AAC in the Time of COVID-19

AAC in the Time of COVID-19 By Josie Randles , Amy Bereiter

Augmentative and Alternative Communication (AAC)

SPRING 2020 In March of 2020, therapists across the United States began to realize that life as they knew it was going to change. With the spread of the coronavirus and state and local shut-down orders pouring in, clinicians across the country, whether in medical, clinical or school-based settings, were in for some serious ad- justments. Those of us working in speech-language clinics and schools found ourselves faced with what felt almost like a career change. Suddenly it seemed, we were all tele-therapists, like it or not. Rules and regulations changed. We all started to get familiar with telepractice lingo and platforms. “You’re on mute” became the new “can you hear me now?” Invitations to webinars and “how-to” courses flooded our inboxes and social media feeds. Questions were raised about which of our students and clients would be good candidates for virtual therapy sessions, and for every clinician heard exclaiming that “everyone can be success- ful with teletherapy” there was a parent, a teacher or a therapist wondering whether this was really true. And so, the two of us, set out on our own journey to answer this question for ourselves. As full time speech-language pathol- ogists, working with many students and clients who are AAC us-

ers, we certainly had our own doubts about the efficacy of tele- therapy for the children we support, particularly those who are emerging language learners and who may require a great deal of support to access and successfully use their AAC systems. In addition to being full-time clinicians, we both also contract as Language Acquisition through Motor Planning (LAMP) Educa- tors through the Center for AAC & Autism. Prior to the pandem- ic, we each traveled extensively across the country and abroad teaching parents, teachers and therapists how to support in- dividuals learning to communicate using AAC. We now found ourselves grounded and wondering if all of these familiar and time-tested strategies we had been using and sharing with oth- ers were going to hold up in this new context. THE LAMP APPROACH The LAMP Approach to teaching AAC was developed by John & Cindy Halloran who direct the Center for AAC & Autism, es- tablished in 2009 by the Prentke Romich Company. The LAMP methodology is a therapeutic approach to teaching AAC based on neurological and motor learning principles. The five key com- ponents of the LAMP approach are: readiness to learn, joint en-

AMY BEREITER received her Bachelor's degree in Communication Disorders from the University of Kentucky and her Master's Degree in Speech-Language Pathology from the University of Redlands. She has been a speech-language pathologist since 2004, working with toddlers through young adults, and has worked in a wide range of settings including in-home early intervention, early childhood special education, elementary self-contained programs, pediatric rehabilitation units, university clinic and private practice. JOSIE RANDLES is a Speech-Language Pathologist and LAMP Educator for the Center for AAC & Autism. After earning her Bachelor’s and Master’s degrees in Speech-Language Pathology at the University of Washington in Seattle she began her career at Seattle Children’s. Currently, Josie resides in Phoenix where she supports students with autism in a public school setting and has the opportunity to provide virtual and in-person trainings for parents, therapists, and educators who want to learn more about the LAMP approach. Josie is passionate about communication and working with teams and families to support AAC users.

BACK TO CONTENTS

Image 1 - The 5 Components of the LAMP Approach

users and provide a framework for communication partners who can model and teach language following a developmen- tal approach (e.g., beginning with single words and providing the means to learn both the form and content of the home lan- guage or language of instruction). Readiness to Learn refers to the idea that individuals must be in a “ready to receive” state. Their state of arousal needs to be compatible with attending and learning, something which can be quite challenging for individuals with developmental disabil- ities. Readiness to learn does not refer to particular linguistic or cognitive prerequisites that must be achieved prior to introduc- ing AAC, but rather that an individual’s unique sensory needs must be met prior to engaging with a communication partner to learn language. We also need to take into account individual learning styles, ability to attend to activities, emotional states and level of motivation. We know that we will be more success- ful teaching when the activity is interesting and engaging for the AAC user.

gagement, consistent and unique motor plans, auditory signals and natural consequences. In their clinical work with young chil- dren with autism who were not developing spoken language, John and Cindy found that an approach that gave access to core words on a speech-generating device, teaching those words in the context of sensory-rich, child-directed activities and having just one consistent and unique motor plan for each word, com- bined with a natural reaction from communication partners pro- vided a means for the development of spontaneous and inde- pendent communication. These findings have been replicated, and the Center for AAC & Autism now provides frequent one and two-day trainings to teach parents and interventionists to apply the LAMP principles to supporting language development. A BRIEF OVERVIEW OF THE PRINCIPLES OF LAMP Each of the five principles listed above are foundational to the LAMP approach (see image 1: Components of the LAMP Ap- proach). These principles support the language learning of AAC

BACK TO CONTENTS

Joint Engagement refers to participating in an activity or event with another person. We know that social interaction is a challenge for many of the individuals that we support, and is a core deficit of individuals on the autism spectrum, so the goal is to provide motivating, child-directed activities that improve the capacity for joint attention and engagement. We are looking for a “moment of joy” (and hopefully a lot of them!). The use of Consistent and Unique Motor Plans means that the motor plan that an AAC user uses to access vocabulary does not change once it is learned. While each of the LAMP principles are impovrtant, this particular aspect of the LAMP approach is sometimes referred to as “LAMP Law”; the consistent and unique locations of every word allows for us to teach vocabulary based on location and allows for an automaticity to develop that is im- possible if an AAC user has to cognitively attend to the icons, categories, or shifting locations of vocabulary items. We know that our brains develop motor plans for movements that are re- peated frequently. Some examples of this include: typing, hand- writing, driving a car, playing the piano, etc. Over time, as we be- come proficient in a specific task or skill, we don’t have to “think” about the actions required to perform it. Likewise, with spoken language, once we are a proficient speaker of a language, we are able to devote cognitive resources to thinking about what we will say with little regard to how we will coordinate our articula- tors to form the words in our message. Auditory Signals are provided to AAC users as they access individual words. In individuals who are developing spoken language along a typical course, these auditory signals are pro- vided as sounds and words are expressed using the vocal folds and the articulators (e.g., lips, tongue, teeth), whereas AAC users are using their hand as an articulator and the auditory output is provided by the speech-generating device. When consistent au- ditory feedback is paired with each unique motor plan, an AAC user is able to learn the meaning of words. Natural Consequences are also incredibly important for language learning. Communication partners should provide animated reactions to the utterances of the AAC users, provide the item or activity that has been requested, or offer an appro- priate response that lets the AAC user know that their message has been received. All attempts at communication should be honored. The goal of incorporating each of these LAMP principles is to help the AAC user develop language. As clinicians, we take what we know about language therapy and intervention with users of spoken language and apply it to our work with AAC users. In fact, it’s vitally important that we don’t lose sight of the fact that we are in fact teaching language. We view teaching language to AAC users through the same lens we use to approach teaching language to non-AAC users, we want to help you to be able to say whatever you want, whenever you want, to whomever you want. Ultimately, it was coming back to this fundamental belief

about how we approach language learning that made us realize that perhaps teletherapy wasn’t going to be quite so different than what we had already been doing in our in-person service delivery models. LONG DISTANCE LAMP BEGINS So just as we began to see some of our own clients via tele- therapy, we decided we should start a conversation within our community of like-minded LAMP-focused interventionists. We developed a 90-minute webinar with the idea of sharing our experience as we learned to navigate these unfamiliar waters, hopeful that we would be able to confirm our hypothesis that these trusted principles would indeed guide the way even as our service-delivery model had changed. Our intention was to create a space for connection and community, to cultivate a safe space to ask questions, an opportunity to share challenges and successes, and to offer reminders of the things we already knew in the context of learning so many new things. What we thought might be a one-off, web-based session, turned into several more, and Amy also developed a LAMP at Home webinar focused on parents. We found that despite our initial concerns and hesitations, that all of our clients were in fact good candidates for teletherapy provided we kept focus on the principles of the LAMP approach and maintained some flexibili- ty for what each individual session looked like. That is not to say that this transition to telepractice was easy. We had moments of anxiety and overwhelm, and as we all know technology can be both friend and foe. As we began meeting with our colleagues to share our experiences, we asked them to provide their one-word reaction to being faced with the prospect of AAC intervention via teletherapy. During each of these sessions, we compiled a word cloud using the interactive presentation software program Mentimer (mentimeter.com) where word frequency was indicated by the size of the word in the cloud. After several sessions, we created a composite word cloud, realizing we were seeing many of the same words, offer- ing a continual reminder that while we were maybe not all in the same boat, we were certainly all in the same storm. (See image 2: Clinician Response to Teletherapy- Mentimeter) APPLYING THE PRINCIPLES VIA TELETHERAPY Before really discussing what application of the LAMP princi- ples would look like in a virtual AAC session, we needed to talk about changes in service delivery and platform. Prior to the pre- cautions put in place related to COVID-19, we had both been seeing our students and clients for in-person, direct therapy. Suddenly, we were showing up in client and student homes on a screen and relying heavily on parents to support us and their AAC users during therapy sessions. We likened this in some ways to the experience of supervising a graduate student, in that we found we needed to wear (at least) two hats, that of clinician/in- terventionist and that of mentor/coach. We found that sessions

BACK TO CONTENTS

Image 2 - Clinician REsponse to Teletherapy - Mentimeter

not landing. Joint Engagement requires us to look for the same social ex- change and moments of joy we would expect in an in-person session. At times, this means becoming an observer and coach as we support a communication partner in following the AAC users lead, always keeping in mind that the goal of each session is increased communication, and not work! Providing Consistent and Unique Motor Plans via an online therapy session requires us to be mindful of how we are mod- eling and prompting use of the device during teletherapy. We need to give in-person communication partners specific instruc- tions and feedback about modeling and prompting, including coaching them to find vocabulary and making use of tools such as vocabulary builder and word finder. We are also able to mod- el through screen-sharing, or the use of an external document camera. If technology resources allow, parents can even log in on a second device to allow for a view of the AAC user access- ing their device. It is particularly important to remind in-person communication partners, not to begin a motor plan for an AAC user (e.g., by pressing the first button in the sequence) so that the AAC user is learning the entire motor plan. Auditory Signals are provided by the voice output function of the device, but dependent on the technology, the clinician may not be able to hear the voice output, so again it is import- ant to have clear communication with the in-person communi- cation partner so that they can provide information or adjust the

tended to fall into three categories: direct, parent-coaching and hybrid, with most falling into the last category. We discovered that it was vital to have conversations with families and communication partners about technology, gaug- ing their comfort level as well as their access to specific tools (e.g., laptop, ipad, smartphone). Pre-planning and communica- tion with families took on increased importance as we realized this could be the difference between a successful treatment ses- sion and an exercise in frustration for all parties. And as we expected, we did find that the LAMP principles we were so familiar with applied to telepractice as well. However, there were additional considerations, which we outline below. Readiness to Learn now applies to both AAC users and par- ent/caregiver/communication partners. We need to ensure that the adult supporting the AAC user is also in a state that allows them to be able to receive benefit from the interaction. Recog- nizing caregiver overwhelm and burnout is helpful for gaug- ing when to introduce new information or practice unfamiliar skills. For the AAC users, we are able to apply what we already know about these individuals to determine what type of ses- sion would be most beneficial. For some this means very few di- rect on-screen activities, and more physical activities with their in-person communication partners. For others it means hand-on activities like making a snack in the kitchen or walking around on a scavenger hunt. Keeping up motivation also means being willing to abandon a carefully laid out plan when you find it is

BACK TO CONTENTS

Image 3 - Language Explosion During COVID School Closure

POSSIBLE SILVER LININGS OF COVID-19 PRECAUTIONS & STAYING AT HOME As we began providing teletherapy services for our clients us- ing AAC, we started to receive feedback from families that they were feeling more comfortable with the devices and vocabulary, that they were enjoying the opportunity to participate direct- ly in sessions, and that many of them were noticing increased communication from the AAC users they were supporting. On May 11, 2020, roughly six weeks following the beginning of school shutdowns across the United States in response to the Coronavirus pandemic, a parent posted the following question to the LAMP Words for Life Users Facebook Group: “Anyone else’s child having an explosion of language (verbal or AAC) since being in quarantine with siblings and parent all day long .... everyday for over a month. We have seen extreme growth in language and expressive ability. Curious if others have seen same result.” The post generated a great deal of engagement including 268 reactions and 105 comments. In total, 72 of the comments were from parents or therapists/interventionists answering “yes” or “no” to the question posed. The other comments were either supportive comments, questions or responses to questions or comments. There were responses from 56 individual parents and 16 in-

technology to allow for a better signal. In some cases, AAC users do not have access to their high-tech speech-generating device due to repairs or devices being kept at school. Reminders need to be given about providing auditory feedback if individuals are pointing to symbols/words on a paper-based system. Natural Consequences can be provided by either the clinician or the in-person communication partner depending on the con- text of the activity. It is important to model natural interaction and avoid using words such as “push, show or press”. Encourage in-person communication partners to continue to respond to all attempts at communication, to generalize words, and to par- ticipate in brainstorming sessions to determine how else they might target vocabulary covered in a session. As in in-person therapy sessions, maintain the focus on lan- guage development. This is language therapy. The modality is different and now the service-delivery is different as well, but the focus remains the same. We have found continued success during this time, and while there are certainly some challenges, it seems there are some decided benefits to this time for some of our AAC users and their families / support systems.

BACK TO CONTENTS

citing new areas of research, and may turn out to be one of the positive impacts of this challenging time.

dividual therapists/interventionists in all. 49 of the 56 parents (87.5%) reported that they had in fact seen an increase in their child’s spoken language and/or use of their AAC device (see im- age 3: Language Explosion During COVID School Closure). All 16 of the therapists/interventions (100%) reported that they had seen increases in spoken language/AAC use or had been giv- en reports of the same by the clients/families they are working with. Combined, 90% of the parents and therapists/interven- tionists that responded to this Facebook post indicated a pos- itive change in their children, clients, or students. Of the 49 parents who reported an increase in language, 26 simply answered in the affirmative (yes!, 100%!, raised hand emoji, etc.). 23 parents provided further information or thoughts about why they thought they were seeing this language “explo- sion”. Several parents noted that they were modeling and using the device more frequently at home than prior to school being shut down. One parent described this as “doing speech therapy every day for a few hours”. Several parents (8) directly reported an increase in the use of spoken language with two noticing an uptick in echoed speech. Several other parents mentioned a de- crease in pressure/stress on their child to use the device or an increase in play/social interaction with siblings/family members. Two parents reported having removed their children from a tra- ditional school setting prior to the pandemic and seeing an in- crease in language then. Two other parents reported an increase in language along with a decrease in challenging behaviors (e.g., hitting/biting). The responses to this Facebook post raised some interesting questions for us. We know that there is research that points to seeing gains in language development when a speaker is en- gaged with someone with whom they have a relationship, and we speculate that the science behind why we are seeing this increase in communication skills may be rooted in the social connection children have for their parents and siblings (Bernier, Dawson, Webb, & Murias, 2007). We also know there is research that posits that many of the individuals we are supporting to learn language using AAC may demonstrate deficits or impair- ments in their Mirror Neuron Systems (Dapretto et. al, 2006, Theoret 2005); the increase in parent modeling and use of the AAC device at home could be helpful for individuals who re- quire multiple models to learn a skill. An additional possibility is that teletherapy sessions act as a form of video modeling, a well -studied evidence-based practice for intervention. In addition to the benefit of providing coaching for in-person communica- tion partners, Charlop, Le, & Freeman (2000) found that gener- alization of tasks occurred only for the tasks that were taught through video modeling. While certainly even the most robust analysis of a Facebook post provides us with anecdotal information, it is fascinating to consider what may be driving the increase in language we are seeing reported while AAC users are at home for extended pe- riods with their parents and/or siblings. This points toward ex-

WHAT’S NEXT? While the future remains a bit uncertain for all of us, we be- lieve it’s fair to say that teletherapy for AAC is here to stay. Even as we move back into in-person therapy sessions, we now have new tools to use and based on our own experiences and feed- back from other clinicians and interventionists, we find that telepractice offers a unique window into AAC use and as Grand- lund et. al. (2008) remind us “the primary context for evaluating the effects of the AAC intervention is the family”. If you are interested in learning more about the LAMP ap- proach, please visit the Center for AAC & Autism at aacandau- tism.com Amy & Josie look forward to presenting Long Distance LAMP: Applying the Principles via teletherapy at this year’s virtual Clos- ing The Gap conference and we look forward to seeing you at our live Q&A session on Wednesday, November, 11th at 11am CST. REFERENCES: Charlop, Marjorie & Le, Loc & Freeman, Kurt. (2001). A Com- parison of Video Modeling with In Vivo Modeling for Teaching Children with Autism. Journal of autism and developmental dis- orders. 30. 537-52. 10.1023/A:1005635326276. Granlund, Mats & Bjorck-Akesson, Eva & Wilder, Jenny & Ylvén, Regina. (2008). AAC Interventions for Children in a Family Envi- ronment: Implementing Evidence in Practice. Augmentative and alternative communication (Baltimore, Md. : 1985). 24. 207-19. 10.1080/08990220802387935. Dapretto, M., Davies, M. S., Pfeifer, J. H., Scott, A. A., Sigman, M., Bookheimer, S. Y., & Iacoboni, M. (2006). Understanding emotions in others: mirror neuron dysfunction in children with autism spectrum disorders. Nature neuroscience, 9(1), 28–30. https://doi.org/10.1038/nn1611 Théoret, H & Halligan, E & Kobayashi, M & Fregni, Felipe & Tager-Flusberg, Helen & Pascual-Leone, Alvaro. (2005). Impaired motor facilitation during action observation in individuals with autism spectrum disorder. Current biology : CB. 15. R84-5. 10.1016/j.cub.2005.01.022.

BACK TO CONTENTS

Page 1 Page 2 Page 3 Page 4 Page 5 Page 6

www.closingthegap.com

Made with FlippingBook Ebook Creator