ( Coding Information Put Together with Assistance from Dr. Carolyn Higdon)

13. How to Diagnose • Comprehensive Speech & Language Evaluation • Oral Motor Examination • Speech Assessment • Receptive Language • Expressive Language • Develop a POC for treatment

14. Evaluation for AAC • What is really needed: • Basic receptive and expressive evaluation (approx. 8-14 hours, consider child’s ability to remain engaged during sessions) • Trialing several different communication devices (6 weeks @ 3 visits to SLP per week) • Feature Match • Trial period (approx. 2 weeks-3 months) • Apply for funding

16. Key Professionals for Evaluation Process

17. Additional Players…

18. SGDs Can … • Increase Expressive langugae • Increase Receptive language • Increase Literacy • Increase Control over environment • Increase Communication initiation

19. The process of language…

20. AAC is Not • A last resort • “Giving up” on speech • Only for those of a certain IQ or Age • Only the job of the speech-language pathologist

21. Myth Busters… Myth and Misconceptions AAC hinders or stops further speech development The Evidence AAC approaches (signs, picture symbols, VOCAs*) do NOT hinder speech development. In fact, speech often increases during AAC treatment approaches *VOCA= Voice Output Communication Aid From: Augmentative Communication News, Volume 18, Number 2, June, 2006

22. Myth Busters… Myth and Misconceptions There is a representational hierarchy of symbols from objects to written words The Evidence Children can learn to understand and use a variety of symbols at a very young age (e.g., sign language) through repeated exposure to the symbol and its referent in natural contexts From: Augmentative Communication News, Volume 18, Number 2, June, 2006

23. Myth Busters… Myth and Misconceptions Children must have certain skills to benefit from AAC (e.g., be at a certain age, have a particular cognitive or linguistic level, etc.) The Evidence There are NO prerequisites for communication. AAC focuses on all aspects of communication and communication begins at birth. AAC is an appropriate intervention approach for anyone with CCN. From: Augmentative Communication News, Volume 18, Number 2, June, 2006

24. Myth Busters… Myth and Misconceptions AAC is a last resort and means professionals are “giving up” on speech The Evidence The “Wait and See approach” is not an effective way for teams (e.g., speech-language pathologists, teachers, paraprofessionals, parents to develop communicative competence) From: Augmentative Communication News, Volume 18, Number 2, June, 2006

25. Impairments needing AAC • Basically, all people (with disabilities)who are not able to express themselves (communicate)verbally to meet their basic needs. • Consider what type of AAC depending on what is “least restrictive” for the individual.

26. Sorting out the Data

27. Methods of Treatment for Limited Verbal Communicator • Augmentative and Alternative Communication (AAC) • Picture systems (i.e., Picture Exchange Communication System) • Gestural (Sign Language) • Low tech devices • High tech devices

28. No Tech AAC

29. Low Tech AAC

30. High Tech AAC

31. Goal = Functional Communication • I don’t like you, Mommy

32. Features of Most SGDs • Displays • Access • Speech • Symbols Sets • Vocabulary Organization • Integrative Functions • Environmental Controls • MP3 players • Phone/Text

33. Feature Match • No tech, light tech, high tech • Symbol sets • Static vs dynamic display • Size of display • Access methods • Weight and portability • Type of voice output • Symbol set • Vocabulary organization

34. Treatment Technique Language Acquisition through Motor Planning (LAMP) The Center for AAC & Autism

35. L.A.M.P.

36. Readiness to Learn • Some children need to be calmed in order to be in a state of readiness to interact. Other children need to have their level of alertness increased to be ready to learn. In either instance, the child must be ready at emotional and sensory levels before learning can occur.

37. Child Directed Follow the child’s lead: • Build on the child’s interests • Carefully use barriers • Join in with the child • Let the child make the moves • Use of Movement

38. Shared Focus • Joint attention: the process by which one alerts another to a stimulus via nonverbal means, such as gazing or pointing. For example, one person may point to another, and then point to an object. In this case, the pointing person is trying to get the other to look at the object. The person seeing the other point responds to the gesture by looking at the object. It typically develops around one year of age in human infants and is essential to building strong social connections. Before one year of age, infants merely look at the hand of the person pointing; after developing joint attention, they look in the direction of the pointing. Chimpanzees also show some understanding of joint attention, although they primarily use it as a means to an end, rather than for pure communicative purposes.[1] Although chimps do display joint attention, the general consensus is that only humans use it in a purely altruistic way. (Wikipedia)

39. Consistent & Unique Motor Plans • Levelt's (1993) model of spoken language focuses on the cognitive processes associated with utterance generation.  Levelt argued that "normally speakers have no conscious access to language encoding or articulation.  For most speakers, language production is relatively effortless."  (The Efficacy of Augmentative and Alternative Communication, Schlosser, 2003 p. 48).

40. Software that Supports LAMP • Unity Screen Shots

41. Software that Supports LAMP

42. Fitts and Posner (1967) proposed a three stage model of motor learning. The first stage is the cognitive stage in which the learner has to attend to the process of learning a motor action. This stage is marked by highly variable performance. The learner may or may not know what they are doing wrong or how to correct their performance and will need guidance to assist them. In the associative stage, he works on refining his skill and is able to detect and correct their errors. The autonomous stage is the result of a lot of practice. At this stage, the learner does not have to concentrate on the movement and can attend to other aspects of the activity.

43. Automaticity Natural Language • Cognitive activity: Formulation of thoughts • Motor activity: Speech & Gesture (automatic) AAC Language • Cognitive activity: Formulation of thoughts • Motor activity: Device activation (automatic???)

44. How Automaticity Works Motor Learning • Acquisition & retention of movement for task Repetition of a neuromotor pathway • Eventually requires less energy • Eventually enhances performance • Example: touch typing

45. Automaticity on an AAC Device Possible when: • Location of icons is consistent • Small icon set allows for immediate recognition • Moving from one icon to the next is predictable Not Possible when: • Significant Navigation is required • Continuous visual refocus & reorientation is required

46. AAC Institute The two most important values expressed by people who rely on AAC are: 1) saying exactly what they want to say, and 2) saying it as fast as they can. AAC services must honor these values of people who use AAC and their families. Achieving the goal of AAC (optimal communication & maximum potential) is best accomplished when the principles of evidence-based practice and performance measurement are used.

47. Auditory Signal/Feedback • La Sorte (1993), he found that synthetic speech facilitated natural speech production. He found that, “Synthetic speech can facilitate the segmenting of speech into word units since the boundaries are more clearly defined than in human speech, and stress is not an important aspect of synthesized speech.”

48. Language Connections • The AAC device is a tool that allows the child to “babble” and learn about language. For example, after saying “more” to get bubbles, the child might think that pressing the key for “more” means “bubbles.” A beginning talker might make the same conclusion. However, in another instance when the child says “more” and gets more juice, the meaning of “more” is revised by the child. • As the child learns with the AAC device, he/she is learning consistent motor patterns that result in an auditory signal. Depending on the natural consequence triggered by the auditory signal, the child may modify his/her perception of what the auditory signal means.

49. Therapy Videos “Language Connections” • Beau at Museum

50. Current Technology • PrentkeRomich Company • www.prentrom.com • Dynavox • www.dynavoxtech.com • iPhone/iPad option • Proloquo2go www.proloquo2go.com